New Treatments for Cancer Pain. Part 6.
The risk for NSAID-induced bleeding is related to their risk for peptic ulcer disease. So your patients who smoke, your patients who drink to excess have a much higher incidence of getting NSAID-induced renal dysfunction or gastrointestinal dysfunction than others.
A word about Tylenol. In a two year period 300 patients were see in 13 major transplant centers who presented with acute liver failure. Now not everyone with acute liver failure makes it into a transplant center. The patients who most often died were patients who were taking Tylenol therapeutically. Not suicide attempts. The most common cause of that renal failure was Tylenol and those who most often died were the patients taking too much, trying to eliminate pain. Did you know that Nyquil has a gram of Tylenol in it? Most of your patients don’t. So they take some Nyquil, they take some aspirin-free Excedrin, they take some Tylenol PM for leg cramps and you give them Vicodin, and since you gave them Vicodin for severe pain they are taking about three times as much as you ordered because that’s the dose that works. So they are throwing down 15, 20 grams of Tylenol. Now the problem is, what the textbooks say about Tylenol toxicity is this, and these are two sentences one right after the other. It says, “Doses of Tylenol above 4 grams a day are implicated with liver toxicity. Reports of toxicity at daily doses below 10 grams are rare.” So the first dose says if you use more than 4 grams a day, you’re wrong. The second dose says, probably ain’t going to hurt. Guess which sentence the lawyer is going to bring out? I mean, if Tylenol were really so toxic that more than 4 grams a day would cause liver toxicity, I would guess that we would all have had a transplant by now.
Ultram is an interesting drug. It’s one drug, two mechanisms which is really unique. One of them is an opiate-like mechanism. The primary mechanism is a serotonin re-uptake inhibition. And it’s an analgesic. Now the serotonin re-uptake inhibiting antidepressants, Prozac and Zoloft and whatever, are not analgesic and cannot be used for the treatment of neuropathic pain. But this drug works slightly differently. Nobody understands it yet – or if they do, I haven’t read it – but this is an analgesic. The advantage is that is does not inhibit prostaglandin synthesis so you can add this into the therapy of your arthritis patients who are very uncomfortable and in whom you cannot increase their NSAID’s anymore. You can add it into the therapy of your fail-back patients, your chronic pelvic pain patients. You can add this into the therapy. Now this is not a great analgesic. As an analgesic it’s about as good as Tylenol with codeine. So you can’t take your patients on Tylox and switch them over to this drug because they are going to hate you. Because it just isn’t that good. It’s indicated for the long-term treatment or the intermediate treatment of moderate pain, or moderately severe pain. The reason it’s indicated for the intermediate or long-term treatment of pain is two-fold. One, it takes several days for it to start working effectively, but two, if you start people out – one tablet four times a day – about 40% of them are going to get distressing side effects. But if you titrate them up slowly – one tablet today, two tomorrow, three the day after and four on Monday – then they will respond much better. There is an indication in the literature that this drug can lower the seizure threshold so you should be cautious in using this drug with other drugs that lower the seizure threshold. Although it’s a tiny risk, I know a lot of people who are on this drug and are on amitriptyline or who are on Prozac who don’t have problems. This drug will not cause a psychological dependence. Absolutely, positively will not. But if the patient has a history or psychological dependence on opiates this drug will reactivate it. So this is not a drug you want to give to the patients who you know are recovering addicts or recovering alcoholics. If they are recovering and they know about this drug, they don’t want to take it.
The antidepressants, these antidepressants, work very well for neuropathic pain which is described as stinging or burning. The anticonvulsants work for the pain that really involves nerve invasion. Most often seen in cancer pain but sometimes seen in acute accidents. This pain the patients describe as “Stabbing” and it’s often accompanies by mild clonic jerks. You have to use therapeutic doses of the anticonvulsants, you have to use significant doses of the antidepressants. Twenty-five mg of Elavil for example, rarely works. Seventy-five works much better.