Drug Therapy The Cornerstone of Pain Treatment

Pain medications are used commonly for acute or chronic pain for patients of all ages, including infants and the elderly, and will relieve pain in about 90 percent of cases. The World Health Organization (WHO) began a revolution in cancer pain therapies with its recommended "ladder" of medications for the appropriate sequence of therapies. It suggests that doctors treat mild cancer pain with mild painkillers and progress to more potent ones as needed, adding supplemental medications that can enhance pain relief or relieve medication-related side effects as necessary.

Who Pain Ladder 2016

Figure 3.4 The WHO's basic pain strategy, called the "analgesic ladder," is now used worldwide to treat cancer pain.

Source: Reprinted with permission of the World Health Organization.

Figure 3.4 The WHO's basic pain strategy, called the "analgesic ladder," is now used worldwide to treat cancer pain.

Source: Reprinted with permission of the World Health Organization.

The Basic Pain Strategy: The Painkiller Ladder

The WHO's basic pain strategy, now used worldwide to treat cancer pain, suggests the following steps:

Step 1: Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

These drugs, useful for mild to moderate pain, include aspirin, acetaminophen (Tylenol, etc.), and ibuprofen (Advil, Motrin, Rufen, Nuprin, Medipren, among others). In fact, there are almost twenty different NSAIDs.

Until recently, the various NSAIDs did not differ greatly from each other, and while most still don't, a doctor may suggest trying different types (medication rotation), because one may work better or be better tolerated in one person than another. Unfortunately, there's no way to know in advance which will be better for a particular person until they are tried, a process of educated trial and error with careful observation.

New specialized NSAIDs, dubbed by the media as the "superaspirins," include agents such as rofecoxib (Vioxx) and celocoxib (Celebrex); they are technically called COX-2 inhibitors (see Chapter 5) because they work preferentially on one of two enzymes involved in the mechanisms associ ated with pain. While they are not necessarily more effective for pain, they are somewhat less likely to cause complications such as ulcers and bleeding, which is particularly important to the elderly or those with a history of alcohol abuse or liver and kidney problems. However, insurers often insist that doctors fill out time-consuming forms justifying their use because of their dramatic additional expense.

Surprisingly, when taken in the right dose (not too high or too low) at the right time (around the clock, as directed), the NSAIDs are often quite effective for even severe pain—especially pain that stems from bone tumors, bone metastases, and local inflammation (tissue irritation).

Often, an adjuvant medication (a complementary or helper medication), such as certain antidepressants, anticonvulsants, and muscle relaxants, may enhance the effects of the more traditional painkillers. Medications to prevent nausea or constipation may also be prescribed.

When taken on schedule continuously, relief is quick, often within twenty-four hours. If there is no noticeable benefit within forty-eight hours, or if side effects such as stomach problems, blood-thinriing effects (bruising, bleeding), or drowsiness occur, the doctor should be informed so that an escalation of the pain treatment strategy to the next logical step can be planned.

Even when they aren't strong enough to eliminate the pain, as long as pain is reduced and there are no serious side effects, NSAIDs should probably still be taken, but usually in combination with a stronger (opioid) medication. Since the two relieve pain by different mechanisms, taken together they can produce an additive or synergistic benefit, so that less opioid medication is ultimately needed.

Step 2: Opioids Conventionally Used to Treat Moderate Pain: Mild or Weak Opioids

Codeine (usually prescribed as Tylenol #3) is the prototype and most familiar of these drugs, with propoxyphene (the active component of Darvon and Darvocet) the most common alternative. Despite the historical popularity of these agents, today other so-called weak opioids are usually preferred, including hydrocodone (Vicodin, Lortab, Norco, etc.), dihydrocodeine (Synalgos DC), tramadol (Ultram), and oxycodone (Percodan, Percocet, Roxicodone, OxyFast, OxylR). Most of the weak opioids come combined obligatorily with aspirin or acetaminophen. This limits how much can be taken (usually two tablets every three to six hours)—not because of the narcotic, but because too much aspirin or acetaminophen can cause serious health problems.

Actually, the distinction between weak and strong opioids has little scientific basis, since higher doses of the so-called weak agents produce effects similar to those of lower doses of strong agents. The distinction is more cultural in nature, resulting from our drug-phobic society and its excessive concern about prescribing morphine and other potent opioids. These agents are really only considered "weak" because safe doses are limited by the need to avoid a buildup of acetaminophen and aspirin. While these agents have a definite role for mild and moderate pain, a doctor's preference for prescribing weaker drugs (and patients' reluctance to advance to stronger ones) can sometimes cloud decisions about which alternative would be the most effective and safe. It is usually wiser to rely more on products with a higher proportion of hydrocodone (instead of a higher proportion of acetaminophen) because it is safer and allows for more flexibility in increasing doses, yet this practice is still unfortunately often ignored.

One of the most common errors made by weli-meaning physicians who still harbor exaggerated concerns about [he risks of addiction is to maintain patients on these weaker opioid medications, often in spiraling doses, when a stronger one would better relieve the pain and—because excessive acetaminophen and aspirin are avoided—may actually be less risky.

Again, at this step, adding an adjuvant medication (most commonly antidepressants, anticonvulsants, and sometimes steroids) can improve pain relief without increasing the opioid dose and, as a result, limits the risks of potential opioid side effects such as nausea, sleepiness, itchiness, and constipation. When pain remains inadequately quelled at maximum recommended doses and, despite dose increases, pain persists for more than twenty-four to forty-eight hours, the next step on the ladder should be considered. See Chapter 6.

Step 3: Opioids for Severe Pain: Strong Opioids

Despite many new alternative opioids, morphine is still usually the drug of first choice and is most commonly recommended for severe pain, not only because of years of experience using it, but also because it is available in a wide variety of dose formulations and can be administered in a variety of ways, including intravenous, subcutaneous, intramuscular, and spinal injections; rectal suppositories; immediate-release and controlled-release pills and capsules; and so on. Nevertheless, as with all opioids, some patients have problems with morphine (there is no best drug for everyone), such as persistent nausea, drowsiness, or dysphoria (feeling strange or unpleasant).

While the fear of taking morphine is not a sufficient reason to reject its use out of hand, if true problems occur, doctors will suggest one of several strategies. Since side effects, especially nausea and grogginess, are common but usually short-lived whenever any opioid is first started, the preferred approach to mild side effects is usually to stick with regular administration. This gives the body a chance to become accustomed and immune to these effects, although an antinausea medication may be recommended for a few days, to allow tolerance to develop. A common physician error, however, is to continue the regular use of antinausea medications beyond a few days even though nausea usually resolves spontaneously.

Also, the drowsiness that occurs is often catch-up sleep, because the pain is finally relieved after having disrupted sleep for a long period. If troublesome side effects persist, other similar opioid drugs can be substituted. A small proportion of patients (especially the elderly and those with kidney problems) are predisposed to the buildup of morphine metabolites; while not dangerous, this may explain grogginess or nausea that doesn't easily wear off. When side effects are not excessive but pain relief is inadequate at a given dose, more morphine (or a similar opioid) is prescribed, a safe and effective practice, since there is no maximum dose for the strong opioids. See Chapter 7.

Again, the adjuvant analgesics as well as an NSAID can continue to be useful at this step because they can enhance pain relief without increasing opioid doses. Similarly, some adjuvant drugs can help reduce anxiety or side effects. See Chapter 8.

Step 4: Surgical and Other Anesthetic Measures

Despite good pain control when the ladder approach is applied thoughtfully, some 10 to 20 percent of patients will benefit from additional, more aggressive pain control techniques at some stage of their treatment.

Although the WHO ladder addresses only medication-based approaches, more aggressive treatments are now available and included in guidelines formulated by the American Society of Anesthesiologists and the U.S. government's Agency for Health Care Policy and Research as additional steps.

Usually administered by trained pain specialists, anesthesiologists, or neurosurgeons, these more aggressive procedures include specialized injections, finely tuned removal of nerves, and more complex surgical therapies that are discussed in detail in Chapter 9.

During Steps 1 to 4: Supplemental Measures Used Throughout Pain Treatment

Many techniques, from relaxation and cognitive skills to new forms of transcutaneous electrical nerve stimulation (TENS), as well as psychological, behavioral, and cognitive therapies (hypnosis, relaxation, guided imagery, traditional counseling and psychotherapy, physical therapy including the use of massage, and newer forms of bodywork such as acupuncture) can often be safely integrated with more traditional treatments. These are described further in Chapter 12 and should be discussed with the physician.

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