New Treatments for Cancer Pain
With drugs there’s only three things we can do to treat pain: we can modify mechanisms at the source of the pain – and that’s what we do when we use Tylenol, NSAID’s – we can alter transmission to the central nervous system with a local nerve block, a local anesthetic. In the case of neuropathic pain, that’s what we do with we give antidepressants or anticonvulsants, or we can alter central perception. That’s what opiates do. They don’t block pain, they alter it. I learned that years ago talking to a cancer patient who I’d gotten very close to. She told me that she still felt something where she used to feel pain but it just wasn’t pain anymore. It wasn’t that there was no sensation but it just isn’t pain anymore. In complex pain states we can do all three. A polypharmacy for the treatment of complex pain is good if you do it intelligently. Having a patient on amitriptyline, Motrin and morphine is very sensible. Having a patient on Tylenol with codeine, Tylenol with Vicodin, fentanyl patch and MS Contin is kind of silly. It indicates to the whole world that you don’t have a clue what you are doing and the patient should try to figure it out for themselves.
We have a couple of guidelines that are really interesting. These guidelines are health policy statements developed by Health Care and Human Services but unlike most things that the Federal Government does, these were developed by clinicians. These were developed by clinicians, most of them physicians and the acute pain guidelines and the chronic pain guidelines have some interesting similarities. The acute pain guidelines say that NSAID’s should be used around the clock for all moderate pain unless it’s contraindicated. Now I know, unless you are really unusual, you use NSAID’s p.r.n. Because that’s how you write them. But think about that for a minute. When you are treating an acute painful condition and the patient comes to you and you make the decision to use an NSAID, that process is as bad as it’s likely to get right then. These drugs work by slowing down a biochemical cascade and it doesn’t make a lot of sense to slow that cascade down every now and then. Especially since most of your patients are afraid of medicine. They really are. They aren’t hot drug takers. They are scared to death of medicine. So what you should do is tell them to take it around the clock – every four hours, every six hours, every 12 hours depending on what you’re taking – for x number of days. And you determine what x is. That’s the time when you think this condition should start resolving. When you do that they’ll get the benefit of the analgesia and the antiinflammatory effect of that drug and they’ll do much better. Then, after x number of days have passed, they can start taking it p.r.n. The acute guideline said that strong opiates such as morphine is what we should use for severe pain. Not Vicodin. Morphine or other strong opiates. They said that Dilaudid is the best morphine alternative. They may not say that now. I think that OxyContin would have replaced that now. But meperidine use is to be avoided except for brief courses – one or two days – in young otherwise healthy patients. It really irritated me when I figured out that they thought young was 40 and under.