Many cancer patients suffer with pain needlessly." Often, they operate under the assumption that, when it comes to narcotics, "more is better."" Physicians may not be knowledgeable of research that shows pain can be effectively controlled, when the appropriate medications and dosages are administered." They, too, often misinterpret a patient's request for additional medication as a dependency, when the patient's pain has not been controlled.
Pain in malignant disease is common, yet in most patients pain can be effectively controlled. For effective pain management there are three basic things, which must be done.
1. Assessment – to identify the TYPES of pain being experienced.
(I have developed an evidence-based pain assessment, called the Carling Algorithm, which uses a detailed" Pain Assessment Sheet.)
There are eight types of pain:
"· only two of them are fully opioid responsive,
"· three are semi-responsive, and
"· three are opioid resistant.
Most patients have more than one pain. Indeed, one third have four or more different types of pain. Before medications are prescribed, we need to know which types of pain you are experiencing, so that the appropriate medications can be prescribed.
2. Titration – adjusting the dosage of medication, which can mean an increase or a decrease, to achieve pain relief with the minimum or no side effects. Once the medications are prescribed, the dosage has to be carefully adjusted until the pain is under control. If you have three types of pain, then you may need three different medications, which will need to be adjusted individually until each pain is brought under control. Some medications, such as opioids (morphine, oxycodone hydromorphone etc), can be titrated fairly quickly. Others, such as antidepressants and anticonvulsants may take several weeks to titrate. You need to be able to differentiate between the different types of pain so that you will know which medication to take.
3. Regular and frequent monitoring. Pain is dynamic – it increases, it decreases and it can change in nature. Your medications may need to be adjusted accordingly.
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Pain should be ‘controlled’ rather than treated. Long acting opioids can control the same level of pain by as much as one third less dosage. It is false economy to wait until you have the pain before you take the medication and you are suffering needless pain.
The aim of using long acting opioid drugs is to obtain and maintain a level which lies inside the therapeutic window. (See diagram) As long as the level stays within the window, you will be pain free and you will have no mental clouding. If the level rises above the upper parameter, you will begin to feel ‘hung-over’ or sleepy and judgment will be cloudy. If it falls below the lower parameter, you will experience breakthrough pain.
Statistically, it takes about 30% of the 12 hour dosage of the SAME DRUG in immediate release form to lift the level back inside the window. If you are taking Morphine Sulphate 60mgs (long acting) 12 hourly, then for breakthrough pain you should be taking Morphine Sulphate Immediate Release (MSIR) 20mgs (short acting) for breakthrough pain.
If you are taking one of the 24 hour morphine medications (long acting) then for breakthrough pain, you should be taking" 5% - 15% of the 24 hour dosage of the SAME DRUG in immediate release form, (MSIR)
If you are taking Oxycodone 40mgs (long acting) 12 hourly, then for breakthrough pain you should be taking Oxycodone 10mgs (short acting). For this drug 25% - 30%" is sufficient.
As a ‘rule of thumb’, if the pain breaks through 2-3 times per day or more, it is an indication that the level is in the lower margin of the window and the 12 hour dose needs to be increased by 50%, with a corresponding increase in the breakthrough dosage to represent 30% of the NEW dosage. (Call your doctor or nurse about this)
Conversely, if your pain comes down, e.g., after radiation therapy, then the medication will need to be reduced. If you wake up feeling ‘hung-over’ and especially if you had no breakthrough pain the previous day or so, then this is an indication that your pain has come down. The 12 hour dosage is then reduced by 30% with a corresponding decrease in the breakthrough medication to represent 30% of the NEW reduced dosage. (Call your doctor or nurse about this).
If you are taking twelve hourly opioids –morphine sulphate, oxycodone - take the same dose in the morning as in the evening, otherwise the level is fluctuating constantly.
Side effects.
1." " " Constipation occurs in EVERYONE taking opioids. You need a ‘pusher’" such as Senokot and a softener from the first dose of opioid. Opioids slow the bowel down. Your ‘pusher’ speeds it up again. It puts the ‘push’ back that the opioid has taken out. Take it EVERY day."
2." " " Nausea and vomiting. If this occurs, it is usually for the first 48 hours after starting on an opioid for the first time. Taking an antiemetic with the opioid for the first couple of days can prevent this. The commonest cause of nausea and vomiting after that time is poor bowel management. Prevent it happening in the first place by taking your ‘pusher’ and softener regularly.
Call your doctors and nurses:
1." " " If the medication you are taking is not controlling the pain.
2." " " If you have breakthrough pain two to three times per day or more.
3." " " If you wake up feeling ‘hung-over’ and especially if you had no breakthrough pain the previous day.
4." " " If you have not had your bowels opened for three days or more.
5." " " If you have nausea and/or vomiting.
6." " " If you develop new pains.
Neuropathic pain occurs in about 15% of patients with Myeloma and in 8 out of 10 of them it precedes the onset of symptoms. Neuropathic pain can be controlled using antidepressants and/or anticonvulsants, which need to be titrated up slowly over several weeks."
These are now available in topical form along with drugs such as Guaifenesin, Clonidine, Ketamine and the NSAIDs and other medications. These have the advantage of reducing side effects considerably, and relief is speedier on considerably lower dosages."
A Compounding Pharmacist would help you with this." "
Remember:
- Pain CAN and SHOULD be controlled
- You have nothing to fear but fear itself
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•" " " Work as Hospice Nurse, Community Nursing Sister, Nurse Midwife, Health Visitor (Nurse Practitioner Pediatrics and Public Health), Specialist Health Visitor for Handicapped Children and College Lecturer.
•" " " Served on the Management Committee that opened the first hospice in the area in the North East of England and member of the Advisory Committee for the Care of the Terminally Ill for that region
•" " " Own Radio Program with the BBC in England, broadcasting live for an hour, once monthly.
•" " " President of the Virginia Cancer Pain Initiative 1996."
Member of the National Speakers Bureau - Purdue Frederick Pharmaceutical Company.
•" " " Member of the Faculty of the American Society of Pain Educators 2006
•" " " Pain Management Coordinator for Riverside Regional Medical Center in Virginia for almost three years, up until April 1998, during which time, taught program of Pain Assessment and Management to nursing staff, physical therapists, pharmacists, medical students from EVMS, OB/GYN and Family Practice Residents."
•" " " Author of multiple articles published in the journals" Analgesia," International Journal of Pharmaceutical Compounding, and theInternational Myeloma Foundation Journal.
MA Carling "© 2009 All Rights Reserved
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