Empowering Patients to Actively Participate In Their Own Pain Management
Pain in malignant disease is common, yet in most patients pain can be effectively
controlled. For effective pain management there are three basic things, which must be
done.
Assessment to identify the TYPES of pain being experienced.
(See Carling Algorithm and Pain Assessment Sheet)
There are eight types of pain and only two of them are fully opioid responsive, three
are semi-responsive, and three are opioid resistant. Most patients have more than one
pain. Indeed, one third have four pains or more. Some have six different types of pain.
Before medications are prescribed, we need to know which types of pain you are
experiencing, so that the appropriate medications can be prescribed.
Titration adjusting the dosage of medication, which can mean an increase or
a decrease, to achieve pain relief with the minimum or no side effects. Once the
medications are prescribed, the dosage has to be carefully adjusted until the
pain is under control. If you have three types of pain, then you may need three
different medications, which will need to be adjusted individually until each
pain is brought under control. Some medications, such as opioids (morphine,
oxycodone hydromorphone etc), can be titrated fairly quickly. Others, such as
antidepressants and anticonvulsants may take several weeks to titrate. You
need to be able to differentiate between the different types of pain so that you
will know which medication to take.
Regular and frequent monitoring. Pain is dynamic it increases, it decreases and it
can change in nature. Your medications may need to be adjusted accordingly.
Titration and the Therapeutic Window
Patient Feels `Hung-Over'
Cloudy Judgment
Pain Free
Breakthrough Pain
2.
Pain should be `controlled' rather than treated. Long acting opioids can control the
same level of pain by as much as one third less dosage. It is false economy to wait until
you have the pain before you take the medication and you are suffering needless pain.
The aim of using long acting opioid drugs, is to obtain and maintain a level which lies
inside the therapeutic window. (See diagram) As long as the level stays within the
window, you will be pain free and you will have no mental clouding. If the level rises
above the upper parameter, you will begin to feel `hung-over' or sleepy and judgment
will be cloudy. If it falls below the lower parameter, you will experience breakthrough
pain.
Statistically, it takes about 1/3 of the 12 hour dosage of the SAME DRUG in
immediate release form to lift the level back inside the window. If you are taking
MS Contin 60mgs 12 hourly, then for breakthrough pain you should be taking
Morphine Sulphate Immediate Release (MSIR) 20mgs for breakthrough pain.
If you are taking Oxycontin 40mgs 12 hourly, then for breakthrough pain you should
be taking Oxyfast or OxyIR 10mgs. For this drug 1/4- 1/3 is sufficient.
As `rule of thumb', if the pain breaks through 2-3 times per day or more, it is an
indication that the level is in the lower margin of the window and the 12 hour dose
needs to be increased by 50%, with a corresponding increase in the breakthrough
dosage to represent 1/3 of the NEW dosage.
Conversely, if your pain comes down, eg after radiation therapy, then the medication
will need to be reduced. If you wake up feeling `hung-over' and especially if you had
no breakthrough pain the previous day, then this is an indication that your pain has
come down. The medication is then reduced by one third with a corresponding
decrease in the breakthrough medication to represent one third of the NEW reduced
dosage.
If you are taking twelve hourly opioids MS Contin, Oxycontin, take the same dose in
the morning as in the evening, otherwise the level is fluctuating constantly.
Do not take the breakthrough medication routinely every four hours to prevent pain.
The long acting drug is for that.
Keep your medication regimen simple. Take your medication with your breakfast and
supper and then you are free for the day to get on with your life. Just take your
`rescue' dose with you in case you need it.
3.
Remember that there are side effects to pain as well as side effects to the medications.
Side effects.
1.
Constipation occurs in EVERYONE taking opioids. You need a `pusher'
eg, Senna and a softener from the first dose of opioid. Opioids slow the bowel
down. Your `pusher' speeds it up again. It puts the `push' back that the opioid
has taken out. Take it EVERY day.
2.
Nausea and vomiting. If this occurs, it is usually for the first 48 hours after
starting on an opioid for the first time. Taking an antiemetic with the opioid
for the first couple of days can prevent this. The commonest cause of nausea
and vomiting after that time is poor bowel management. Prevent it happening
in the first place by taking your `pusher' and softener regularly.
Call your doctors and nurses:
1. If the medication you are taking is not controlling the pain.
2. If you have breakthrough pain two to three times per day or more.
3. If you wake up feeling `hung-over' and especially if you had no breakthrough
pain the previous day.
4. If you have not had your bowels opened for three days or more.
5. If you have nausea and/or vomiting.
6. If you develop new pains.
Neuropathic pain occurs in about 15% of patients with Myeloma and in 8 out of
10 of them it is one of the first symptoms. Neuropathic pain can be controlled
using antidepressants and/or anticonvulsants, which need to be titrated up slowly
over several weeks.
These are now available in topical form along with drugs such as Guaifenesin,
Clonidine, Ketamine and the NSAIDs and other medications. These have the
advantage of reducing side effects considerably, and relief is speedier on
considerably lower dosages.
A Compounding Pharmacist would help you with this.
Pain CAN and SHOULD be controlled
You have nothing to fear but fear itself
MA Carling © 2000 All Rights Reserved