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How to choose a prescription pain relievers

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Posted on Wed, 27 February 2008 at 11:35 pm
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What Are the Different Kinds of Prescription Pain Relievers?

For many years, the most widely used prescription pain relievers have been narcotics. Narcotics are drugs that relieve pain and cause drowsiness or sleep. In addition, they all have similar side effects. Historically, these drugs came from the opium poppy. They are also called opioids or opiates. Today, many narcotics are synthetic, that is, they are chemicals manufactured by drug companies. Frequently used opioid pain relievers include the following:

Oxycodone

1. With additive pain relievers.

with aspirin - (Percodan, Endodan, Roxiprin)
with paracetamol/acetaminophen - (Percocet, Endocet, Roxicet, Tylox)
with ibuprofen - (Combunox)

2. Without additive pain relievers.

Timed release - OxyContin, RoxiContin.
Immediate release - Endone, OxyIR, OxyNorm, Percolone, OxyFAST, Supeudol, and Roxicodone.

Oxynorm is also available in liquid form (some countries only) 10mg/ml in 100ml bottles.
OxyNorm is also available as a liquid in a 1mg/1ml in a 250ml bottle.
OxyNorm is available in 5mg, 10mg and 20mg gelcaps.
Roxicodone is available in 20, 40 and 80mg pills.
Oxycontin is available in 10, 20, 30, 40, 45, 60, 80 and 160mg pills. (although note that not all of these dosages are marketed in the USA)

Oxycodone is available in various salt forms around the world including: phosphate, sulphate, pectinate, tartrate, bitartrate, citrate and iodide.

Hydrocodone

Marketed as Vicodin, Anexsia, Dicodid, Hycodan (or generically Hydromet), Hycomine, Lorcet, Lortab, Norco, Novahistex, Hydroco, Tussionex, Vicoprofen, Xodol, Bekadid, Calmodid, Codinovo, Duodin, Kolikodol, Orthoxycol, Mercodinone, Synkonin, Norgan, Hydrokon.

Those containing less than or equal to 15 mg per dosage unit in combination with acetaminophen or another non-controlled drug are called hydrocodone compounds and are considered Schedule III drugs. Hydrocodone is typically found in combination with other drugs such as paracetamol (acetaminophen), aspirin, ibuprofen and homatropine methylbromide.

Oxymorphone

Markred as Opana, Numorphan

Opana is available as 5 mg and 10 mg pills
Opana ER, an extended-release form of oxymorphone, is available as pills in strengths of 5 mg, 10 mg, 20 mg, and 40 mg.
Hydromorphone

Marked as Dilaudid, Hydal, Sophidone, Hydrostat, Hydromorfan, Hydromorphan, Laudicon, Hymorphan, Palladone

An extended-release version of Palladone called Palladone SR was available for a short time in the United States withdrawn from the market after an FDA advisory released in July 2005.

  • Tablets (Pills) - 0.5mg, 1mg, 2mg, 3mg, 4mg, 8mg
  • Capsules (Palladone) - 1.3mg, 2.6mg
  • Modified Release capsules (Palladone SR) - 2mg, 4mg, 8mg, 16mg, 24mg, 30mg, 32mg
  • Controlled Release capsules (Hydromorph Contin) - 3mg, 6mg, 12mg, 18mg, 24mg, 30mg
  • Suppository - 3mg, 5mg
  • Powder for injection - 250 mg (hydromorphone HCl)
  • Oral liquid (HCl) - 1 mg/mL (480 mL)
  • Cough Syrup - 1 mg/5 ml
  • Injection (HCl) - 1 mg/mL (1 mL), 2 mg/mL (1 mL, 20 mL), 4 mg/mL (1 mL)
  • Dilaudid-HP - 10 mg/ml (1 mL, 5mL, 50mL)

Fentanyl

The pharmaceutical industry has developed several analogues of Fentanyl:

  • Alfentanil (trade name Alfenta), an ultra-short acting (5-10 minutes) analgesic,
  • Sufentanil (trade name Sufenta), a potent analgesic (5 to 10 times more potent than fentanyl) for use in heart surgery.
  • Remifentanil (trade name Ultiva), currently the shortest acting opioid, has the benefit of rapid offset, even after prolonged infusions.
  • Carfentanil (trade name Wildnil) is an analogue of fentanyl with an analgesic potency 10,000 times that of morphine and is used in veterinary practice to immobilize certain large animals such as elephants.

Dihydrocodeine

Dihydrocodeine, also called DHC, Drocode, Paracodeine and Parzone and by the brand names of Synalgos DC, Panlor DC, Panlor SS, SS Bron, Drocode, Paracodin, Codidol, Didor Continus, Dicogesic, Codhydrine, Dekacodin, DH-Codeine, Didrate, Dihydrin, Hydrocodin, Nadeine, Novicodin, Rapacodin, Rikodeine, Fortuss, Remedeine, Dico, and DF-118

For use against pain, dihydrocodeine is usually formulated as pills or capsules containing a quarter grain (15 or 16 mg) or a half grain (30 or 32 mg) with or without other active ingredients such as aspirin, paracetamol, ibuprofen, or others. The usual dose is one tablet taken every 4-6 hours when necessary.

Controlled-release dihydrocodeine is available for both pain and coughing as indicated below as waxy pills containing 60 to 120 mg of the drug, and some formulations intended for use against coughing and the like have other active ingredients such as antihistamines, decongestants and others. Generally, the starting dose would be 60 mg every 12 hours.

Other oral formulations such as packets of effervescent powder, sublingual drops, elixirs and the like are also available in many places.

Injectable dihydrocodeine is most often given as a deep subcutaneous shot.

The above doses are typical starting doses for “opioid na?ve” patients.

Dihydromorphine

Marked as Paramorfan, DHM, Paramorphan

Dihydromorphine is available as pills for oral use, ampoules of solution for injection by various routes, suppositories, and liquids for oral and sublingual use.

Nicomorphine

Marked as Vilan, Subellan, Gevilan, MorZet

It is a strong opioid agonist analgesic two to three times as potent as morphine with a side effect profile similar to that of dihydromorphine, morphine, and diamorphine.

Morphine

Morphine relieves moderate to severe pain. Morphine may also be used to treat pain associated with cancer, heart attacks, sickle cell disease and other medical conditions. This type of morphine is for people who need pain medicine for more than a few days. These capsules and tablets are especially designed to release morphine over a period of time. Do not share this medicine with anyone else.

Generic Available
Excludes capsule, controlled release pills, sustained release pills, extended release liposomal suspension for injection

U.S. Brand Names
Astramorph/PF, Avinza, DepoDur, Duramorph, Infumorph, Kadian, MS Contin, MSIR, Oramorph SR, RMS, Roxanol, Roxanol 100, Roxanol-T

Canadian Brand Names
Kadian, M-Eslon, Morphine HP, Morphine LP Epidural, M.O.S.-Sulfate, MS Contin, MS-IR, PMS-Morphine Sulfate SR, ratio-Morphine SR, Statex

Codeine

Codeine (INN) or methylmorphine is an opiate used for its analgesic, antitussive and antidiarrheal properties. It is marketed as the salts codeine sulfate and codeine phosphate. Codeine hydrochloride is more commonly marketed in continental Europe and other regions.

Dosage should be adjusted according to the severity of the pain and the response of the patient. It may occasionally be necessary to exceed the usual dosage recommended below in cases of more severe pain or in those patients who have become tolerant to the analgesic effect of narcotics. Codeine pills are given orally. The usual adult dose is 15 to 60 mg every 4 hours as needed.

Pethidine

Isonipecaine, Lidol, Pethanol, Piridosal, Algil, Alodan, Centralgin, Demerol, Dispadol, Dolantin, Petidin, Dolargan, Dolestine, Dolosal, Dolsin, Mefedina more commonly known as meperidine or by its brand name Demerol.

Pethidine is indicated for the treatment of moderate to severe pain, and is delivered as its hydrochloride salt in tablets, as a syrup, or by intramuscular or intravenous injection.

Withdrawn from use in a lot of countries because extreme side effects when compared to newer and readily available opiate synths.

[NOTE] It seems that Europe, especially germanic speaking countries, have access to most of the larger dosage (and in some opinions just downright BETTER) opiates. There have been a lot of restrictions on opiate drugs and dosages in a fair number of English speaking countries. An example would be America. One can go to a doctor in America and get Vicodin or an Oxycodone fairly easily depending on what state they are in but in most states there is no OTC codeine. Whereas in Australia OTC codeine is common place but getting Vicodin is unheard of and getting Oxycodone is fairly hard in some cases (although easy in others). Interestingly enough One can be prescribed real Heroin in Switzerland. Instead of the methadone program they decided to go with providing their own Heroin to already known and registered Addicts. This eliminated a fair amount of the street use and drug trade there and the majority of the people on this Heroin program are now “productive members of society” (going to work every day etc etc) and are no longer a government statistic. So it seems again that Europe has a far “looser” policy towards opiates/opioids than any other region. Also interestinly enough, if one reads enough data, one will find that most of these analogues were “first made by German scientist Dr BlahBlah in 1905″ or whatever. One wonders if there is some sort of coincidence here . . .

You can get these pain relievers only with a doctor’s written prescription. They may be taken by mouth (orally or PO), by injection (intramuscularly or IM), through a vein (intravenously or IV), or by rectal suppository. There are also other methods of giving pain medicines for more continuous pain relief. Not all narcotics are available in each of these forms. Another group of prescription pain relievers is similar to ibuprofen (in large doses, ibuprofen requires a prescription). They are called nonsteroidal anti-inflammatory drugs (NSAIDs). Included in this group of pain relievers are Motrin, Naprosyn, Nalfon, and Trilisate. They are useful for moderate to severe pain. They may be especially helpful in treating the pain of bone metastasis. Because NSAlDs are not narcotics, their use does not result in drug tolerance or physical dependence. These drugs are used alone or with nonprescription pain relievers to treat moderate to severe pain. Some are more effective than others in relieving severe pain.

What about Tramadol?
Tramadol is not a true opiate. It does not meet the requirements for being an opiate / opioid via the real definition. Here is a quick definition of what is required of an opiate.

Sigh… while tramadol’s affinity to mu-opioid receptors is negligible, its main metabolite O-desmethyltramadol has significant opioid activity.

If one would not consider tramadol an opioid (because it has virtually no mu-opioid affinity per se), then codeine would not even be an opiate, because by itself it is has negligible affinity to opioid receptors and would thus be an “inactive” compound in popy.

Tramadol is used medically in single doses of 50 or 100 mg, most commonly 200 mg per day. Up to 400 mg per 24h are allowed to be consumed medically.
Recreational doses start in the 150 mg range (with no opiate tolerance).

How Do I Decide Which Pain Medications To Use?

This is not something you should decide alone. Discuss this with your doctor, nurse, or pharmacist before you use any drugs for pain. Medications that worked for you in the past or that helped a friend or relative may not be right for you at this time. Never take someone else’s medicine! Only one doctor should prescribe your pain medicine. If a consulting doctor changes your medicine, be sure the two doctors discuss your treatment. Otherwise, you may take too much or too little. Let your doctor or nurse know whether your pain medication gives you relief. Work together to find the medication or pain-relief program that is best for you. Remember, your need for pain medicine may change as your cancer treatment changes. It is important to record the name and amount of pain medication you take. You can then give precise information to the doctor or nurse about its effect on your pain.

Will I Become Addicted if I Use Narcotics for Pain Relief?

No. Narcotic addiction is defined as dependence on the regular use of narcotics to satisfy physical, emotional, and psychological needs rather than for medical reasons. Pain relief is a medical reason for taking narcotics. Therefore, if you take narcotics to relieve your pain, you are not an “addict,” no matter how much or how often you take narcotic medicines. If you and your doctor decide that narcotics are a proper choice for your pain relief, use them as directed. Addiction is a very common fear of people who take narcotics for pain relief. Narcotic addiction is an emotionally charged subject. You may hear people use the term “addiction” very loosely without understanding exactly what it means - the compulsive use of habit-forming drugs for their pleasurable effects. Drug addiction in cancer patients is rare. Generally, when narcotics are used under proper medical supervision the chance of addiction is very small. Most patients who take narcotics for pain relief can stop taking these drugs if their pain can be controlled by other means. It is important to remember that if narcotics are the only effective way to relieve pain, the patient’s comfort is more important than any possibility of addiction. If you take narcotics for several weeks or more, be prepared for someone to express a concern about addiction. Most people with prolonged pain who take narcotics have faced this problem. Remind yourself that other people’s concerns about addiction are often due to lack of information. If you have concerns about addiction, share them with those who are caring for you. These fears should not prevent you from using narcotics to effectively relieve your pain.

What Is Drug Tolerance?

When certain drugs are taken regularly for a length of time, the body doesn’t respond to them as well as it once did, and the drugs at a fixed dose become less effective. Larger or more frequent doses must be taken to obtain the effect that was achieved with the original dose. People who take narcotics for pain control sometimes find that over time they will need to take larger doses. This either may be due to an increase in the pain or the development of drug tolerance. Increasing the doses of narcotics to relieve increasing pain or to overcome drug tolerance is not addiction.

Can Taking Narcotics Be Dangerous?

All medicines can be dangerous if they are not taken properly. The risks of improperly taking narcotics include overdose, drug interactions, and accidents resulting from drowsiness.

Overdose: Too large a dose of a narcotic may cause breathing to slow down or stop (respiratory depression). Doses required for good pain relief are rarely, if ever, large enough to cause death. Doctors carefully adjust the doses of narcotic pain relievers so that pain is relieved with little effect on breathing. You may have heard of addicts dying from narcotic overdose. This usually is due to taking the narcotic with other drugs that interact with it, or to taking a much higher dose than would be necessary for pain relief, or to impurities in illegally obtained narcotics. The first sign of narcotic overdose is a feeling of unusual sleepiness or difficulty in waking up. If you have either of these problems, someone should contact your doctor or nurse as soon as possible.

Drug Interactions: Combinations of narcotics, alcohol, and tranquilizers can be dangerous. If you drink alcohol or if you take tranquilizers, sleeping aids, antidepressants, antihistamines, or any other drugs that make you sleepy, tell your doctor how much and how often. Even small doses might cause problems. The use of alcohol or any of these drugs with narcotics can lead to overdose symptoms such as weakness, difficulty in breathing, confusion, anxiety, or more severe drowsiness or dizziness. These drug interactions may result in unconsciousness and death. Tell your doctor about any medicine or combination of medicines that makes you drowsy or sleepy.

Accidents: Narcotics often cause drowsiness or dizziness. If you are aware of this, you can be extra careful to avoid accidents. Sometimes it may be unsafe for you to drive a car or even to walk up or down stairs. Avoid operating equipment such as saws or drills, or performing activities that require alertness. Be aware of the effect narcotics have on you so that you can take necessary precautions.

How Much Narcotic Pain Reliever Is Safe for Me To Take?

The amount of pain reliever you take should be determined by your doctor. Analgesics affect different people in different ways. A very small dose may be effective for you, while someone else may need to take a much larger dose to obtain pain relief. You need to ask these questions:

  • How much should I take? How often?
  • If my pain is not relieved, can I take more?
  • If the dose should be increased, by how much?
  • Must I call the doctor before increasing the dose?
  • What if I forget to take it or take it late?

Your doctor will try to prescribe the amount of narcotic that will be both safe for you and effective for your pain. Take the medicine as your doctor or nurse has prescribed but tell them at once if your pain is not controlled or if you have severe side effects such as extreme drowsiness or difficulty in breathing. If you do not need as much narcotic as has been prescribed, your doctor or nurse will tell you how to reduce the dose or frequency.

What if the Medicine That Has Been Recommended Doesn’t Relieve My Pain?

Tell your doctor or nurse as soon as you can if you are not getting effective pain relief. Don’t wait for your next appointment! They need to know:

  • How much, if any, pain relief you get.
  • How long the pain is relieved.
  • Any side effects that occur or do not occur, especially drowsiness.
  • How pain interferes with your normal activities such as sleep, work, eating, or sex.

With your doctor’s help, you can usually get good pain relief. When the medicine does not give you enough pain relief, the doctor may increase the dose or the frequency or prescribe a different drug. Some narcotics are stronger than others, and you may need a stronger one to control your pain. If your pain relief is not lasting long enough, ask your doctor about long acting forms of medicine. Morphine is now available in a tablet form that releases it over a long period of time (MS Contin or Roxanol SR). You may have developed drug tolerance if you have taken narcotics for a long time. As a result, doses that may have been too large for you a few weeks before may be safe now. The desired effect is pain relief with as few side effects as possible, regardless of the size of the dose. Some doctors are reluctant to prescribe large enough doses or stronger narcotics for pain control. However, with careful medical observation, the doses of strong narcotics (by mouth or injection) can be safely raised enough to ease severe pain. Do not increase the dose of your pain medicine on your own. Remember, you are the best judge of whether your pain is relieved. If you still have pain and your doctor does not seem to be aware of other alternatives, ask to see a specialist in cancer pain management.

What Are the Side Effects of Narcotics?

Although not everyone has side effects from narcotics, some of the more common ones are drowsiness, constipation, and nausea and vomiting. Some people also might experience dizziness, mental effects (nightmares, confusion, hallucinations), a moderate decrease in rate and depth of breathing, or difficulty in urinating. You should always discuss side effects with your doctor or nurse. Side effects from narcotic pain relievers can usually be handled successfully.

What Can I Do About Drowsiness?

At first, narcotics cause some drowsiness in most people, but this usually goes away after a few days. If the narcotic is giving you pain relief for the first time in a long time, your drowsiness might be the result of the decrease in pain, allowing you much needed rest. This kind of drowsiness will go away after you “catch up” on your sleep. Drowsiness will also lessen as your body gets used to the medicine. Call your doctor or nurse if you feel you are too drowsy for your normal activities after you have been taking the medicine for a week. If you are drowsy, be very careful to avoid situations in which you might hurt yourself as a result of not being alert such as cooking, climbing stairs, or driving. Here are some ways to handle drowsiness:

  • Wait a few days and see if it disappears.
  • Check to see if there are other reasons for the drowsiness. Are you taking other medicines that can also cause drowsiness?
  • Ask the doctor if you can take a smaller dose more frequently.
  • If the narcotic is not relieving the pain, the pain itself may be wearing you out. In this case, better pain relief may result in less drowsiness. Ask your doctor what you can do to get better pain relief.
  • Sometimes a small decrease in the dose of a narcotic will still give you pain relief but no drowsiness. If drowsiness is severe, you may be taking more narcotic than you need. Ask your doctor about lowering the amount you are presently taking.
  • Ask your doctor if you can take a mild stimulant such as caffeine, or your doctor can prescribe a stimulant such as dextroamphetamine (Dexedrine) or methylphenidate (Ritalin).
  • If drowsiness is severe or if it suddenly occurs after you have been taking narcotics for a while, notify your doctor or nurse right away.

What Can I Do About Constipation?

Narcotics cause constipation in most people. The stool does not move along the intestinal tract as fast as usual and becomes hard because more water is absorbed. Your doctor will probably prescribe a stool softener and a laxative. After checking with your doctor or nurse, you can try the following:

  • Eat foods high in fiber or roughage such as uncooked fruits and vegetables and whole grain breads and cereals. Adding 1 or 2 tablespoons of unprocessed bran to your food adds bulk and stimulates bowel movements. Keeping a shaker of bran handy at mealtimes makes it easy to sprinkle on foods. A dietitian can suggest other ways to add fiber to your diet.
  • Drink plenty of liquids. Eight to ten 8-ounce glasses of fluid each day will help keep your stools soft.
  • Exercise as much as you are able.
  • Eat foods that have helped relieve constipation in the past.
  • Try to use the toilet or bedside commode when you have a bowel movement, even if that is the only time you get out of bed.
  • Plan your bowel movements for the same time each day, if possible. Set aside time for sitting on the toilet or commode, preferably after a meal.
  • Have a hot drink about half an hour before your planned time for a bowel movement.
  • If you have difficulty eating enough bran or other foods high in fiber, check with your doctor, nurse, or pharmacist about using a bulk laxative such as Metamucil.

Be sure to check with your doctor or nurse before taking any laxative or stool softener on your own.

What Can I Do for Nausea and Vomiting?

Nausea and vomiting caused by narcotics usually will disappear after a few days of taking the medicine. The following suggestions may be helpful:

  • If your nausea occurs mainly when you are walking around (as opposed to being in bed), remain in bed for an hour or so after you take your medicine. This type of nausea is like motion sickness. Sometimes the doctor will tell you to use medicines (such as Bonine or Dramamine) that can be bought without a prescription to counteract this type of nausea. Do not take these medicines without checking with your doctor, nurse, or pharmacist.
  • If pain itself is the cause of the nausea, using narcotics to relieve the pain usually makes this nausea go away.
  • Medicine (such as Compazine, or Torecan by mouth or by rectal suppositories) can sometimes be prescribed.
  • Ask your doctor or nurse if some other medical condition or other medications you are taking such as steroids, anticancer drugs, or aspirin might be causing your nausea.

Some people mistakenly think they are allergic to narcotics if the narcotic causes nausea. Nausea and vomiting alone usually are not allergic responses. But nausea and vomiting accompanied by a rash or itching may be an allergic reaction. If this occurs, stop taking the drug and notify your doctor at once.

I’ve Heard That Some People Who Stop Taking Narcotics Have Withdrawal Effects. Is This True?

You should not stop taking narcotic pain relievers suddenly. People who stop taking narcotic medicine usually are taken off the drug gradually so that any withdrawal symptoms will be mild or scarcely noticeable. If you stop taking narcotics suddenly and develop a flu-like illness, excessive perspiration, diarrhea, or any other unusual reaction, tell your doctor or nurse. These symptoms can be treated and tend to disappear in a few days to a few weeks.

If My Pain Becomes Severe, Will I Need Shots for Pain Relief?

Probably not. Intramuscular injections or “shots” are rarely used for relieving cancer pain. Narcotic rectal suppositories can be effective, and new methods of giving narcotic pain relievers have been developed. Long-acting morphine tablets are now available, and some narcotics provide quick pain relief when they are given under the tongue (sublingually). One narcotic drug, fentanyl, is now available as a skin patch which continuously releases the medicine through the skin for 48 to 72 hours. If you and your doctor have not been able to find a way to get good pain control with medicine you take by mouth, some kinds of pain medicine can be given intravenously. You may want to ask about patient-controlled analgesia. With this method, a portable computerized pump containing the medicine is attached to a needle that is placed in a vein. Whenever pain relief is needed, the patient presses a button on the pump that delivers a preset dose of pain medicine into the vein. A new simple, safe, and effective method of pain control is called continuous subcutaneous infusion. A small electronic pump dispenses the drug automatically through a small needle placed under the skin. Another way of treating cancer pain is to inject pain medicine into the spinal cord (intrathecal) or into the space around the spinal cord (epidural). Your doctor or a pain specialist can give you more information about these advances in pain treatment.

Is It True That Severe Pain Can Only Be Relieved by Heroin?

No. That is not true. Some newspaper and magazine articles have suggested that heroin is the only way to relieve severe pain, but the reported success with heroin was due more to how the drug was given (in a preventive way) than to the effects of the drug itself. Strong narcotics such as morphine and Dilaudid usually can relieve very severe pain. In fact, the body converts heroin to morphine. Heroin is available in England and has been used there to treat pain in cancer patients. However, even in England, morphine now is being used routinely because it has been shown to be just as effective as heroin. In the United States, heroin is not legally available.

What Other Prescription Medicines Are Used To Relieve Cancer Pain?

Several different classes of drugs can be used along with (or instead of) narcotics to relieve cancer pain. They may have their own pain-relieving action or they may increase the pain-relieving activity of narcotics. Others lessen the side effects of narcotic pain relievers. The following classes of non narcotic drugs might be prescribed by your doctor to help you get the best pain relief:

  • Antidepressants such as Elavil, Tofranil, or Sinequan are used to treat the pain that results from surgery, radiation therapy, or chemotherapy.
  • Antihistamines such as Vistaril or Atarax relieve pain, help control nausea, and help patients sleep.
  • Antianxiety drugs such as Xanax or Ativan may be used to treat muscle spasms that often go along with severe pain. In addition they are helpful for treating the anxiety that some cancer patients feel.
  • Dextroamphetamine (Dexadrine) increases the pain-relieving action of narcotic pain relievers and also reduces the drowsiness they cause.
  • Anticonvulsants such as Tegretol or Klonopin are helpful for pain from nerve injury caused by the cancer or cancer therapy.
  • Steroids such as prednisone or Decadron are useful for some kinds of both chronic and acute cancer pain.
  • NSAIDs such as Motrin decrease inflammation and lessen post surgical pain and the pain from bone metastases.

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