New Treatments for Cancer Pain. Part 7.
And we are really afraid of opiates. Your neighbors are afraid of opiates. The people you go to church with are afraid of opiates. We can’t change their irrational fears but there is something that I want to suggest to you that will really increase the compliance of your patients in taking the medications you prescribe. Patients are afraid of narcotics. Cocaine – I’d like you think of it this way – from this day forward, marijuana is a narcotic, heroine is a narcotic, cocaine is a narcotic. All the things you prescribe for severe pain are opiates. Opiates are medicine. It works. I know it sounds hokey, but it really does work. Refer to them as opiates. Opiates are medicine. Taking medicine the way your physician prescribes it is called compliance, not drug abuse. And you need to tell them that too. “It’s really important that you follow my advice.”
We have other strong opiates. We have short-acting strong opiates, Dilaudid, Demerol, morphine and OxyContin we have long-acting strong opiates, topical Fentanyl, Levo-Dromoran, methadone, sustained release morphine and sustained release OxyContin.
This is the hierarchy of effect when you give a patient a strong opiate. The only guarantee is constipation. You must have a reflex. You must never write for a strong opiate without writing for a stimulant laxative and a stool softener. Opiates cause constipation by three mechanisms, two of which we can affect with drug therapy. One of the mechanisms that we cannot effect is that it alters enzymatic action in the bowel. I increases the resorption of water from the bowel and it slows motility. So we have to give them a drug that increases water retention in the bowel and a drug that stimulates activity. Analgesia is the second most common event. If I, right this minute, gave each of you a 10 mg dose of opiate, a 10 mg dose of morphine, the most predictable outcome would probably be vomiting, but the most common event would be dysphoria. For patients without pain almost all of them find opiates unpleasant. They don’t make you feel good.
I need to explain to you about opiate potencies because I know, if you have been paying attention at all to what the drug company salesman has been saying, it’s confusing. Because they all have a different story. The FDA, when they assess opiate potencies, they do it very differently than any other drug. They take the super, the little 5% sample. That says the drug is super-potent and they use it. First of all, they don’t want to get screamed at by some senator running for election next year, they want to do no harm and they are absolutely convinced that if it’s not enough you are going to change the dose tomorrow anyway. They don’t know that the patients don’t tell you it’s not working, they increase it on their own or whatever. And the drug companies love this because they do their pricing based upon the cost of the other guys therapy. My proof? When Nalbuphine was introduced, it says Nalbuphine is milligram for milligram as potent as morphine. Well, it is as a sedative, but as an analgesic it takes 1 ½ to 2 times as much. Same thing with Butorphanol. They said 2 mg equals 10. Doesn’t. Takes 3 to 4. When meperidine was introduced it says 50 mg of Demerol equals the analgesic potency of 10 mg of morphine. Wrong. Takes 100. Fentanyl patches are twice as good as Jansen says they are. And Purdue-Frederick is now saying that OxyContin is twice as good as morphine. I don’t think so. I think it’s 1 ½ times.
What I suggest however, is that you use those conservative potencies but understand that on day two you need to get a report back from the patient on how they are doing and adjust the dose based upon t he patient response. Because about 10% or so will respond to those lower doses. About 80% will respond to a higher dose and 10% will need a much higher dose. Remember there’s a 10% over here that needs lower doses, there are people who are going to need higher just because it balances out the human response curve.