New Treatments for Cancer Pain. Part 8.
Just some real quick characteristics about the drugs that I think will help your patients. First of all, I know – remember what I showed you on that chart – that Tylenol is better than codeine. I know your most common prescription is Tylenol number 3, one or two every four to six hours p.r.n. pain. Now the fact is, the drug only works for four hours but when you have pain and you take Tylenol, do you ever take one? Doesn’t work does it. You have under-dosed the best drug in the combination when you tell a patient to take one T3. Now I don’t want to suggest that you change your prescribing practices, because I know you can’t – I’ve been around awhile – but what I suggest is that next time you write that order you tell the patient, “When you decide just to take one, take a plain Tylenol with it.” It will work much better, it really does.
Hydrocodone: you’ve heard me take a couple of shots at Vicodin. Now Vicodin is an excellent drug, it really is. Vicodin now is combined with ibuprofen and Vicoprofen. These are real good analgesics. If was going to take something like that I would much prefer to take Vicodin than Tylenol with codeine because I think it’s a much better analgesic. The problem is that physicians as a group – I’m not talking about you individually – are afraid to write schedule II prescriptions. You are. You will go through all kinds of mental gymnastics to convince yourself that you can write a schedule III or that the patient doesn’t need a schedule II. With severe herpes pain, you can’t treat it with a moderate analgesic. So what happens is you write Vicodin when the patient needed morphine or oxycodone. The patient takes the Vicodin, it takes the edge off but they still hurt a lot. They now have two choices: follow your directions or double the dose. You want to guess what they are going to do? They are going to do what you would do if it was your pain. So now you’ve got a patient taking two Vicodin ES every four hours – there’s 750 mg of Tylenol in a Vicodin ES – so two times six, times 750 is 9 grams of Tylenol a day. That’s the problem with these hydrocodone products. They are a wonderful drug but only for moderate pain. For severe pain you’ve got to use strong opiates.
Methadone is a great analgesic. Tricky to use. We used to use it a lot for cancer pain before we had the controlled release forms of morphine available. We seldom use it now, in fact, most teaching hospitals avoid it like the plague because it’s so tricky to use and the residents can’t figure out the complex dosage reductions that have to be done to keep patients out of trouble. So we just don’t use it very much. If you use it in your practice then you understand how to use it. It’s advantage is it’s cheap. But understand that if you are using it, that the patient’s methadone half life is roughly equal to their age in years. And that’s a pretty accurate statement about methadone. The patient’s methadone half life is roughly equal to their age in years. So if you are giving it to me and we start out today, I’ll reach steady state in about 300 hours. Which is May something. Really.
This is the problem with meperidine. At therapeutic doses it’s toxic. The therapeutic dose of meperidine, the amount designed to relive severe acute pain, in 2/3 of the instances is 100 mg every three hours. The drug only works for three hours. I know – unless you are really unusual – if you write meperidine you write 50 to 75 mg every four to six hours p.r.n. pain. If the patient starts asking for it every three hours, the nurse comes to you and says, “He really likes this stuff” and so you cut the size of the order. But the therapeutic dose is 100 mg and it only works for three hours. So the problem is that that dose is toxic. At safe doses it’s relatively ineffective. It’s not what you want to have to treat your pain. Now I will make a confession. My chart says, “Allergic to Demerol.” I’m not. Now that’s not a problem here because the people who provide care here – if we are going to prescribe severe stuff for severe pain – they let me do it my way.
Levo-Dromoran is a good drug. We don’t use it that much anymore because we have sustained release products. Oxycodone, the opiate in Tylox and Percocet, Percodan, is really good. Again, if you are using those products use enough peripheral analgesic. There’s only 300 mg acetaminophen in a Percocet. There’s only 225 aspirin in a Percodan. We have a controlled release product available now, OxyContin, which is really good for chronic non-malignant pain because it doesn’t have a distribution phase. The drug has two release characteristics and its level looks like this, so it’s not a lot of fun to take.
Morphine is the gold standard. This is what we measure everything else against. The sustained release products are called the most effective and cost effective therapy.
New Treatments for Cancer Pain