Handbook for Mortals : Controlling Pain : Choosing the right pain medicine

Over-the-counter medicines

You may have already taken non-prescription, over-the-counter medicines: aspirin, acetaminophen (Tylenol®), ibuprofen (Advil®, Motrin®, etc.), or similar medications. These are the same medications your doctor is likely to suggest for mild pain.

Opioids

If these over-the-counter medications are not relieving your pain, tell your doctor. The doctor needs to know that you are in pain, where the pain is located and how it feels, what medications you have tried and in what doses. Your doctor will probably add a medication called an opioid (sometimes called a "narcotic").

These medications are often given in pills that also contain aspirin or acetaminophen. These combinations of medicines have a synergistic effect - that is, they work together to relieve pain better than either drug could do alone.

For example, people with cancer that has spread to their bones (bone metastases) might try a non-steroidal anti-inflammatory agent (ibuprofen or similar drug) in addition to an opioid. However, these drugs have many side effects and patients should always check with their doctor before taking them. People with a history of stomach ulcers, internal bleeding, or liver or kidney disease are especially prone to side effects.

If these opioids or combination medications do not relieve your pain, or if you are having severe pain, other opioids should be prescribed. Although there are many such medications, the commonly used ones include morphine, oxycodone, hydromorphone, methadone, and fentanyl. One older opioid called meperidine (Demerol®) has too many side effects and too short a period of activity and should rarely be used. If your doctor prescribes any opioid, ask if you should add an over-the-counter medicine to your schedule.

Common opioids

  • Codeine
  • Oxycodone
  • Hydrocodone
  • Morphine
  • Hydromorphone
  • Fentanyl
  • (but avoid meperidine)

Other medications that relieve pain

Pain that starts in the nerves themselves, "neuropathic pain," is best treated with antidepressants and anticonvulsants, often in combination with opioids. These are often used in doses lower than the doses used to treat depression or seizures. However, if someone has neuropathic pain and also has depression or seizures, these medications may be prescribed in traditional doses to treat both conditions at the same time.

Steroids (prednisone, dexamethasone, and others) also help relieve pain when used with opioids. The steroids reduce inflammation that can exert pressure on an already painful area. They also reduce cerebral edema (fluid in the brain tissues) associated with tumors or metastases in the brain, thus improving pain and some neurological symptoms. Steroids can also improve appetite and overall sense of well-being. Side effects of steroids usually depend on the dose and how long someone takes them. Most of the short-term side effects, such as elevated blood sugar, swelling of the legs and arms from fluid, difficulty sleeping, and con-fusion, can be managed. Because steroids can cause stomach ulcers, your doctor might prescribe an anti-ulcer medication whenever steroids are taken.

Finally, when pain is coming from a specific place, but is difficult to manage with the usual medicines, nerve blocks may be performed, usually by an anesthesiologist. A nerve block is performed by injecting the area of the nerve with an anesthetic to keep the nerve from transmitting painful impulses. This is just like anesthesia for dental procedures, but it can be longer lasting. Other nerve blocks can be performed by placing a catheter in one of the spaces around the spinal cord and instilling small amounts of opioids and anesthetics. If such a catheter is placed, a pump may be used to deliver small quantities of medicine continuously to maintain pain relief.

"I am taking opioids. Should I keep taking the medicine I used to take, too?"

If your doctor writes a prescription for a pain medication, ask if you should continue to take your over-the-counter medications. Do not continue to take over-the-counter medications unless your doctor tells you that it is safe to do so.

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Handbook for Mortals book cover Copyright © 1999, 2006 by Joanne Lynn. This extract from the Handbook for Mortals by Joanne Lynn, M.D. and Joan Harrold, M.D. is used with permission. To learn more about improving care at the end of life visit the main web site for Americans for Better Care of the Dying.
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