Ask the Pharmacist

Q: I have been recently diagnosed with cancer and have been told to eventually expect a significant amount of pain. My oncologist thinks I should have some narcotic pain killers available just in case, but with everything I read about all of the overdoses, I’m a little nervous to use them. What should I do?

A: With the recent spike in overdoses throughout Canada and the press reports indicating Canada, and specifically Ontario, are among the highest users of narcotics in the world, there has been a great amount of scrutiny brought upon the prescribing of opioids that is well overdue.

However, it would not just be naïve but downright foolish to think the treatment of all types of pain can be conducted effectively and humanely without the use of these pain killers. One such example of a situation, where narcotics will continue to play an important role, is in the treatment of cancer pain.

Now, that is not to say that all types of cancer involve significant pain. For many, pain can range from a non-issue to a minor one and for this level, your traditional pain killers, such as acetaminophen or an anti-inflammatory like naproxen or ibuprofen, may well be sufficient.

But unfortunately, over half of cancers do involve degrees of pain that can vary from moderate to severe and for which the previously-mentioned drugs are unlikely to be adequate on their own. The adequate management of pain is critical to patients going through cancer treatment as poorly-controlled pain can lead to all sorts of complications, such as inadequate sleep or nutrition, both of which are associated with poor prognoses.

Pain from cancer can be a result of a number of different causes. First off, there is the pain of the tumour, itself, as it grows and pushes on the various tissues that surround it.

Then, unfortunately, there is the pain that may occur from the various treatment regimens used to eradicate the cancerous cells. Pain resulting from treatment, can include that from the effects of surgery, from the infusion of chemotherapy into your circulatory system, from the potentially burning effects of radiation, sores that develop within your mouth (mucositis) or the damage to your bones that may be caused by the use of high-dose corticosteroids or biphosphonates.

The first step in treatment of the pain is to get a detailed description of it: where is it occurring, what does it feel like (throbbing, stabbing, etc.), is it constant or only occasional, and what triggers it, if anything. It’s also important to get an indication as to how severe the pain is. Most clinicians like to rate it on a scale of one to 10.

For most patients who rate their pain from one to three, over-the-counter pain medicines such as acetaminophen and supportive care, have an excellent chance of relieving the discomfort. For those who assess their pain at a higher level, the use of opioids is likely to be necessary.

Initially, a low dose of a short- or quick-acting narcotic, such as hydromorphone or morphine, should be tried in patients for whom narcotics are considered a sound therapeutic option. If pain is intermittent, the dose is increased, as needed, until relief is achieved.

If pain is continuous, once an effective amount of the initial short-acting pain killer has been determined, it is usually a wise course of action to convert this does to a lower amount of a long-acting narcotic. The logic behind this step is two-fold.

One, is to improve the duration of sleep. Most short-acting pain killers last four hours or less. As such, the return of pain throughout the night causes major impairments to sleep quality, and a host of other problems can arise from that. Secondly, once again due to the drug's short duration, pain will continually reoccur throughout the day as the dose wears off every couple of hours, leading to a level of anxiety about its return that can be both problematic for mental health as well as detrimental to one’s innate pain tolerance.

Once a long-acting pain killer has been established, the cancer patient should still have some of the initial short-acting pain killer available for breakthrough pain. Keep in mind that pain is rarely static for long so that doses can and should be adjusted up or down, depending on the need.

There is no such thing as a maximum dose for narcotics. As long as they are slowly increased, they can be increased to very high levels although it is rare for doses of more than 300 milligrams (mg) of morphine (or its equivalent in other narcotics) to be necessary.

Dosing, however, can be limited by the side effects that narcotics produce in their users. These can include sedation, nausea, vomiting, itchiness, physical dependence, respiratory depression and, of course, constipation. While many of those get better on their own, constipation is frequently a real challenge for many. Most experts suggest starting a laxative such as PEG 3350 or Senokot upon initiation of opioid therapy in an attempt to prevent this uncomfortable adverse event from even getting started.

As well, while opioids are an important part of the tool chest for controlling cancer pain, there are a variety of other treatments that can be added to them or perhaps, in some cases, even used to replace them. These include a number of creams that are very effective for radiation burns (Glaaxo base is both inexpensive and highly recommended, as well as a number of specialty creams we have compounded with great success for a few of our patients over the years), a few compounded liquids that are collectively known as “magic” mouthwashes that can greatly relieve mucositis, corticosteroids for bone pain and a bevy of drugs that reduce the burning and tingling of neuropathic pain.

With so many options out there, the vast majority of cancer patients should be able to have their pain relatively well controlled. In fact, many of our biggest pain control issues occur because some of our cancer patients are too leery of these drugs to take them in doses that are likely to help them. That’s a shame, because while these drugs do come with significant concerns, when managed properly, they can be safe and effective aids in a patient’s path to recovery.

For more information about this or any other health-related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination. Also check the website at www.gordon-pharmasave.com/ and the Facebook page at www.facebook.com/GordonPharmasave/?fref=ts