Getting Adequate Treatment:

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Getting Adequate Treatment:

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The pharmacological treatment of_ pain must follow the principles of treatment

of any condition. The correct medicine must be selected; the proper doses

prescribed; and the risks and side-effects must be carefully monitored and

weighed against the benefits. With pain medications utilized for intractable

pain, the most serious considerations are for excessive sedation, severe

constipation, and underdosage. If the patient is not adequately relieved of the

pain, or is relieved for only a part of the day, the treatment is inadequate.

From among the pain-killing drugs, one must choose a medicine strong enough so

that excessive numbers of pills are not required to accomplish pain relief.

Because of the inclusion of phenacetin in combination oral pain medicines, large

numbers of pills (greater than six to eight a day) should be avoided through the

use of a stronger class of pain reliever. Sustained relief formulations are

preferable to short-acting, to effect sustained relief. In severe pain, fentanyl

patches and morphine-sulfate patches and suppositories, should be considered. In

the most severe cases, in which oral and transdermal routes are inadequate,

implantable pumps and invasive blocks are life-saving. If the pain is

legitimate, it must be treated aggressively and with pharmacological

sophistication.

Consideration must be also given to what has been described as a neuropathic

element in pain, which is thought to arise from direct injury to nerves and

nervous tissue. Probably a factor in all pain, neuropathic pain sometimes

responds to medications which stabilize nervous tissue activity, such as

Neurontin and Depakote. In some cases the patients pain can be relieved by the

addition of these medications, which reduces the amount of opiate-derived

medication required to achieve sustained relief.

Consideration must be also given to what has been described as a neuropathic

element in pain, which is thought to arise from direct injury to nerves and

nervous tissue. Probably a factor in all pain, neuropathic pain sometimes

responds to medications which stabilize nervous tissue activity, such as

Neurontin and Depakote. In some cases the patients pain can be relieved by the

addition of these medications, which reduces the amount of opiate-derived

medication required to achieve sustained relief.

http://www.paincare.org

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Opioid Pain medication:

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These medications are most often used to treat moderate to severe pain, and

they are always prescription medications. Opioids are sometimes combined with

acetaminopen (Percocet) or aspirin (Percodan), for example. These medications

can be taken in a wide variety of ways orally, by patch, rectally, by injection,

transmucosally and are formulated to be long- and short-acting. Almost always,

opioid treatment for pain begins with a low dose, and the dosage is increased

until pain relief is satisfactory to the person in pain. For many people

experiencing pain that is expected to continue, opioids should be administered

on an around-the-clock basis, rather than given only when pain becomes intense.

The around-the-clock approach provides a consistent level of the medication in

the blood, and this helps to provide a fairly consistent level of pain relief,

preventing abrupt peaks and valleys of pain. Additionally opioid formulations

for breakthrough pain probably should be provided.

Side Effects:

Constipation:

Almost without exception, every person using opioid medications on a regular

basis experiences constipation, unless he or she is given information about a

special bowel regimen designed to head off this problem, which can be very

painful. Many pain experts recommend that a bowel regimen be started immediately

when opioid medications are prescribed. People taking these medications should

also drink 8- 10 glasses of water each day, and increase fiber in their diet, if

possible.

Nausea and vomiting:

Some people experience nausea and sometimes vomiting when they begin using

opioids. There are excellent anti-emetic (anti-nausea) prescriptions medications

available today, such as Zofran and Kytirl; ask your health care provider about

using them to combat nausea. For most people, the nausea fades away after taking

the medication for a short period of time.

Sleepiness:

It is not unusual for some people beginning opioids to experience sleepiness

for several days. For most people, this is a temporary side effect, and it is

worthwhile to stay on the medications for a few days to see if the drowsiness

fades away. If the sleepiness is severe, contact your health care provider.

Respiratory depression. A serious side effect of opioids is slow, shallow

breathing. This side effect rarely occurs when opioids are taken as prescribed._

If you have concerns about this side effect, be sure to discuss them with your

health care provider.

http://www.cancer-pain.org/treatments/treatments.html

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Getting the right pain medication:

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It's important to know that there are different types of pain and different

types of medication used to treat pain. Often more than one medication is

necessary to effectively manage pain. For example, many people with chronic pain

also experience intermittent flares of severe pain called breakthrough pain.

These flares of pain are normal and can occur even though a person is taking

analgesic medications on a fixed schedule for pain control. (It's called

breakthrough pain because the pain " breaks through " the regular pain medication

schedule.) Like other pain, breakthrough pain can severely impact a person's

quality of life. Thus, breakthrough pain needs to be treated with the

appropriate medications. Instead of being taken on a fixed schedule,

breakthrough pain medications are taken as needed (i.e., when the pain occurs).

These medications are often referred to as supplemental or " rescue " medications.

Managing pain is not a " one-shot " deal. It may take several tries to get the

right combination of medications. And some medications take time to before they

begin working. Also a person's level of pain may change over time and over the

course of the illness, necessitating a change in medication or the frequency of

medication. Good pain relief should not leave the patient feeling overmedicated.

If the medication stops the pain but leaves the person " in a fog " or unable to

get out of bed, then the medication should be changed or the dosage adjusted. If

your loved one is not experiencing adequate pain relief or is feeling

overmedicated, you should contact his or her doctor or nurse to discuss

adjusting the dose or trying another type of medication.

Barriers to pain management:

Several barriers often stand in the way of good pain management. Some

physicians have not received adequate training in pain management or they may be

more focused on the control the disease rather than control of the pain ( Von

Roenn JH, et al., Ann Intern Med 1993;119 121-6). Another barrier is that pain

may be underreported by the patient or there may be language or cultural

differences. For example, studies have shown that elderly and minority patients

with cancer are less likely than other groups to receive optimum pain relief.

The severity of their pain is more likely to be underestimated by their doctors

( Barnabei R, JAMA;279:1877-82; Cleeland CS, et al., Ann Intern Med

1997;127:813-16). If you think that barriers such as these may be influencing

the expression or treatment of pain in the person you're caring for, initiate a

discussion about pain with the patient and his or her physician. If the patient

is not getting adequate pain relief, you may want to request a consultation with

a pain management specialist.

http://www.cancer-pain.org/caregivers/know.html

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Using Opioids to Control Pain:

Doctors and Patients Are Unnecessarily Cautious about Using Opioids to Treat

Pain

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Most people facing a very serious illness fear dying in pain as much as they

fear death itself. But 95 percent of pain, including the worst pain, can be

controlled. When lesser painkillers fail, morphine and its synthetic cousins

(opioids) should be considered. Patients and American doctors (who should know

better) are unreasonably afraid of opioids. This " opiphobia " is not based on

fact, but is a product of outmoded knowledge and the War on Drugs. Medical

research demonstrates the utility and safety of opioid use for otherwise

untreatable pain. Major medical organizations have created policies and

standards to advise doctors on the findings and resultant practice guidelines. A

recent joint statement by the American Pain Society and the American Academy of

Pain Medicine outlines current goals and standards for the use of opioids in

pain management. Despite this activity at the top of the profession, pain

management in hospitals, nursing homes and doctors' offices in the United States

falls far short of the standard for medical care. Doctors only recently had good

pain management training available to them. They are often very reluctant to use

opioids effectively, even when a patient is dying. Many never even consider

opioids for long-term therapy for non- pain. Very sick patients are entitled to

the best modes of pain control. They, not their doctors, are the best judges of

how much pain they feel and whether a particular mode of pain management is

working. For chronic pain patients the key is whether the medications make them

better able to function in their daily lives than do more frequently dispensed

pain medications. Opioids are not the answer to every pain problem or even every

severe pain problem. They are serious and, if abused, dangerous drugs. However,

every patient should receive consideration of pain that is not clouded by

ignorance or unreasonable fear of particular medications.

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Dispelling the Myths about Opioids:

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Pain patients very rarely become addicted:

An addict is a person who compulsively takes drugs for nonmedicinal purposes.

Addicts will continue to seek out the drugs despite bad effects on their ability

to function in the community, to hold a job, to care for their families and to

maintain social relationships. In contrast, pain patients often take very large

amounts of opioids and other medications to improve their function, but do not

seek out the drug for its own sake or " crave " the medication. Their ability to

work, care for families and live productive lives is improved by their

medications. A recent study demonstrates that fewer than one percent of pain

patients receiving opioids become narcotics abusers. No patient in pain should

hear that relief is barred because " you will become an addict. " No patient in

pain should reject opioids out of fear of becoming addicted. Even former and

current substance abusers can be treated for severe pain by doctors with

experience in the field.

There is a critical difference between " addiction " and " tolerance:

" Tolerance " is a physical event that will always happen when a patient takes

opioids. Tolerance begins with even one dose. This physical fact is not linked

to harmful effects. It means only that, over time, pain patients can be expected

to need higher doses of the medication to obtain the same relief. A patient who

has been receiving opioids for pain over time can tolerate levels that would

kill a person who is " opioid naive " (someone who has not built up any

tolerance). For this reason it is often said that there is no theoretical upper

limit to the amount of opioids than can appropriately be prescribed to control

pain. Careful physicians will monitor dosage closely and increase it when

necessary as tolerance builds to maintain a good effect on pain control.

Moreover, some medications mix opioids and other pain relievers such as aspirin,

acetaminophen and other non- steroidal compounds. A patient taking these

medications will reach a ceiling dose at some point because the other drugs in

the compound are toxic. Some pain relievers, such as Demerol, should not be used

for any extended period because of toxicity.

Confusion between " addiction " and " tolerance " is common even among physicians.

Identification of patients with substance abuse problems is even more difficult.

The best distinction between the two is the patient's ability to function. Pain

patients can expect to improve function with optimal dosages of opioids.

" Dependence " is another physical fact. It refers usually to the need to maintain

opioid levels in a tolerant individual or experience withdrawal. Both addicts

and legitimate pain patients will experience withdrawal if the drug is withdrawn

abruptly.

Until a patient achieves pain relief there is no such thing as " too much "

morphine or other opioids.Pain experts agree that there is no " theoretical upper

limit " for opioid dosages for pain relief. The upper limit is " what works. " It

is important not to assume that high dosages or a large number of prescribed

pills means that the patient is " an addict. " Of course, the doctor must monitor

to make sure that the dose is appropriate for that patient. Morphine and its

derivatives do have side effects. The most frequent is constipation. Most side

effects can be managed. A doctor may have to try a number of pain medications or

combinations of medications to reach the maximum relief with minimum side

effects. Patient and doctor need to work together to reach an appropriate dose

for the patient.

Careful pain management does not kill:

Pain researchers and informed clinicians now agree that morphine, properly

prescribed, does not depress respiration and kill opioid-tolerant patients. Pain

is a powerful antagonist to respiratory depression. (Think, for example of how

your heart beats faster and you breathe more quickly when you're in serious

pain.) The American Pain Society and the American Academy of Pain Management

have concluded in a consensus statement that " respiratory depression induced by

opioids tends to be a short-lived phenomenon, generally occurs only in the

opioid-naive patient, and is antagonized by pain. Therefore, withholding the

appropriate use of opioids from a patient who is experiencing pain on the basis

of respiratory concerns is unwarranted.

" Despite well-documented evidence to the contrary, the fear of respiratory

depression and resulting death permeates medical, legal and ethical discussions

of pain management:

Advocates will have to be educators and should never fall into the trap of

accepting misinformation, however well-intentioned. It is very possible to kill

an opioid-naive patient with opioids. The critical factor is the physician's

intent and his or her adherence to good precepts of pain management.

Pharmacists often err on the side of caution:

Pharmacists are not trained to understand pain control. They have legal

responsibilities under state and federal licensing regimes to refuse to fill

prescriptions they believe are not for appropriate medical purposes. They often

err on the side of caution and refuse to fill any opioid prescriptions, or do so

with exaggerated scrutiny.

A nervous, agitated and upset pain patient may look like an " addict " to them:

Recent studies signal the possibility of racial profiling in filling and

refusing to fill particular prescriptions. Pharmacies in poor inner-city

neighborhoods may refuse to carry opioids because they fear robbery.

Pharmacists' legitimate concerns too often translate into hardship for

legitimate pain patients. Patients should not allow pharmacists to intimidate

them when they submit valid prescriptions to control their pain. Asking the

doctor to intervene should change the pharmacist's approach.

If a pharmacist challenges a prescription, the patient should ask the

pharmacist to call the prescribing doctor immediately. Patients should also

discuss the problem directly with their doctors.

Doctors who have legitimate pain practices should make efforts to work closely

with pharmacies. They should also, with the patient's consent, be willing to put

a note on the prescription showing diagnosis.

http://www.cancer-pain.org/treatments/treatments.html

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Special Procedures:_

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Surgery and other non-medication special procedures are useful tools in the

arsenal of methods to treat some forms of pain._

Special Procedures:

Special procedures is a catch-all term that includes a variety of

pain-relieving methods. Some special procedures used to treat pain include:

Nerve blocks:

_Nerve blocks involve the injection of anesthetic medication into specific

areas of the body where pain is experienced, notably the nerves. Medications

sometimes used for nerve blocks include lidocaine or bupivacaine, used alone or

in combination with corticosteroids._ The effectiveness of nerve blocks is

usually tested by doing what is called a " temporary block " first and if this

brings relief, then a " permanent " nerve block may be performed._ Permanent

blocks are not usually permanent, but may provide three to six months of pain

relief._ There are other types of nerve blocks that can be used to relieve pain

as well.

Non-Drug Approaches:_

hese are methods that can help supplement pain medications and other forms

of pain relief, and are generally not intended to resolve pain all by

themselves.

Heat: Heat can relax muscles and ease spasms, as well as encourage

circulation in the body. Warm packs and heating pads can bring comforting

relief._ Be sure not to apply heat to tumor sites or to areas that have recently

been radiated. Apply heat for 10-20 minutes, then remove it for the same amount

of time before applying again, if needed.

Cold:

Cold, usually in the form of a cold pack wrapped in one or more layers of

cloth to prevent direct contact with the skin, is excellent for reducing

inflammation and can help ease nerve pain. Use cold packs carefully, keeping

them applied to the body for no more than 10-20 minutes at a time, repeating as

needed after rest periods of the same amount of time.

TENS:

TENS stands for transcutaneous electrical nerve stimulation, and it is a

low-voltage current that is transmitted to the body via electrodes placed on the

skin. A portable_battery is the power source. A tingling sensation is felt (and

this is adjustable in intensity, for comfort) and for some people, pain is

reduced where the TENS is applied. A health care professional can instruct you

in placing the electrodes and using the equipment.________

PENS:

PENS stands for percutaneous electrical nerve stimulation, and involves the

insertion of needles into the soft tissue around bones. A low-level current is

passed into the body through the needles, and for some people this helps relieve

the bone pain associated with cancer.

Positioning:

Using orthotic devices can immobilize and support painful or weakened areas

of the body._ Examples of orthotic devices include a splint on a painful limb or

a collar for patients_with neck or back pain. When cancer has weakened bones,

positioning can, in some instances, provide relief.

http://www.cancer-pain.org/treatments/techniques.html

Pain relief is most effective when medications are taken on a fixed schedule

throughout the day, for example every 8 or 12 hours, to achieve

" around-the-clock " pain control with an additional, supplemental dose available

as needed for " breakthrough pain " . Unfortunately, some people will try to take

the medication only when they need it, waiting until they are in pain before

seeking relief. Don't let them wait until the pain comes back: it is more

difficult to regain control of pain than to maintain pain relief.

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Myths and Issues of Narcotic Pain Management:

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" Opioid medications allow us to treat chronic pain as aggressively as we would

any pathogen, but we must first overcome ingrained misconceptions about

patients' motivations for seeking treatment and about the addictive properties

of the drugs. " Brookoff

Short half-life drugs, such as codeine are used for mild to moderate pain.

Hydrocodone or oxycodone are used for moderate to severe pain. Severe pain is

often treated with long-acting sustained-release agents such as morphine,

hydromorphine and levorphanol. Methadone and fentanyl are used for severe

intractable chronic pain, and are usually prescribed by a licensed pain

specialist

Opioid prescriptions can bring up a wide variety of issues for patients and

physicians, including appropriate use versus inappropriate use, drug abuse,

addiction, dependency and tolerance. As an IC patient using opioids as a means

for pain control, it is imperative to understand the underlying issues that face

the chronic pain patient and the medical community.

Appropriate use versus inappropriate use:

An appropriate use of pain medications is to promote functionality in a

patient's life and provide comfort from symptoms so that they can return to work

and fulfill their daily responsibilities. In contrast, if the patient is using

the drugs to escape life, such as family, social and financial problems or using

them for purposes other than those for which it is normally intended, or in a

manner or in quantities other than directed, than that patient is using the

drugs inappropriately.

Addiction:

Drug addiction is a chronic and progressive psychiatric illness, which arises

from the inappropriate and compulsive use of one or more substances that results

in psychological and physical harm. Research has demonstrated that chronic pain

patients rarely become addicts.

" If a physician prescribes a pain medication in good faith for the treatment

of pain, anyone who leaves the practice an addict was already an addict before

treatment " Brookoff " Patients in bad pain don't get high or europhoric.

They use meds to get back into their lives. Patients not in pain, take the meds

to get euphoric. Currrent research demonstrates that the risk for addiction is

minimal for chronic pain patients. " Brookoff

Pseudoaddiction:

" Individuals who have severe, unrelieved pain may become intensely focused on

finding relief for their pain. Sometimes such patients may appear to observers

to be preoccupied with obtaining opioids, but the preoccupation is with finding

relief of pain, rather than using opioids per se. " (1) This is a common behavior

of pain patients receiving inadequate pain medications. In this incident the

patient is seeking pain control by increasing his/her medications without

supervision from his/her medical care provider " ..one type of addiction can

occur and will be caused by physicians. Pseudoaddiction begins with poor pain

management. The patient is given some pain medications, which work for them.

Encouraged, they then ask for more and are met with anger from their medical

care team. The patient becomes angry and the team gets frustrated thinking " you

only want the medicine I don't want to give you. " The team then avoids and

isolates the patient. Isolation is the worst form of suffering of all.. and

leads to a crisis. This disease is caused by medical care providers.. "

Brookoff

Physical Dependence:

In physical dependence, our bodies have adapted to the presence of pain

medications after continued use. When we stop those medications, we may

experience withdrawal symptoms. These symptoms are managed by gradual lessening

of the medication over time.

Tolerance:

Tolerance is a physiologic state resulting from regular use of a drug in which

an increased dosage is needed to produce the same effect, or a reduced effect is

observed with a constant dose.

http://www.ic-network.com/handbook/painmed.html

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Pain Meds-FAQ's:

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I'm afraid that if I use strong pain medicine now, there won't be anything

left to treat my pain later, when it gets worse?

Pain medications don't work like this. Opioids used by themselves do NOT have

a " ceiling " dose, meaning a level beyond which no more medication can be given.

And if one opioid becomes less than satisfactory in providing pain relief,

others may be used, as well as other medications and techniques for pain relief.

There is ALWAYS more that can be done to ease your pain. Don't deprive yourself

of your pain medication because you fear nothing can help later. It just isn't

true.

I've heard that pain medicines will make me sleepy all the time. Is this true?

No. It is true that some people experience drowsiness when they begin taking

opioid medications, but this usually goes away after a few days, after the body

adjusts to the medication. If drowsiness becomes a problem during these first

days, try caffeinated drinks or speak with your health care provider about other

medications that can counteract the drowsiness. If drowsiness persists after

several days or if you're having trouble remaining awake even when you're fully

engaged in conversation or activity, call your physician for assistance.

How can I avoid becoming addicted to my pain medicine?

Addiction is a psychological need for drugs. Pain relief is a physical need,

and that makes an enormous difference in this situation. When you no longer need

your opioid pain medication, your physician or nurse will help you slowly reduce

the amount you are using, all the way to zero, and you will not want to take

this medication any more.

I've tried some drugs for my pain and they haven't really worked well. Is

there anything left for me to try?

There are always more options for pain relief. What medications to try next

will depend on the kind of pain you have, what medications you've tried that

haven't helped enough, and so forth. Seek assistance from your health care

provider for your pain, and, if necessary, ask for and work with a pain

specialist to find the right combination of medications and other techniques for

your situation.

My doctor told me that there is nothing else he can do for my pain. Now what?

You need to find another physician or a pain specialist (a physician or nurse

who specializes in pain management). There is ALWAYS more that can be done to

manage your pain. Never accept the statement that " nothing more can be done " for

pain. Insist on the help you need to find relief.

I can't seem to get on a good schedule for pain medications. I'm supposed to

take my pill every four hours, but sometimes the pain is back before it's time

to take the next pill. What should I do?

Your schedule of medication sounds like it is being administered on an

around-the-clock basis, which is a good choice for people with pain that is

expected to continue or recur. However, the medication you are using does not

sound like it is providing sufficient relief in the dosage you take now. It's

likely that a change is needed, so speak with your physician and ask for a

medication that works more effectively.

I've been told to take my pain medication whenever I need it but sometimes

that means I'm in pain for an hour or more before any relief begins. Is there a

better way?

For pain that is constant, or expected to recur, the best method of

administration is to take the medication on an around-the-clock, scheduled way,

such as a tablet every 6 hours. This means that you'll have a steady level of

medication in your bloodstream, which will help avoid the situation you

describe.

If you are not experiencing constant or frequently-recurring pain, then it

might be helpful to think about activities that appear to trigger your pain,

such as walking or riding in a car, for example. If there is a link between the

pain and something you do, then you can arrange to take the medication in

sufficient time to have sufficient relief in place when you undertake the

activity.

I take my pain medications on an around-the-clock basis, but at times I have

pain anyway. What can I do about this?

The pain you experience is called breakthrough pain, and you probably need a

medication to handle that kind of pain, as well as the pain your

around-the-clock medications are designed to ease. Breakthrough pain can occur

for no obvious reason, or as the result of some activity that seems to trigger

it, such as walking, coughing, etc. Regardless of the reason, it's likely that

you'll need an additional medication to use during these times.

Sometimes I've had difficulty in finding a pharmacy willing to fill my pain

medication prescription. What can I do?

Some pharmacies are reluctant to stock opioid medications, because of a

variety of concerns. Speak with your health care provider or your hospital

social worker or pharmacist to learn the names of pharmacies that stock the

medication you need and arrange to have your prescriptions filled there.

I don't have health insurance that covers my prescription medications for

pain, and I can't afford to pay for them. Is there any way to get help with

this?

Yes. Many pharmaceutical companies have programs to provide prescription

medications to patients who cannot afford to pain for them. Most programs

require your physician to make the contact regarding the medication. There are

two web sites that list companies who offer this assistance:

http://pain.com/top/top_drugassistanceprogram.cfm

http://www.phrma.org/patients/index.html

I take pain medications around the clock, and sometimes this means I have to

wake myself up several times during the night to take a pill. Can this be

handled differently?

Yes, very probably. It may be possible for your health care provider to switch

you to a different form of your medication or to a different medication that is

longer-lasting, one that will allow you to sleep through the night. Speak with

your physician about ways to solve this. Your sleep is very important to all

aspects of cancer management, including pain management.

I'd like to learn more about the pain medications I use. Where can I find

information about them?

The web site of the Pharmaceutical Manufacturers Association has a listing of

more than 500 prescription medications on its Internet Drug List, found at

http://www.rxlist.com.

The site also has information about non- prescription medications.

Additionally, the U.S. Food and Drug Administration has a great deal of

information available on its web site at http://www.fda.gov.

My wife thinks I am taking too much pain medication and sometimes tries to

persuade me to take less. I don't know what to tell her.

It's likely that your wife doesn't know the facts about how cancer pain

medications like opioids really work, and she is concerned for your well-being.

It might be useful to have her read some sections of this web site including the

caregiver's guide herself, so she can learn that it is important for you to take

sufficient medication to relieve your pain, and enjoy a good quality of life.

You may also encourage her to speak about her concerns with your physician,

oncology nurse or pain specialist.

http://www.cancer-pain.org/faqs/faqs.html

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Breakthrough pain:

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Many people with chronic pain experience intermittent flares of pain that can

occur even though a person is taking analgesic medications on a fixed schedule

for pain control. These severe flares of pain are called breakthrough pain

because the pain " breaks through " the regular pain medication. About one-half to

two thirds of patients with chronic cancer-related pain also experience episodes

of breakthrough cancer pain (Portenoy RK and Hagen NA, Pain 1990;41:273-281). .

If you take a prescription pain medicine for pain on a fixed schedule and you

also have occasional flares of intense pain, you may be experiencing

breakthrough pain.

Almost all people experiencing chronic pain should receive pain medications

for around-the- clock pain control AND a medication specifically for treatment

of breakthrough pain. If this has not been offered to you, discuss this with

your health care provider.

The characteristics of breakthrough pain vary from person to person, including

the duration of the breakthrough episode and possible causes. Generally,

breakthrough pain happens fast, and may last anywhere from seconds to minutes to

hours. The average duration of breakthrough pain in one study was 30 minutes

(Portenoy RK and Hagen NA, Pain 1990;41:273-281). . This kind of pain can happen

unexpectedly for no obvious reason, or it may be triggered by a specific

activity, like coughing, moving, or going to the bathroom. Most people who have

breakthrough pain experience several episodes a day.

If you are consistently experiencing pain just before it is time to take your

next dose of medication as part of your around-the-clock pain management plan,

this is not true " breakthrough pain, " but rather an indication that the dose of

the fixed-schedule medication needs to be adjusted.

The ideal medication for breakthrough pain should be easily administered, work

rapidly, and be excreted from the body within a relatively short period of time

(Simmonds MA. Oncology. August 1999). . Most of these medications are opioids.

The route of administration is important to consider; most people prefer oral

medications (that can be taken by mouth) but these are not always fast-acting.

Also, some people may not be able to take an oral drug due to difficulty in

swallowing, nausea or other gastrointestinal problems. Breakthrough pain

medications can be taken in other ways, including by injection, under the tongue

(sublingual), rectally, or transmucosally absorbed in the mouth but not

swallowed.

A new transmucosal drug for the treatment of breakthrough pain is now

available. Called ACTIQ (Oral Transmucosal Fentanyl Citrate), it is the only

analgesic drug to be approved by the Food and Drug Administration specifically

for breakthrough pain, and the first analgesic medication that comes in the form

of a lozenge on a handle. ACTIQ dissolves through the mucus membranes in the

mouth and provides rapid pain relief within 5 to 10 minutes. If one dose is not

sufficient for good pain control, discuss taking a second dose with your health

care provider. Studies show that people find the drug easy to use, effective,

and they tolerate it well. Other opioid medications, notably oxycodone and

hydromorphone, can also be used for breakthrough pain, although these

medications are not available as lozenges.

Cognitive techniques, including relaxation training, hypnosis, imagery, and

distraction may also help relieve breakthrough pain for some people.

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Pain medication delivery:

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Pain medications can be delivered by a number of different methods. The

choices made for each person will depend on the nature of the pain being felt,

and other circumstances of cancer treatment. Also, at any given time, people

with cancer may be using several of these pain medication delivery methods to

manage pain: Pain medications can be delivered by a number of different methods.

The choices made for each person will depend on the nature of the pain being

felt, and other circumstances of cancer treatment. Also, at any given time,

people with cancer may be using several of these pain medication delivery

methods to manage pain:

Oral:

This includes tablets, pills, capsules, and liquids that are meant to be

swallowed.

Oral medications -- and almost all medications are made in this form as well

as others -- are preferred because they are the easiest and most convenient

method. These medications may be short- or long-acting (timed release), and they

enter the gastrointestinal tract immediately.

Oral Transmucosal:

These medication are administered in the mouth but are meant to be absorbed

through the oral mucosa in the mouth--not swallowed. These delivery routes

include the following:

transmucosal - medications in lozenge form are taken this way, notably the

opioid medication used for breakthrough pain, Actiq®, which is a lozenge on

stick that the patient moves around inside his mouth. Saliva dissolves the

medication and it very quickly enters the bloodstream.

sublingual - medications are placed under the tongue and absorbed. The

medication most commonly administered this way is nitroglycerin, in tablet form,

but sometimes certain opioid medications in liquid form are administered

sublingually in people who are unable to swallow medication or who have poor

venous access.

By Injection:

Many pain medications are administered by injection, either because a

particular medication should not be taken by mouth, or because the particular

drug is works best if administered this way. There are three basic ways to

receive medication by injection:

intravenous (IV) - medication enters the bloodstream quickly through a vein.

This is a useful method when a patient cannot swallow oral medications, and

sometimes pain relievers work fastest when injected. Intravenous administration

can also be used over a period of time, when a steady level of pain reliever is

needed. In some cases notably following surgery, PCA - patient-controlled

analgesia - is used. This is a pump system that delivers pain medication and

allows the patient to retain a measure of control over his or her pain

management. When pain is felt or expected (such as when a person moves or

walks), the PCA control button can be pushed, providing an extra dose of

medication.

intramuscular (IM) - a needle with pain medication is injected into a muscle.

This is not often the best choice for administering pain medications because the

drug may not be evenly absorbed into the bloodstream, and because it is

generally a slow approach to pain relief, with at least 30 minutes needed before

the medication begins to work. Additionally, it can be particularly

uncomfortable for patients. If you are routinely given pain medication by

intramuscular injection, ask why, and ask for other options.

subcutaneous (SQ): - a needle with pain medication is inserted just under the

skin into the fatty tissue there, usually in an area of the body where there is

sufficient fat to make this approach minimally painful, such as the abdomen or

the thigh. Some medications should not be taken orally, and in some instances,

the subcutaneous approach is best. Also, if using an intravenous approach is not

desirable or practical, subcutaneous administration is useful.

Transdermal:

Transdermal means " through the skin, " and in cancer pain, this means the use

of a medicated " patch " that is affixed to the skin. The transdermal patch is

designed to deliver medication slowly through the skin for a long period of

time, usually 48 to 72 hours. It is important to know that it takes some time,

sometimes as long as 12 hours, before the patch has reached its full

pain-relieving capacity._ Duragesic®, a transdermal patch that contains the

opioid fentanyl, is commonly used to treat chronic cancer pain, and it is

available in a variety of strengths.

Rectal:

Opioid medications, notably morphine, oxymorphone and hydromorphone, are

sometimes administered through the rectum in patients who are unable to take

pain medications orally. Medications given rectally are administered in the form

of a suppository (a waxy or gelatin capsule that quickly dissolves), or by the

use of a needle-less injection. Rectal administration can provide quick pain

relief but absorbtion in the rectum is variable and so is the amount of pain

relief provided.

Infusion pump:

This method administers pain medications through a catheter near the spine.

The other end is connected to a pump with pain medication that is programmed to

deliver medication over a period of time. These pumps can be placed internally

or externally. Infusion pumps may be an efficient and effective choice if your

cancer-related pain is expected to last for a long time. Discuss this approach

with a pain management specialist. It's important to understand that many people

with cancer will use one or more of these methods to achieve good quality pain

management. Working with your health care provider and discussing your pain

needs is the best way to approach decision-making about which medication

delivery methods are best for you.

http://www.cancer-pain.org/treatments/medication.html

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Adjuvant Medications:

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Some medications originally developed to treat medical conditions other than

cancer have been found to have pain-relieving qualities. These medications --

called " adjuvant " , meaning something that helps or assists -- may be prescribed

for you along with first-line cancer medications, like opioids and NSAIDs, to

treat particular types of pain that sometimes occur in cancer especially bone

pain and nerve pain. They may also be prescribed in combinations together. ____

Some of the more frequently-used adjuvant medications include:

Antidepressants: These are not taken to relieve depression, but because they

may help relieve nerve pain that sometimes develops from cancer treatment._ Some

commonly-prescribed antidepressants in this category include Elavil®, Pamelor®

and Norpramin®._ It's important to understand that antidepressants take time to

become effective, sometimes several weeks. Side effects may include dizziness

and gastrointestinal problems. Antidepressants may also help people cope with

insomnia, and are often recommended to be taken at bedtime.

Anticonvulsants: These drugs, originally developed to help manage seizures,

are helpful in relieving cancer-related neuropathic (nerve) pain. Some

anticonvulsant medications used for cancer pain management include Neurontin®,

Tegretol® and Klonopin®, among others. Side effects can include lowered blood

counts, dizziness, blurred vision, and nausea. Anticonvulsants may take some

time to reach peak effectiveness._ Another medication, baclofen (Lioresol®),

which is not an anticonvulsant, is also effective for some people experiencing

shooting, stabbing and knife-like neuropathic pain.

Corticosteroids: Corticosteroid medications, such as dexamethasone and

prednisone, work effectively to reduce inflammation, thereby helping to ease

some forms of cancer pain. Short-term used of these medications may cause

increased appetite and fluid retention. Long-term use can result in weight gain,

" moon face, " osteoporosis, and other side effects.

Bisphosphonates : These medications help relieve the pain of cancer that has

spread to the bones. Bisphosphonates like Aredia® and Clodronate® are most

commonly used for this purpose.

Calcitonin:_ This medication, Miacalcin®, helps some people in obtaining

relief for bone pain. It is usually administered by nasal spray.

Radiopharmaceuticals : These medications also work to help reduce the pain of

cancer that has spread to the bones. The drugs have few side effects and act on

the cancer while sparing soft tissue throughout the body. The onset of effect is

slow (2 or more weeks) but pain relief from radiopharmaceuticals is usually

relatively long-term ( 3-6 months). Be aware that in some patients,

radiopharmaceuticals may cause a temporary pain increase before it decreases.

Strontium-89 (Metastron®) is a radiopharmaceutical used for pain relief.

Octreotide (Sandostatin®):_ This medication is used to treat the pain of bowel

obstruction, which can occur in the course of some cancers. The medication helps

control severe diarrhea.

http://www.cancer-pain.org/treatments/adjuvant.html

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The myth of addiction:_

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Many cancer patients, as well as some health care professionals, fail to

manage cancer pain well because of needless fears of patient addiction to the

medications that represent the front-line of cancer pain management,

opioids.____ This is an unfortunate situation, not only because it can be the

source of needless suffering, but also because these fears are founded in

ignorance of the FACTS about the use of opioids for cancer pain and the enormous

difference between " addiction " , " physical dependence " and " tolerance. "

Addiction:_

Addiction is a psychological dependence and a compulsion to use drugs for

non-medical purposes other than pain relief._ The key word here is

" psychological. " _ People who are addicted are driven by craving for the

substance, not by physical pain. This craving is physical and emotional, and an

addict needs his drug the meet psychological needs and to get " high. " _ People in

pain want medication to feel relief -- not to feel drugged. A study of patients

with cancer who used opioids to manage their pain reported that of 24,000

patients, only 7 became addicted to their medication_ [Friedman 1990]___

Physical dependence: This describes the result of the use of some medications,

including opioids, on the body of someone who has been taking these medications

for a period of time. One's body adapts to the presence of the medication, and

when the medication is no longer needed, it's necessary and prudent to slowly

taper off the use of these medications, in order to avoid unpleasant physical

side effects like nausea, cramps, restlessness, and more. Your physician or

nurse can provide information on how to do this.____

Tolerance:_

Tolerance is a term health care professionals use to describe the actual

process a person's body undergoes to adapt to using opioids and some other

medications. Over time, in many instances, it is expected that a person will

need to increase the amount of medication taken to achieve the level of pain

relief needed, usually increasing the amounts by small doses at a time.

Tolerance is an expected development, and is readily managed once the medication

is no longer needed, by gradually decreasing the medication levels to zero.

__Some people in pain are reluctant to take opioid medications not only

because of fears of addiction, but also because they fear that taking the

medications will " cloud the mind. " _ This is where the assistance of a health

care professional with knowledge of the use of opioids is very important. These

experts will work with you to find a level of relief and alertness that gives

you the quality of life you want, without depriving you of your ability to work

and live a productive life. ___

Sometimes health care professionals are reluctant to provide cancer patients

and others in pain with opioid medications in sufficient quantities to handle

the pain being experienced. This reluctance is often based in a lack of

understanding about the use of opioids. If your health care provider is not

providing you with appropriate medication, it will become important to find

someone who will do so. One approach in this situation is to ask for the

assistance of a pain care specialist.These are physicians and nurses who

specialize in managing pain, and they will have the knowledge (without the

prejudice against opioids) to provide relief.

Opioids are the most effective medications there are for cancer pain relief.

Don't let ungrounded fears, held by you or by members of your family, keep you

from enjoying the best quality of life possible without pain as a constant and

disabling companion.

http://www.cancer-pain.org/treatments/addiction.html

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First-Line Pain Medications:

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Medications are the cornerstone of pain treatment, and their use is aimed at

providing the greatest pain relief possible with the fewest number of side

effects and the most ease of administration. What medications should be used for

each person, and for each kind of pain that should be treated with medications,

forms the art of effective pain relief.

Medications used for pain are selected by your health care professional to

meet the pain needs you have. For some kinds of pain , non-prescription

medications may be sufficient. For other degrees and kinds of pain, prescription

medications are used.

The following medications may be used, based on the severity of your pain:

Mild pain - For mild pain, acetaminophen or nonsteroidal anti-inflammatory

medications (NSAIDs), such as ibruprofen, are often used._

Mild to Moderate Pain - For mild to moderate pain, when pain relief is not

achieved with acetaminophen or NSAID medications, opioid medications are often

used, usually as combination tablets with NSAIDs or acetaminophen. Some of the

opioid medications used as combination products are hydrocodone, codeine, or

oxycodone. Adjuvant medications may also be used for pain that is difficult to

manage. Adjuvants are medications that were originally designed to treat

conditions other than pain, such as tricyclic antidepressants.

Moderate to Severe Pain - Moderate to severe pain is usually best treated with

higher doses of opioid medications often not given as combination products.

Adjuvant medications, NSAIDs, and acetaminophen may also be used._ The opioid

medications used to treat moderate to severe pain include morphine, fentanyl,

oxycodone, and hydromorphone.

Additionally, breakthrough pain medications are often provided, intended to

deliver quick relief for flares of pain that occur despite the use of other pain

medications. These medications are used only when breakthrough pain occurs and

are intented to provide quick relief. When you begin taking medications for

pain, it's very important to tell your health care providers what other

medications (prescription and over-the-counter) you may be taking to treat other

health-related conditions. You should also discuss any vitamin or mineral

supplements or herbs that you take on a regular basis. Medications can and do

interact, sometimes harmfully -- and this process of full disclosure will reduce

the chances of problems occurring in your pain treatment. It's useful to

understand some basic facts about each kind of medication used for pain, and its

side effects. Remember, side effects should not prevent you from using

medications for your pain. Discuss side effects with your health care provider,

and get assistance in managing these.

NSAIDs (ibuprofen, aspirin, naproxen, acetaminophen):

These medications, available over-the-counter as well as by prescription, do

their work by reducing swelling and inflammation. Some NSAIDs, notably

ibuprofen, aspirin and naproxen, have a greater impact on inflammation than does

acetaminophen. As mentioned above, sometimes NSAIDs are combined with opioids to

fight pain.

Side Effects:

Some NSAID medications can cause gastrointestinal problems, especially

ibuprofen and aspirin. Acetaminophen does not cause this side effect, and the

newest NSAIDs, the COX-2 inhibitors Celebrex and Vioxx, reportedly have a

minimal impact on the gastrointestinal tract. However, it's important to know

that the COX-2 inhibitors have not been tested for cancer pain relief, and are

presently used only to treat arthritis pain. Acetaminophen should not be taken

by people who have three or more alcoholic drinks in the course of 24 hours, as

damage to the liver can result.

If you are taking pain medications that contain NSAIDs, don't take additional

over-the-counter pain medications without discussing this with your physician or

nurse.

http://www.paincare.org/pain_manage...l/adequate.html

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What To Do If Pain Is Not Treated:

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Studies confirm that far too many Americans die in pain in our hospitals and

nursing homes, and that many patients who are not terminally ill suffer

unnecessarily from a painful disease or condition. Physicians have an ethical,

moral and legal obligation to manage pain or to refer the patient to another

doctor who is competent and willing to do so. Nonetheless, reality often

intrudes. This document is a self-help guide for patients and their family,

friends and advocates on what to do when if doctors or nurses refuse to

acknowledge and treat pain.

Patients: Just Say " Ouch! "

Medical experts estimate that doctors can relieve 90 percent of all pain in

terminal illnesses. Hospitals and doctors have access to ample sources of

education, standards and other guidance on how to treat pain and where to get

help if they're stumped. It is unforgivable for patients still to have

undertreated and untreated pain. But they do.

Here are some cases that have come to the Palliative Care Project:

A woman spent 18 agonizing hours before her death with only over-the-counter

Tylenol7 for her pain, despite her family's pleas for a better medication. Her

advance directive specified comfort care and the doctor had specifically assured

the patient and her family that he would manage her care for comfort.

A 74-year-old man was discharged from the ICU to die of congestive heart

failure only 48 hours after his left leg was amputated. His doctor prescribed no

pain medication and family pleas were ignored. The hospital backed the doctor.

Only the family's decision to replace the attending physician summarily with a

more compassionate doctor allowed him to die in peace. That doctor was later

penalized by the hospital.

An elderly man was admitted to the hospital on a Friday night because of

intolerable post-operative pain. He received no pain medication until Monday

morning, although his family and nurses pled for better care. The man died four

days later of a massive stroke that the family believes was induced by stress,

agitation and pain during that long interval.

A doctor confronted with the obvious suffering of a woman dying of cancer

refused to administer pain medication. When asked why, he responded: " I have my

reasons, " and walked away. No pain medication was ever prescribed.These are not

unique experiences. Study after study has confirmed that far too many Americans

die in pain in our hospitals and nursing homes. The same is true for patients

who are not terminally ill, but who have a painful disease or condition. This

year for the first time the organization that accredits American hospitals and

nursing homes is implementing requirements for assessing and treating pain. This

is a big step. Every accredited hospital and nursing home should be working on

meeting these standards even though they won't be " graded " on them until 2002.

Hospitals will have to treat pain like a " fifth vital sign " --as important as

temperature, blood pressure, pulse and respiration. When they find pain, they

must treat it as effectively as possible. Physicians have an ethical, moral, and

legal obligation to manage pain or to assure that the patient is referred to

another doctor who is competent and willing to do so. The American Medical

Association's Ethical Standard E-2.20 states that " Physicians have an obligation

to relieve pain and suffering and to promote the dignity and autonomy of dying

patients in their care. " Nonetheless, reality intrudes. The patient or advocate

will have to play an active and assertive role to protect the patient's right to

good palliative care. It is rarely easy. Doctors are authority figures, upon

whom patients are dependent for their very survival. They can be intimidating,

patronizing and dismissive. If " please " fails, be prepared to press on.

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What You Can Do About Pain:

What to Do If Doctors or Nurses Refuse to Acknowledge and Treat Pain:

quote:

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Beginning at the bedside, you, as a patient's advocate, can take a sequence of

steps to enforce the right to pain management. If the pain is very severe, you

will need to move quickly through the list. Even an hour of severe pain seems to

last forever. Doctors and hospitals or nursing homes can be very intimidating,

but in this situation, doctor does not always know best. A physician can

determine how best to solve the problem, but only the patient can say that the

problem is solved.As you move through the following steps, keep a list of the

people you talk with and what they say. Advocacy while someone you love is in

pain is intensely stressful. Keeping a record will help you stay focused and

will enable you to be accurate if you eventually have to file a formal

complaint, either with the hospital or with an outside agent. Let the attending

physician know that pain management is a priority.

Tell the doctor that you have heard that pain is very often overlooked and

undertreated and ask what his or her plan is for pain management.

By requesting pain management, you are not " telling the doctor how to practice

medicine. " Excuses such as " he'll become an addict " or " morphine will depress

his respiration " or " I'll lose my license " are outdated myths. If the response

to your request is such an excuse, you may not be able to change the doctor's

mind, nor is that your responsibility. You will just have to get busy as an

advocate.

Talk to the nurse. He or she can be an advocate for the patient. Get the nurse

to acknowlege and record the pain. Ask what strategies sometimes work for

patients who are hurting. For example, if the patient is yo-yoing from comfort

to pain because the pain medication is short-acting, the nurse can suggest to

the doctor switching to a longer-acting medication or a patient-controlled pump.

Talk with the head nurse of the unit. He or she has an important

responsibility for quality care. These nurses are generally well-respected in

the hospital. They can " cover " for the patient's nurse and address the doctor

frankly.

Ask for a palliative care consultation. Doctors have an ethical obligation to

consult with a specialist in pain management if they cannot successfully relieve

pain (or will not try). Under the American Medical Association's Ethical

Standard E-8.04, a doctor who cannot adequately treat pain, or whose patient

believes he or she cannot adequately treat pain, is obliged to obtain an outside

consultation. The patient may also ask to be referred to a consultant. Under

Ethical Standard E-8.041, a doctor may not abandon a patient simply because the

patient asks for a second opinion. If your doctor appears insulted by a request

for an outside consultation or delays a referral, you have a problem doctor.

Many hospitals do not yet have a formal palliative care service, but all

hospitals have at least one anesthesiologist. These specialists are trained in

pain management, although their education concentrates more on procedures than

on pharmacological relief of pain. A consultation may be helpful.

Doctors have an ethical obligation to manage pain competently. If the patient

is still in pain, find out what the hospital's procedure is for filing a

patient/family complaint. Write out a short statement that tells management what

the problem is and take a copy directly to the hospital medical director's

office. Be sure to keep a copy.

JCAHO: The Federation of State Medical Boards has a list of the state boards

and JCAHO complaint forms are available online. If the patient's care is paid

for by an HMO, add the state insurance commissioner to your list. .

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has

established and publicized pain assessment and management requirements that will

be part of the organization's review of every accredited hospital and nursing

home. Although the pain management standards are not yet incorporated into

JCAHO's scoring, they will be used in JCAHO's 2001 surveys. Other JCAHO

standards relating to patients' rights also require hospitals to respond to and

resolve patient complaints quickly. Complaints are easily made by writing or

emailing JCAHO. Complaints about nurses who do not respond to requests for pain

care or who do not follow doctors' pain management orders can be made to the

state board that licenses nurses. State nursing boards with active websites

usually post information about making complaints or post a form complaint that

can be submitted on line. The National Council of State Boards of Nursing

provides contact information and website links for nursing licensure in each

state. If the need is immediate, make your complaint first by telephone. But be

sure to follow up with a written complaint that references your initial

telephone report and the name of the state board contact with whom you talked.

Complaints do not have to be elaborate, but a clear summary of the facts

involved is important. Identify the name of the doctor, name of the facility,

patient condition, and efforts already made to resolve the complaint. It is very

important for medical boards to hear about undertreatment of pain. Boards have

been quick to censure doctors for prescribing " too many " opioids. Pain patients,

by and large, have been the losers. They need to understand the flip side.

That time has passed. Clear standards are now available from many sources,

notably JCAHO, the AMA, EPEC and professional specialty boards.

http://www.painlaw.org/nontreatment.html

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Patients' Right to Palliative Care:

Doctors Have a Legal and Ethical Obligation to Treat Pain as Effectively as

Possible

quote:

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The Patient Self Determination Act (PSDA), 42 U.S.C. its implementing

regulations require medical facilities (hospitals, nursing homes and

home-nursing programs) to provide written information to patients about their

rights under state law, including the right to accept or refuse treatment and to

give advance directives. The provider must also document advance directives in

each patient's record, educate the staff and patients about advance directives

and not discriminate in care for or against patients with advance directives.

The statute requires every facility to have and to communicate a policy about

implementing advance directives. If advance directives are violated, these

required policies may be useful to show that the hospital should have made

caregivers aware of advance directives.

Prescribing pain medication properly is not illegal.

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Codes & Principles of Medical Ethics:

quote:

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The medical profession has long subscribed to a body of ethical statements

developed primarily for the benefit of the patient. As a member of this

profession, a physician must recognize responsibility to patients first and

foremost, as well as to society, to other health professionals, and to self. The

following Principles adopted by the American Medical Association are not laws,

but standards of conduct which define the essentials of honorable behavior for

the physician._

Principles of Medical Ethics:_

A physician shall be dedicated to providing competent medical care, with

compassion and respect for human dignity and rights.

______

A physician shall uphold the standards of professionalism, be honest in all

professional interactions, and strive to report physicians deficient in

character or competence, or engaging in fraud or deception, to appropriate

entities.

A physician shall respect the law and also recognize a responsibility to seek

changes in those requirements which are contrary to the best interests of the

patient._

A physician shall respect the rights of patients, colleagues, and other health

professionals, and shall safeguard patient confidences and privacy within the

constraints of the law.

A physician shall continue to study, apply, and advance scientific knowledge,

maintain a commitment to medical education, make relevant information available

to patients, colleagues, and the public, obtain consultation, and use the

talents of other health professionals when indicated._

A physician shall, in the provision of appropriate patient care, except in

emergencies, be free to choose whom to serve, with whom to associate, and the

environment in which to provide medical care.

A physician shall recognize a responsibility to participate in activities

contributing to the improvement of the community and the betterment of public

health._

A physician shall, while caring for a patient, regard responsibility to the

patient as paramount.

A physician shall support access to medical care for all people.

_

http://www.ama-assn.org/ama/pub/category/2512.html

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FAQ's on P.Mgmt:

http://www.addiction-free.com/pain_...diction_faq.htm

Controlled Substances Act http://www.dea.gov/pubs/csa.html

Misunderstood Prescription Drugs and Needless Pain:

http://www.nytimes.com/2002/01/22/h...omy/22BROD.html

I hope this finds you and yours well

Mark E. Armstrong

casca@...

www.top5plus5.com

PAI NW Rep

ICQ #59196115