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Pain Management in Cancer: Avoiding Opioids

Disclaimer: Sajjad Iqbal, MD is a retired physician and rare cancer survivor who routinely supports, mentors and guides other patients through their perilous cancer journeys. Any opinions, suggestions, or advice provided is solely from Dr. Iqbal’s perspective as a well-informed and knowledgeable cancer patient, not as a physician. The patients must discuss their health with their own doctors and follow their advice.


During their long & tumultuous journey, cancer patients suffer from a multitude of very difficult and troublesome problems. Pain is perhaps the most common and debilitating one.  The pain can be caused by the cancer itself, as when it erodes the healthy tissues or when it attacks the nerves or nerve endings.  The pain of terminal cancer is regarded as one of the most severe pains known to mankind. Pain is also a very common side effect of virtually all of the cancer treatments, such as chemotherapy, radiation therapy, and the various surgical procedures, leading to devastating physical and emotional impact on the patient. 

Despite that, the medical community has historically done quite a poor job of managing the chronic pain and alleviating the suffering of the cancer patients. In the 1990s a renewed focus on pain management emerged and the pain assessment became one of the vital signs that the health professionals need to record for every patient. Unfortunately, while this did do some good to better manage the patients’ pain and suffering, it also led to the epidemic of opiate addiction. The emergence of the medical specialty of Pain Management (Algology) and overly aggressive and, at times, deceptive marketing by a greedy and unethical faction of the pharmaceutical industry led to an alarming increase in opioids prescriptions and thus the widespread addiction.  The opioids have an important role to play but were never meant to be used for chronic pain.  Opioids work best when given for a very short duration, such as after a tooth extraction or a surgery.  The patient is supposed to get off these medicines after a few short days. The risk of addiction that may be extremely low in the first few days of use, starts to increase exponentially beyond 2 weeks of regular usage. It stands to reason that, unless dealing with a short-term pain, the use of opioid painkillers for cancer patients makes very little sense.  

Some examples of such narcotic painkillers are Vicodin (hydrocodone), Percocet (oxycodone), Dilaudid (hydromorphone), Duragesic (fentanyl). All of these, and many other like these, are opium derivatives. Beyond the risk of addiction and tolerance, there are many other serious side effects, such as substantial physical and mental impairment, nausea, dizziness, and severe constipation that can lead to abdominal pain and rectal bleeding.  Opioids can also slow down breathing which can cause hypoxia (decreased oxygen supply to the brain).  An overdose of these drugs can lead to respiratory depression, coma and quite often, death.  In 2019, 50,000 people in the US died from Opioid overdose. Therefore, it is imperative that the doctors who treat cancer patients must find better pain management strategies with less side effects and without a risk of opioid addiction.  

There are a few strategies that patients can employ on their own to provide pain relief. Number one would be the better use of non-narcotic pain killers. Everyone is familiar with acetaminophen (Tylenol) and ibuprofen (Advil or Motrin). Neither one of those alone can provide adequate pain relief in severe pain associated with cancer, but the recent studies show that we can utilize these two simpler medicines much more effectively.  

These two medicines work very differently and are metabolized very differently in the body. They have very little in common with each other. Yes, eventually they both relieve the pain, but whereas acetaminophen works primarily on the pain receptors in the brain, Ibuprofen works primarily by reducing the inflammation at the site of the pain.  For years, the mothers of small children had been using a staggered schedule of both these medicines for the relief of their children’s pain or fever. There used to be a fear that you should not use both medicines together, however we now know that such fear is not rational.  The recent studies show that the two medicines, Ibuprofen & acetaminophen, are complimentary when used together because they have a different mechanism of action. The pain relief achieved by using Tylenol as well as Advil is greater than either of these medicines used singularly. In this case, 2+2 adds up to 5, rather than 4. You can find this date here.    

We also learned that for a severe & unrelenting pain, one can use a somewhat higher dose of either medicine.  In fact, one study showed that if you use the higher, but still less than the maximum allowed, doses of acetaminophen and Ibuprofen together you can achieve a pain relief that is equal to or better than the opioids. You can find that data here.

At the same time, the safety parameters were far better than the opioids. 

One must remember that this regimen of the higher doses used together is only recommended for the relief of a severe pain that fails to respond to the usual regimen.  Acetaminophen which is metabolized in the liver, should be used with a great degree of caution by any patient with a liver disorder.  An overdose of Acetaminophen (Tylenol) can cause liver failure and even death. 

 On the other hand, Ibuprofen is eliminated from the body by the kidneys and it tends to irritate the stomach.  Therefore, it should be used with caution by the patients with stomach ulcers or chronic kidney disorders. 

But for the average cancer patient suffering from severe & longstanding pain, both these medicines are very safe. The FDA allows 4000 mg as the highest daily dose for acetaminophen. However, some doctors prefer to cap it at 3250 mg in 24 hours.  This means 6-8 tablets of 500 mg extra strength Tylenol during a period of 24 hours. Acetaminophen is also available now in a 650 mg strength, which is marketed, as arthritis strength formula. There really is nothing extra in there for the arthritis relief. It’s just acetaminophen in a higher strength and cancer patients can certainly use that. So, two tablets of 650 milligram each of acetaminophen taken every eight hours will still keep you below the maximum allowed dose. It is worth emphasizing again that one should try the lower dosages first before reaching close to the maximum allowed dose. 

The maximum allowed dose of Ibuprofen is 3200 mg per day. Ibuprofen [Advil] comes in 200 mg tablets. There is also an 800mg prescription strength Motrin, which is the same medicine, Ibuprofen. Doctors often advise their patients with various degrees of pain to use three tablets of ibuprofen, 600mg total, at a time. Cancer patients can definitely use up to a maximum of 800 milligram of Ibuprofen every 8 hours, total 2400 mg in 24 hours, that will keep them well under the maximum allowed daily dose.  

So, if we use both these non-narcotic medicines properly and rationally, we can achieve a lot more effective pain relief without resorting to narcotics.  

In a nutshell, a cancer patient in severe pain who needs opioids can instead take up to a maximum of 2 tablets of 650 mg strength acetaminophen plus 600 to 800mg of Ibuprofen together and can repeat it every 8 hours. Then we’ll still have less than the maximum allowed dose of either one, and the studies show that the pain relief is equal or even better than with the opioids (Cochrane Reviews). I do not recommend that you should immediately go to that top dose as there are several options to try first. Start with lower doses and/or single drug and then go up in the doses if needed. You could take the higher dose of acetaminophen or you could take the higher dose of Ibuprofen, or you can combine them.  The pain may be bad enough at night that you need to take the maximum dosage of both medicines at night, but take the lower dose or just one medicine during the day time. The point is that you can manage your pain without resorting to opioids.  

The second strategy would be to use anti-depressants. The type of anti-depressants which are called SSRI, Selective Serotonin Reuptake Inhibitors, such as Escitalopram (Lexapro), Duloxetine (Cymbalta), and others have a beneficial effect on the chronic pains when used along with painkillers. These medicines work by increasing the level of the chemical serotonin in the brain. Serotonin is a neurotransmitter or hormone that is often referred to as a mood stabilizer or “the happiness hormone”. It protects the brain from harmful stimuli such as the pain signals.  When a patient in pain takes these medicines, the pain may still be there, but the misery factor goes down dramatically and they’re able to tolerate the pain far better than with the pain medicines alone. It is not uncommon for a patient with chronic pain to get off the opioids after the addition of SSRI antidepressants to the pain management regimen.  

 It’s important to remember that these medicines, Lexapro, Cymbalta, etcetera, require at least one week to start working. So, one cannot expect an immediate benefit. Lexapro (Escitalopram) is a simpler medicine and may be preferable for most patients, especially the elderly. The pain-relieving action of these drugs have not quite caught on yet. Generally, doctors treating cancer patients will reserve these medicines for the treatment of depression. I highly recommend that the cancer patients in severe and poorly controlled pain should seek their doctor’s opinion about the use of SSRI anti-depressants combined with the pain medicine. In fact, patients are strongly encouraged to discuss with their doctors all my recommendations prior to implementing them.  

Another useful strategy is to employ the alternative therapies such as meditation, prayers, yoga, other relaxation techniques, acupuncture, therapeutic massage.  

The last option is to ask for a referral to pain medicine specialist. A good and accomplished pain medicine specialist can do many things to assess the origin of pain and then determine how best to block it. There are procedures such as epidural injections, nerve blocks, nerve stimulations and many others. These modalities are especially useful for pain that may be coming from metastasis in the spine.  

 Ultimately, the important takeaway for cancer patients is that there are ways to improve pain outside of narcotics.  Talk to your doctor about some of these ideas and find what works best for your individual scenario as there is no “one size fits all” approach.  It may take a few different combinations of these treatments to find what works best for you, but hopefully these tips help improve your pain.

The Role of Coffee in Pain Management

Not only is coffee one of the most sought after, popular and enjoyable drinks on the planet, studies show that it has a significant role to play in pain management too. The role of caffeine in pain management has been receiving more attention in recent years and is currently a subject of interest and ongoing research in the medical profession.

Once the effects of coffee on pain have been fully understood it can be harnessed in even more ways to help people with a range of conditions both treat and manage their pain symptoms. Not only that, but there is mounting evidence to suggest that coffee may play an important role in reducing the risks of a range of life-threatening diseases such as cancer, heart disease, type 2 diabetes and even Alzheimer’s.

The Role of Coffee in Pain Perception

Coffee can help modulate and reduce pain due to its action on the adenosine receptors in our brain which play a role in pain perception. Certain chemicals in coffee will bind to and block the adenosine receptors which can have a pain-relieving affect. Coffee also stimulates the release of dopamine and beta-endorphins which are neurotransmitters that act as a natural pain killer in the body.

Caffeine and Pain-Relief Medicines

You may have noticed when buying analgesics such as paracetamol or ibuprofen for pain relief that some of the preparations are mixed with caffeine. This is because caffeine has been shown to increase the level of pain relief in those with acute pain. A standard dose of one of these pain killers combined with the equivalent of a mug of coffee [1] showed an increase in the amount of people with a good level of pain relief by 5% to 10% [2], in comparison to those who just took pain relief alone.

Caffeine Can Reduce Muscle Pain

A reduction of muscle pain is brought about principally by the effect caffeine has on reducing pain perception. This makes caffeine a good choice for people who work out and exercise regularly as it can help with exercise recovery by reducing muscle soreness. Research has shown that caffeine can reduce post exercise muscle pain by as much as 50%[3]

Caffeine can also help reduce inflammation in the body which can lead to pain. It is thought that this is due to chemicals in the coffee blocking pathways involved in the production of inflammatory molecules [4]. High levels of inflammation in the body has been liked to a wide range of life-threatening illness, so the more that can be done to reduce inflammation in the body the better.

The Impact of Caffeine Tolerance

The habitual consumption of coffee will cause your body to build up a tolerance to caffeine so its pain-relieving effects will not be as apparent, therefore, to benefit from the pain-relieving effect of caffeine you would need to drink more than your body is used to.

Given that people build up a tolerance to caffeine, be aware that if you usually drink caffeine every day and then you stop suddenly, this can actually both cause and worsen muscle pain and headache. With this in mind, it is important to modulate your caffeine intake to help ensure that your body doesn’t build up too much of a reliance on it so you can benefit from its pain relieving qualities.


Resource Links:

[1] Is Fair Trade Coffee Good or Bad?

[2] Caffeine as an analgesic adjuvant for acute pain in adults

[3] Caffeine Cuts Post-workout Pain By Nearly 50 Percent, Study Finds

[4] Caffeine may be able to block inflammation, new research says

Non-Medical Remedies For Managing Cancer Pain

Treating cancer often involves treating multiple symptoms, both physical and emotional. The symptom of pain, however, has been highlighted as one of the most critical due to the effect it can have on recovery and overall mental well-being. Pain is seen in approximately 25% of newly diagnosed patients, 33% of those having active treatment and up to 75% of those with advanced disease according to The American Pain Society. The World Health Organization have also identified cancer pain to be a global health concern, and also mention that a large percentage of patients are not adequately treated for pain.

While the normal regimes of medication treatments are usually prescribed by a variety of healthcare professionals, some elements of the pain or personal circumstances can be overlooked. In some cases the clinical approach doesn’t always work, leading many patients to look for alternative or holistic approaches to managing their pain.

Acupuncture, Reflexology and Art Therapy

Known as a physical therapy, medical acupuncture is an evidence-based medicine. It involves inserting sterile needles into certain points in the body which then stimulates the nerve to release natural chemicals which in turn give you a feeling of well being. Acupuncture, used alongside established drug therapy, has been shown to be most effective.

Reflexology is a type of massage that focuses on applying pressure to the hands and feet. There is no scientific evidence to support its use, but many people have reported positive outcomes in managing their pain. The belief is that having your feet and hands massaged in a specific way stimulates certain organs in the body which allows for the natural release of the body’s healing process and energy pathways – similar to the way acupuncture works.

Art therapy is a type of mental therapy that helps channel your focus away from the pain itself. “Art therapy does not replace the need for pain medication, but it can be used as an effective complement and reduce perceptions of pain experiences,” says Kelsey A. Skerpan, an art therapist with Harvard-affiliated Massachusetts General Hospital.

Furthermore, a study done in early 2018 and published inThe Arts in Psychotherapy looked at approximately 200 people who had been hospitalized for pain and found that just 50 minutes of art therapy significantly increased moods and lowered levels of pain.

The Benefits of Exercise

Depending on the stage of cancer you’re at and the treatment you’re having, exercise may be an option to help with chronic pain. Exercise regimes can be specifically tailored depending on your personal circumstances. Studies have shown that aerobic exercises like running, walking, cycling and swimming can have a positive influence on the way individuals react to their pain, resulting in effective pain management in the long-term.

The Importance of Sleep

Sleeping is the body’s natural way to rejuvenate and heal. If you’re living with chronic pain due to your cancer, a good night’s sleep may be difficult to achieve. Some medicines used in the treatment of cancer can also affect your sleep. To help get a better night’s sleep, try and be active during the day, avoid caffeine and carbonated drinks at night or sleep on a special mattress that curves to the shape of your body.

Pain can be difficult to manage if you have cancer. Speak openly and honestly about your symptoms with your doctor or nurse. If you’re planning on trying any therapies or alternative ways of managing your pain, always check with your healthcare team first.

Pain Management of Chronic Pain Conditions

Editor’s Note: This blog was written by Lisa Davis-Budzinski

If you found your way to this article, that means you or someone you know and love has a chronic pain condition and are searching knowledge for treatments.

I have been managing a chronic pain condition known as Central Pain Syndrome, due to having a stroke, since 2002. I am also managing an autoimmune condition known as Grave’s Disease that wreaks havoc on the endocrine system and dealt me cancer of the thyroid. Plus a few other blood & spinal fluid related autoimmune issues.

I wanted to write this article to give you some direction and knowledge that you can take along the way with you as you put together a treatment plan that will help you manage a better quality of life.

First, we are all different and a blanket medication is not going to work for everyone. Example: penicillin helped a lot of people but not people like myself who is dangerously allergic to it. We know this because we all have different DNA codes. (See my DNA article HERE.) So that would stand to reason that we all need a more precision type of pain management treatment. We can also take into effect that men and women have different reactions to pain sensory levels. See this article for more information: Brain differences between male and female on pain.

Now we have to take all of that into account when trying to find what will work for you.

Once you find the doctor who can help you with your type of condition; Endocrinologist for Diabetes, Neurologist for MS, Parkinson’s and other nerve conditions etc., the doctor will tell you about treatments. There are many types and below is an outline:

In addition to medications, you want your pain management treatment to be well rounded:

  •  Try acupuncture, chiropractors, etc.
  • Get hormone labs done; hormones affect pain levels
  • Meditation, aromatherapy
  • Heating pads, cold packs
  • TENS unit
  • Spinal stimulator

Diversionary tactics help to raise dopamine/serotonin levels:

  • Doing something to make you laugh or makes you happy
  • A fun activity that can raise adrenaline levels
  • Keep it lighthearted to counter stress and depression
  • Cognitive-Behaviorial Therapy: CBT

Find your Teams:

  • Healthcare Team
  • Support communities

Find your pain triggers:

  • What triggers your pain
  • Write them down so you can actually “see” what they are
  • Sound, heat, cold, walking to far, over-doing anything, staying somewhere to long, sitting up to long while visiting

Seek natural treatments as well:

  • Holistic
  • Oils
  • Herbal treatments from Eastern medicine

As you can see, there are many treatments available to us than ever before. But we must know of the dangers before trying treatments and medications or putting them together as a whole. Before taking any medications it’s imperative to weigh the benefits vs the side effects. There is a huge book called the PDR that all physicians have. It stands for Physician’s Desk Reference for medications. This book is extremely expensive. It contains information just like the printouts you see from your pharmacy. What the medication was made to do, the color and shape for identification purposes, its molecular state, adverse reactions and side effects. You can ask the pharmacy to print this information for you and you can look up medications on sites like: https://www.drugs.com/pdr/ . This is something that you can talk to you doctor and family about. I’ve tried medications that the side effects were worse than any benefit it provided. It’s not worth continuing with that type of reaction. Since medications are synthetic, there is always a danger of it damaging the liver and kidneys because of the process our bodies need to take to break it down. Your doctor can also keep a watch on your organs while you take the medication with lab work.

Another danger of natural and/or synthetic medications are the interactions caused by mixing the wrong ones together.

Find out from your doctor or pharmacists, or online: http://www.webmd.com/interaction-checker/ , to make sure it will not be a lethal mix.

In this new scientific technological era, healthcare is changing more quickly than ever before. Keep apprised of new medications, new medical technology and methods. The internet helps us to be in the know of what is out or coming out to help with different diseases and conditions.

Though it has taken me a decade and more of trying different medications, trials and errors to find my right combo of teams and treatment; it doesn’t have to take you as long by learning from those of us that have gone before you. You can find help this type of help for answers and up to date information in forums, online groups and sites, like this one, and Twitter chats.

Please know you are not alone and there is help and there is a way to live a better quality of life than suffering in pain.


Citations and Resources:

https://dnamelody.com/2017/02/14/our-dna-heritage-and-our-health/

http://www.medicalnewstoday.com/articles/316207.php

https://www.drugs.com/pdr/

http://www.webmd.com/interaction-checker/

http://psycnet.apa.org/psycinfo/2000-02102-015

Supportive Care: How It Can Help Men With Prostate Cancer

Interview with Judith A. Paice, PhD, RN, FAAN, Director of the Cancer Pain Program, Division of Hematology-Oncology; Research Professor of Medicine, Feinberg School of Medicine Northwestern Medicine and Russel Szmulewitz, MD, Associate Director, Genitourinary Oncology Program, Assistant Professor of Medicine University of Chicago

The panel explores how men with prostate cancer are usually reluctant to share their feelings or complain about pain. However, Judith says that it is so crucial for patients to share with their health care professionals what is going on. Don’t be afraid to speak up! Having time to talk with others, or even a social worker will lead to an overall better quality of life. Watch the full video below for all the doctors’ advice.

Supportive Care: How It Can Help Men With Prostate Cancer from Patient Empowerment Network on Vimeo.