Opioids for Cancer Pain

Opioids (narcotics) are used with or without non-opioids to treat moderate to severe pain. They are often a necessary part of a pain relief plan for cancer patients. These medicines are much like natural substances (called endorphins) made by the body to control pain. They were once made from the opium poppy, but today many are man-made in a lab.

Safe use of opioids

Doctors and cancer care teams may prescribe opioids for patients having increasing or severe pain from their cancer or their treatment. Opioids should be prescribed and used with great care for several reasons:

• Some pain medicines may interfere with other medications.
• Pain medicines may affect people differently. Because of this, some cannot be given to older adults, young children, or certain people being treated for other medical conditions.
• The growing concern of what is being called an “opioid epidemic” in the U.S. It’s important to remember that opioids can be safely prescribed and used to help control cancer pain.

Your cancer care team will understand any safety concerns you or your loved ones may have about opioids. They also know it’s their responsibility to treat your cancer-related pain in the most effective way. Sometimes opioids are needed as part of a pain relief plan.

Because of safety concerns, you will always need a signed, written prescription (not faxed, emailed, or called in) for opioid pain medicines. For this reason, it’s important that only one doctor prescribe your pain medicines. If you have 2 or more doctors, be sure that one does not prescribe opioids for you without talking to the others about it.

Your doctor may ask you and your loved ones questions before prescribing opioids to be sure they will not be used in wrong or unsafe ways. They may ask you who you live with, if children are in the home, how your medications are stored, and other questions. Doctors will also watch you carefully and adjust the doses of pain medicine so you don’t take too much. While taking opioids, you may need to have regular urine or blood tests to check drug levels.

If you drink alcohol or take tranquilizers, sleeping pills, antidepressants, antihistamines, or any other medicines that make you sleepy, your doctor will need to know how much and how often you do this. Taking opioids (even small doses) while drinking alcohol or taking tranquilizers may cause problems and can lead to overdoses and symptoms like weakness, trouble breathing, confusion, anxiety, or more severe drowsiness or dizziness.

If you are taking opioids to help relieve your cancer pain, here are some important tips.

• Store your medications securely, such as in a locked box.
• Only take the drug as instructed.
• Don’t share your medication with anyone.

Common opioids used for cancer pain

Here are some of the opioids used in cancer care. Some of the more common brand names are in parentheses.

• Tramadol (Ultram)
• Hydromorphone (Dilaudid)
• Methadone (Dolophine, Methadose)
• Morphine (Apokyn, Avinza, Kadian, MS-Contin, and others)
• Oxycodone (OxyContin, OxyIR, Roxicodone)
• Hydrocodone
• Oxymorphone (Opana)
• Fentanyl (Actiq, Duragesic, Fentora, Lazanda, Subsys, and others)
• Tapentadol (Nucynta)

An “ER” behind the name of any opioid drug names stands for “extended release,” and is a sign that the drug is taken on a regular schedule to treat chronic pain. An “IR” stands for “immediate release” and means that the drug will work quickly and for only a short time. These rapid-onset opioids are used to treat break through pain. Examples of these types of drugs are fast-acting oral morphine; fentanyl in a lozenge, “sucker,” or under-the-tongue spray. (These forms of fentanyl are absorbed from your mouth – they are not swallowed.)

A short-acting opioid, which relieves breakthrough pain quickly, is often used with a long-acting opioid.

Many times the same opioid drug is used to treat both chronic and breakthrough pain. But, it might be prescribed in 2 different pill forms, one that has only the opioid in it and one that combines an opioid with a non-opioid. Be sure you know what you’re taking because it’s important not to mix them up!

Common opioid and acetaminophen or NSAID drug combinations

See Non-opioids and Other Drugs to Treat Cancer Pain for more on acetaminophen and NSAIDs (non-steroidal anti-inflammatory drugs) like aspirin and ibuprofen.

Oxycodone

Oxycodone may be added to aspirin, acetaminophen, or ibuprofen. For instance:

• Percodan has aspirin in it
• Percocet, Roxicet, Roxilox, Oxycet, and Tylox all have acetaminophen
• Combunox has ibuprofen

Hydrocodone

Hydrocodone may be added to acetaminophen or ibuprofen. For instance:

• Vicodin, Zydone, Norco, and Lortab all contain acetaminophen
• Vicoprofen and Reprexain have ibuprofen

If you’re taking a combination pain medicine, be sure you know what drugs are in each pill.

How to get proper pain relief with opioids

If you feel the drug is not helping to control your pain, talk with your doctor. When a medicine doesn’t give you the pain relief you need, your doctor may prescribe a higher dose or tell you to take it more often. When your cancer care team is working closely with you, doses of strong opioids can be raised safely to ease severe pain. Don’t decide to take more pain medicine on your own. If changing the dose doesn’t work, your doctor may prescribe a different drug or add a new drug to the one you’re taking.

If your pain relief isn’t lasting long enough, ask your doctor about extended-release medicines that come in pills and patches. These can control your pain for a longer period of time.

If your pain is controlled most of the time, but you sometimes have breakthrough pain, your doctor may prescribe a fast-acting medicine or immediate-release opioid that will give you faster pain relief right when it’s needed.

Opioid tolerance

You might find that over time you need larger doses of pain medicine. This may be because the pain has increased or you have developed a drug tolerance. Drug tolerance occurs when your body gets used to the opioid you’re taking, and it takes more medicine to relieve the pain as well as it once did. Many people do not develop a tolerance to opioids. But if you do develop drug tolerance, usually small increases in the dose or a change in the kind of medicine will help relieve the pain.

Having to increase your dose of opioids to relieve increasing pain or to overcome drug tolerance DOES NOT mean that you are addicted.

Side effects of opioids

Not everyone has side effects from opioids. The most common side effects are usually sleepiness, constipation, nausea, and vomiting. Some people might also have dizziness, itching, mental effects (such as nightmares, confusion, and hallucinations), slow or shallow breathing, or trouble urinating.

Many side effects from opioid pain medicine can be prevented. Some of the mild ones such as nausea, itching, or drowsiness, often go away without treatment after a few days, as your body adjusts to the medicine. Let your doctor or nurse know if you’re having any side effects and ask for help managing them.

Here are a few of the more common side effects:

Drowsiness or sleepiness

When you first start taking them, opioids might make you sleepy, but this usually goes away after a few days. If your pain has kept you from sleeping, you may sleep more for a few days after starting opioids while you “catch up” on your sleep. You also will get less sleepy as your body gets used to the medicine. Call your doctor or nurse if you still feel too sleepy for your normal activities after you’ve been taking the medicine for a week.

Sometimes it may be unsafe for you to drive a car, or even to walk up and down stairs alone. Don’t do anything that requires you to be alert until you know how the medicine affects you.

Here are some ways to handle sleepiness:

• Wait a few days and see if it goes away.
• Check to see if other medicines you’re taking can also cause sleepiness.
• Ask the doctor if you can take a smaller dose more often or an extended-release opioid.
• Ask your doctor what you can do to get better pain relief, if the opioid is not relieving the pain. The pain itself may be tiring you out. In this case, better pain relief may lead to less sleepiness.
• Ask for a small decrease in the opioid dose. It will still relieve your pain but won’t cause drowsiness. If the drowsiness is very bad, you may be taking more medicine than you need. Talk to your doctor about lowering the amount you’re taking.
• Ask your doctor about changing to a different medicine.
• Ask your doctor if you can take a mild stimulant such as caffeine during the day.
• If drowsiness is bad or if it suddenly starts to be a problem after you’ve been taking opioids for a while, call your doctor or nurse right away.

Constipation

Opioids cause constipation in most people, but it can often be prevented or controlled. Opioids slow the movement of stool through the intestinal tract, which allows more time for water to be absorbed by the body. The stool then becomes hard. When you start taking opioids, it’s best to take a laxative, stool softener, or other treatment to help keep your stool soft and your bowels moving.

Nausea and vomiting

Nausea and vomiting caused by opioids will usually go away after a few days of taking the medicine.

Some people think they’re allergic if they have nausea after they take an opioid. Nausea and vomiting alone usually are not allergic reactions. But a rash or itching along with nausea and vomiting may be an allergic reaction. If this happens, stop taking the medicine and call your doctor right away. If you have swelling in your throat, hives (itchy welts on the skin), or trouble breathing, get help right away.

When you no longer need opioids

You should not stop taking opioids suddenly. People who need or want to stop taking opioids are usually tapered off the medicine slowly so that their bodies have time to adjust to it. If you stop taking opioids suddenly and develop a flu-like illness, excessive sweating, diarrhea, or any other unusual reaction, tell your doctor or nurse. These symptoms can be treated and tend to go away in a few days or weeks. Again, slowly decreasing your opioid dose over time usually keeps these kinds of symptoms from happening. Check with your doctor about the best way to taper off your pain medicines.