Pain Medications for Palliative Care

If you or someone you love has been diagnosed with a life-threatening illness, one of the first things you may wonder about is pain. How much pain are you likely to be in? How will you cope with it? What can your doctors do about it?

The good news is that there is a lot that you and your doctors can do to keep pain at bay. You have multiple options, one of which is medication.

When it comes to medications for pain management, there are two broad categories: opioids, which dull pain systemically, throughout the body; and adjuvant analgesics, or helper medications that can target specific types of pain, often by fighting inflammation.

Opioids

Opioid medications are available only by prescription. There are several opioid drugs that palliative care physicians most commonly prescribe for moderate to severe pain in the context of a serious, life-threatening illness. They are known as opioid analgesics:

  • codeine (only available in generic form)
  • fentanyl (Abstral, Actiq, Duragesic, Fentora, Onsolis)
  • hydrocodone (Hysingla ER, Zohydro ER) 
  • hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)
  • hydromorphone (Dilaudid, Exalgo)
  • meperidine (Demerol)
  • methadone (Dolophine, Methadose)
  • morphine (Kadian, MS Contin, Morphabond)
  • oxycodone (Oxaydo, OxyContin)
  • oxycodone and acetaminophen (Percocet, Roxicet)
  • oxycodone and naloxone

These drugs can be taken in a number of different ways. If the person can swallow, all can be given by mouth. If the person can no longer swallow, some medications can be given intravenously, and some by subcutaneous injection.

There are other options, as well. "With a compounding pharmacist's support, we can mix an opioid with a gel to deliver it topically, through the skin," says Muir. "There are also formulations of fentanyl, for example, that can be delivered by patch or through a cheek film that crosses the mucous membranes in the mouth."

Although opioids are excellent in controlling pain, they do have side effects. Among the most common are:

  • Constipation . This is the one you can't get around. Most people who take an opioid experience some degree of constipation, and it doesn't tend to go away as your body gets accustomed to the medication. But as a preventive measure, regularly taking a stool softener and laxative can keep most constipation under control. Also, the drugs lubiprostone (Amitiza), methylnaltrexone (Relistor), naldemedine (Symproic), and naloxegol (Movantik) are approved to treat constipation specifically due to opioid use in those with chronic pain not caused by cancer.
  • Nausea . Nausea is a common side effect of opioid medications. About 30% of people get nauseated as a result of taking opioids. Most of the nausea is from the drugs' slowing effect on the bowels. If you keep the bowels moving, you're less likely to be nauseated. In many cases, the nausea induced by opioid medications will abate after a few days on a new drug. If not, there are also other medications that palliative care specialists can prescribe to help with nausea.
  • Extreme sedation: Confusion, Sleepiness, and Breathing Problems. Many people worry about becoming mentally foggy or constantly sleepy when on medication for chronic pain. Sedation commonly occurs when first initiating an opioid medication. The sedation usually improves and often resolves in 3 to 4 days unless the dosage of the opioid medication is too high.

 

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Adjuvant Analgesics

One way to use opioids while minimizing side effects is to combine them with the broad category of adjuvant analgesics, or "helper medications."

In addition to opioids, there are a number of other helper medications that palliative care specialists use to help control pain. They include:

  • Non-steroidal anti-inflammatory drugs (NSAIDS)
  • Steroids
  • Tricyclic antidepressant medications
  • Serotonin and norepinephrine reuptake inhibitor antidepressant medications (SNRIs)
  • Anticonvulsant medications

These drugs are particularly helpful for people who are experiencing bone or nerve pain.

Bone Pain

There are many causes for bone pain in life-threatening illness, including cancer metastases to the bone and compression of bones in the spine from degenerative bone disease or damage from long-term use of steroids to treat a condition like lung disease.

Using anti-inflammatory adjuvants -- even something as simple as ibuprofen, or something stronger such as a corticosteroid -- can lessen bone pain.

Nerve Pain

Nerve pain, or "neuropathic" pain occurs when one or more nerves is injured or damaged. It can develop as a result of long-term chemotherapy or cancer itself, trauma, or other medical disorders.

AIDS, diabetes, and shingles are examples of diseases often associated with neuropathic pain.

Tricyclic antidepressants and anti-seizure medications can each lessen nerve pain because they change the way pain sensations travel to the brain.

You may have to try several different medications, or different combinations of medications, to find the ones that are right for you or your loved one. A good palliative care team can help to identify the most effective drugs and minimize side effects.

WebMD Medical Reference Reviewed by Melinda Ratini, DO, MS on November 01, 2017

Sources

SOURCES:

J. Cameron Muir, MD, executive vice president for quality and access, Capital Caring, Washington, D.C .

National Institute of Neurological Disorders and Stroke, Bethesda, MD.

Peripheral Neuropathy Fact Sheet, National Institute of Neurological Disorders and Stroke.

News release, FDA.

Medscape. “FDA Okays Naldemedine (Symproic) for Opioid Constipation.”

National Institutes of Health: "Drug Interactions of Clinical Importance among the Opioids, Methadone and Buprenorphine, and other Frequently Prescribed Medications: A Review."

Medline Plus: "Oxycodone." "Fentanyl." "Hydrocodone." "Hydrocodone Combination Products." "Hydromorphone." "Methadone."
 

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