Ask the Pharmacist
by Ron & Marla Chapleau

February 5, 2017


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Q) I have been recently diagnosed with cancer and have been told to eventually expect a significant amount of pain. My oncologist thinks I should have some narcotic pain killers available just in case, but with everything I read about all of the overdoses, Iím a little nervous to use them. What should I do?

A) With the recent spike in overdoses throughout Canada and the press reports indicating Canada, and specifically Ontario, are amongst the highest users of narcotics in the world, there has been a great amount of scrutiny brought upon the prescribing of opioids that is well overdue.

However, it would not just be naÔve but downright foolish to think the treatment of all types of pain can be conducted effectively and humanely without the use of these pain killers. One such example of a situation where narcotics will continue to play an important role is in the treatment of cancer pain.

Now, that is not to say that all types of cancer involve significant pain. For many, pain can range from a non-issue to a minor one and for this level your traditional pain killers such as acetaminophen or an anti-inflammatory like naproxen or ibuprofen may well be sufficient. But unfortunately, over half of cancers do involve degrees of pain that can vary from moderate to severe and for which the previously mentioned drugs are unlikely to be adequate on their own.

The adequate management of pain is critical to patients going through cancer treatment as poorly controlled pain can lead to all sorts of complications such as inadequate sleep or nutrition, both of which are associated with poorer prognosisís. Pain from cancer can be a result of a number of different causes.

First off, there is the pain of the tumor itself as it grows and pushes on the various tissues that surround it. Then, unfortunately, there is the pain that may occur from the various treatment regimens we utilize in our attempts to eradicate the cancerous cells.

Pain resulting from treatment can include that from the effects of surgery, from the infusion of chemotherapy into your circulatory system, from the potentially burning effects of radiation, sores that develop within your mouth (mucositis) or the damage to your bones that may be caused by the use of high dose corticosteroids or biphosphonates.

The first step in treatment of the pain is to get a detailed description of it: where is it occurring, what does it feel like (throbbing, stabbingÖ), is it constant or only occasionally and what triggers it if anything. Itís also important to get an indication as to how severe the pain is.

Most clinicians like to rate it on a scale of 10. For most patients who rate their pain from 1-3, over the counter pain medicines such as acetaminophen and supportive care have an excellent chance of relieving the discomfort. For those who assess their pain at a higher level, the use of opioids is likely to be necessary. Initially a low dose of a short and quick acting narcotic such as hydromorphone or morphine should be tried in patients for whom narcotics are considered a sound therapeutic option.

If pain is intermittent, the dose is increased as needed until relief is achieved. If pain is continuous, once an effective amount of the initial short acting pain killer has been determined, it is usually a wise course of action to convert this does to lower amount of a long acting narcotic. The logic behind this step is two-fold. One is to improve the duration of sleep. Most short acting pain killers last 4 hours or less. As such, the return of pain throughout the night causes major impairments to sleep quality and a host of other problems can arise from that.

Secondly, once again due to their short duration, pain will continually reoccur throughout the day as the dose wears off every couple of hours leading to a level of anxiety about its return that can be both problematic for mental health as well as detrimental to oneís innate pain tolerance.

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Once a long-acting pain killer has been established, the cancer patient should still have some of their initial short-acting pain killer available for breakthrough pain. Keep in mind that pain is rarely static for long so that doses can and should be adjusted up or down depending on the need. There is no such thing as a maximum dose for narcotics. As long as they are slowly increased, they can be increased to very high levels although it is rare for doses of over 300mg of morphine (or its equivalent in other narcotics) to be necessary.

Dosing however can be limited by the side effects that narcotics produce in their users. These can include sedation, nausea, vomiting, itchiness, physical dependence, respiratory depression and of course constipation.

While many of those listed here get better on their own, constipation is frequently a real challenge for many. Most experts suggest starting a laxative such as PEG 3350 or Senokot upon initiation of opioid therapy in an attempt to prevent this uncomfortable adverse event from even getting started.

As well, while opioids are an important part of the tool chest for controlling cancer pain there are a variety of other treatments that can be added to them or perhaps in some cases even replace them.

These include a number of creams that are very effective for radiation burns (Glaaxo base is both inexpensive and highly recommended as well as there are a number of specialty creams we have compounded with great success for a few of our patients over the years), a few compounded liquids that are collectively known as ďmagicĒ mouthwashes that can greatly relieve mucositis, corticosteroids for bone pain and a bevy of drugs that reduce the burning and tingling of neuropathic pain.

With so many options out there, the vast majority of cancer patients should be able to have their pain relatively well controlled. In fact, many of our biggest pain control issues occur because some of our cancer patients are too leery of these drugs to take them in doses that are likely to help them. Thatís a shame, because while these drugs do come with significant concerns, when managed properly, they can be safe and effective aids in a patientís path to recovery.


For more information about this or any other health related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination in Port Elgin and Kincardine.

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