New Treatments for Cancer Pain. Part 2
The cancer pain guidelines are very similar. Now the chronic pain guidelines are being developed and in many aspects the chronic non-malignant pain guidelines are going to be little different from the cancer pain guidelines. In the pharmacologic use of the drugs there’s practically no differences. But look at the similarities. All mild to moderate pain therapies(soma) should include an NSAID or Tylenol unless it’s contraindicated. Use these as chronic pain guidelines. You add an opioid if pain persists or increases. If the patient is already on an opioid change from a weak one to a strong one, or change from a strong one to more of a strong one. And I never cease to never to just totally not understand the tremendous fear that we seem to have towards opiates. One of my colleagues on the faculty came to me two weeks ago. His wife had developed shingles. Fortunately they are in their 30’s because if they are in their 50’s this would be a horrible problem. She developed ocular shingles and at first they thought the problem she was having was related to her history of Bell’s palsy. But it turns out to be shingles. The shingles were resolved but now she has incredible pain. And this is severe pain. She went to a physician who gave her an NSAID. And NSAID’s don’t work for severe pain. Shingles pain is severe pain. Went back to the physician. The physician gave her Lortab 10. That’s hydrocodone and acetaminophen, 10 milligrams of hydrocodone. And after a week she said it took the edge off a little bit so the physician prescribed her Lortab 5, take two at a time, which is basically the same thing. I told him what the contemporary therapy of shingles is. It’s strong opiate, antidepressant because it’s a neuropathic pain. Went back to the physician. The physician gave them OxyContin which is what I suggested they talk to the physician about. Ten milligram tablets. It probably isn’t enough, but start at this. Ten milligram tablets once a day. They work for 12 hours. The pain is now successfully being treated. Now this is a patient who is never going to be addicted, she’s going to be physically dependent when she finishes the treatment for her herpes, or the secondary pain from the herpes infection that she had. But physical withdrawal from opiates is not a problem. It just is not. Even if we didn’t have Clonidine to block all the symptoms, most patients don’t want to be on opiates anyway.
Chronic pain guidelines say that opioid tolerance and physical dependence do not equate with addiction. They are expected. But they are very easily dealt with in 95% of the people, and why should we brutalize the 95% because of our fear of the 5%? The oral route is preferred. It’s the most convenient. It’s the most cost effective. Rectal and transdermal should be reserved for patients who fail the oral route. This is an unbiased panel. And fail the oral route means that you’ve given them really adequate doses and they can’t absorb it or they can’t remember to take it often enough and it just doesn’t work.
Motrin
Pain is really deadly. Pain can cause a number of horrible problems for our patients. Poor wound healing, muscle weakness, tissue breakdown. In acute painful conditions patients won’t do deep breathing exercises. They won’t move around in bed so they are going to be at increased risk of thromboembolic events. They won’t do deep breathing exercises, they splint, they breathe shallowly so they are at greater risk for atelectasis and pneumonia. A number of other physiologic events occur and there are immunological factors. It decreases NK killer cells activity, causes negative motions, anxiety, depression, sleep deprivation, and over time then pain, especially chronic pain, can lead to tremendous suffering. If you don’t think we should get actively involved in physician-assisted suicide, you are totally in control of that. Now I was a hospice pharmacist for 13 years. And I know that no one wants to live more than people who know that the end is approaching if we can make them comfortable. And you have the resources. Ninety to 95% of painful conditions can be treated by tools that you commonly employ and have available to you. I’m not talking about intrathecal therapy, I’m not talking about epidural therapy, I’m talking about oral drugs that you are capable of prescribing; 90% to 95% of painful conditions.