There is minimal systemic absorption. The patch is usually applied 12 hours per day, but a few studies indicate a high level of safety with up to three patches for periods up to 24 hours [ ].
An adequate trial may require several weeks of observation. The most frequently reported adverse event is mild to moderate skin redness, rash, or irritation at the patch application site. Although it may be applied to larger areas for the treatment of neuropathic pain, its use typically is limited by cost. Capsaicin is the ingredient in chili pepper that produces its pungent taste. When applied topically, it causes the depolarization of the nociceptors and release of substance P. Regular use eventually leads to depletion of substance P from the terminals of afferent C-fibers, potentially leading to decreased pain perception.
There are two commercially available concentrations 0. A trial of several weeks is needed to adequately judge effects. Many patients experience severe burning pain after the first applications related to the initial release of substance P , which usually decreases gradually over a few days if the cream is applied regularly. Some patients tolerate the lower concentration cream better, or tolerate application only if preceded by a topical local anesthetic or ingestion of an analgesic.
Numerous anti-inflammatory drugs have been investigated for topical use in populations with neuropathic pain, and results have generally been mixed. These formulations have established effectiveness for musculoskeletal pains.
This pain should have been neuropathic radiculopathy confirmed by physical examination was required , with no evidence of additional co-morbid chronic pain, neurological, or psychiatric conditions. The exception to this is children with intermittent or unpredictable pain, e. But like its nonprescription cousins, it poses serious risks to your heart and stomach when taken regularly, as millions of Americans do. Hashmi, J. Participants visited the lab on six occasions over 8 weeks and underwent identical scanning protocols on four of those visits Fig.
Bone pain is a common problem in the palliative care setting. Radiation therapy is usually considered when bone pain is focal and poorly controlled with an opioid, or is associated with a lesion that appears prone to fracture on radiographic examination. Calcitonin may have several pain-related indications in the palliative care setting, including pain from bone metastasis [ — ].
The most frequent routes of administration are subcutaneous and intranasal. If subcutaneous boluses are used, they should be preceded by skin testing with 1 IU to screen for hypersensitivity reactions, especially in patients with a history of reactions to salmon or seafood. The optimal dose is not known.
A trial may be initiated at a relatively low dose, which then can be gradually increased if tolerated. The intranasal formulation avoids the need for subcutaneous injections, facilitating the use of this drug in home care. It is administered once daily, with an initial dose of IU in one nostril, alternating nostrils every day. There are no data from which to judge the dose-response relationship for pain; escalation of the dose once or twice is reasonable if the first response is unfavorable. Apart from infrequent hypersensitivity reactions associated with subcutaneous injections, the main side effect is nausea.
The likelihood and severity of this effect may be reduced by gradual escalation from a low starting dose. It usually subsides after a few days and is less frequent with the intranasal form. Periodic monitoring of calcium and phosphorus is prudent during treatment. Bisphosphonates are analogues of inorganic pyrophosphate that inhibit osteoclast activity and, consequently, reduce bone resorption in a variety of illnesses.
Pamidronate has been extensively studied in populations with bone metastases [ ]. Its analgesic effects have been shown in breast cancer [ — ] and multiple myeloma [ ]. The dose usually recommended is 60—90 mg i. There are dose-dependent effects, and a poor response at 60 mg can be followed by a trial of 90 or mg. The reduction of skeletal morbidity pathological fractures, need for bone radiation or surgery, spinal cord compression, hypercalcemia described with the administration of pamidronate in multiple myeloma and breast cancer patients is another incentive to use it as an adjuvant [ — ].
Adverse effects, including hypocalcemia and a flu-like syndrome, are dose related and typically transitory. Nephrotoxicity occurs rarely, usually following relatively rapid infusions, and typically is transitory; the drug can be used in those with impaired renal function. It has been shown to reduce pain and the occurrence of skeletal-related events in breast cancer [ , , ], prostate cancer [ ], and multiple myeloma [ ], as well as a variety of solid tumors, including lung cancer [ ]. It is effective in both osteoblastic and osteolytic lesions [ ].
It is as effective as pamidronate [ , ], and its use is more convenient, as it can be infused safely over 15 minutes at a dose of 4 mg every 3 weeks. The side effects are similar to those encountered with pamidronate, and the dose does not have to be adjusted in patients with mild-to-moderate renal failure [ ]. Data on the analgesic effect of clodronate are conflicting, but it has been shown to be effective in prostate cancer and multiple myeloma [ ].
The main advantage of clodronate over pamidronate is its good oral bioavailability, which avoids the need for i. An oral dose of 1, mg daily seems to be optimal [ ]. Clodronate is not available in the U.
These drugs, which are very potent, are likely to be analgesic. Radionuclides that are absorbed at areas of high bone turnover have been evaluated as potential therapies for metastatic bone disease. Strontium and samarium, which are commercially available in the U.
Given the potential for myelosuppression associated with their use, these drugs usually are considered when pain is refractory to other modalities. Pain that originates from injury to muscle or connective tissue is frequent in patients with cancer [ ]. The efficacy of so-called muscle relaxants and other drugs commonly used for the treatment of musculoskeletal pain has not been evaluated in cancer patients.
The so-called muscle relaxants include drugs in a variety of classes, including antihistamines e. Paul, MN [ , ] , tricyclic compounds structurally similar to the tricyclic antidepressants e. Although these drugs can relieve musculoskeletal pain, these effects may not be specific, and there is no evidence that they relax skeletal muscle in the clinical setting. Although they have been shown to reduce musculoskeletal pains [ — ], their risk:benefit ratio relative to the NSAIDs or opioids is unknown [ ].
The most common adverse effect is sedation, which can be additive to other centrally acting drugs, including opioids. Treatment should be initiated with relatively low initial doses. The potential for abstinence, as well as abuse by predisposed patients, warrants caution when discontinuing therapy or administering these drugs to those with a substance abuse history [ ]. If a muscle spasm is present and is believed to be responsible for the pain, drugs with established effects on skeletal muscle should be tried in place of the muscle relaxants.
Injections of botulinum toxin can be considered for refractory musculoskeletal pain related to muscle spasms [ ], including those occurring after radiation therapy [ ]. The management of symptoms associated with malignant bowel obstruction may be challenging.
If surgical decompression is not feasible, the need to control pain and other obstructive symptoms, including distension, nausea, and vomiting, becomes paramount. The use of opioids may be problematic due to dose-limiting toxicity including gastrointestinal toxicity or the intensity of breakthrough pain. The use of these drugs may also ameliorate nonpainful symptoms and minimize the number of patients who must be considered for chronic drainage using nasogastric percutaneous catheters.
The somatostatin analogue octreotide inhibits the secretion of gastric, pancreatic, and intestinal secretions, and reduces gastrointestinal motility.
Can you spot Joe's mistakes? Joe didn't make every mistake in the book. But he made quite a few. Here's WebMD's list of common pain pill. Books. Period pains: Can anti-inflammatory drugs help? Period pain and cramps (dysmenorrhea) are very common. These medications are all non- steroidal anti-inflammatory drugs (NSAIDs). You can find a detailed description of how our health information is produced and updated in our methods.
These actions, which can occur more rapidly than similar effects produced by anticholinergic drugs [ ], probably underlie the analgesia and other favorable outcomes that have been reported in case series [ ] and one randomized trial [ ] in patients with bowel obstruction. Octreotide has a good safety profile, and its considerable expense may be offset in some situations by the avoidance of gastrointestinal drainage procedures. Anticholinergic drugs could theoretically relieve the symptoms of bowel obstruction by reducing propulsive and nonpropulsive gut motility and decreasing intraluminal secretions.
Two small series demonstrated that a continuous infusion of hyoscine butylbromide scopolamine at a dose of 60 mg daily can control symptoms from nonoperable malignant bowel obstruction, including pain [ , ]. The symptoms associated with bowel obstruction may improve with corticosteroid therapy. The mode of action is unclear, and the most effective drug, dose, and dosing regimen are unknown. The potential for complications during long-term therapy, including an increased risk of bowel perforation [ , ], may limit this approach to patients with short life expectancies.
Specialists in pain management often undertake combination therapy with multiple analgesics, including two or more adjuvant analgesics, during the treatment of severe, refractory pain. The treatment of a patient with severe cancer-related neuropathic pain, for example, ultimately may require the addition of an antidepressant, an anticonvulsant, and a lidocaine patch to an opioid regimen. In the setting of advanced disease, a corticosteroid also is commonly added. Combination therapy of this type, like that used to treat other disorders, such as epilepsy [ ], must be undertaken cautiously.
In most cases, drugs are added sequentially, starting with low initial doses. If meaningful analgesia is observed during dose titration, the dose is optimized and the drug is continued as another is tried. If therapy is ineffective because of side effects or the administration of a maximum safe dose without benefit, the drug should be discontinued usually with a tapering of the dose.
Although this approach to combination therapy has received very little study, one open-label trial reported that the addition of levetiracetam to gabapentin provided synergistic relief [ 70 ], and one small randomized controlled trial suggested that adding lamotrigine to phenytoin or carbamazepine was beneficial [ 63 ]. Data are insufficient to posit recommendations for preferred drug combinations, or the sequence in which various adjuvant analgesics should be tried.
Unfortunately, drug selection during these trials is based on clinical judgment and is executed in a trial-and-error fashion. Some clinicians prefer to choose drugs in different classes, but there is no specific evidence to support this approach. In all cases, however, careful attention should be given to potential interactions between drugs during sequential trials.
Cancer patients with pain often require multiple drugs, analgesic and otherwise, and are therefore at increased risk for drug-drug interactions.
An understanding of the types of drug interactions can help a clinician anticipate and minimize risk. Drug interactions can be classified as being either pharmacodynamic or pharmacokinetic. Pharmacodynamic interactions involve drug actions independent of pharmacokinetics and may relate to competition for the same receptor, or to additive or inhibitory effects on effects other than analgesia.
For example, an opioid and a benzodiazepine both cause CNS depression, and their concomitant use can result in additive sedation without a change in the plasma concentrations of either drug. In contrast, pharmacokinetic interactions imply that one drug interferes with the absorption, distribution, metabolism, or elimination of another, resulting in alterations in the concentration of one or both. Many pharmacokinetic drug interactions are mediated through the hepatic cytochrome P CYP enzyme system, which is responsible for the metabolism of numerous drugs, including analgesics, antidepressants, anticonvulsants, steroids, anticoagulants, chemotherapeutic agents, and others.
Within the CYP system, drugs can be further classified as substrates, inducers, or inhibitors. Substrates are agents that are metabolized by a particular enzyme, while inducers and inhibitors increase or decrease, respectively, the metabolism of other agents that are substrates of the same enzyme.
Likewise, paroxetine is a well-known inhibitor of CYP2D6 and may lead to higher or toxic levels of drugs that are substrates for that enzyme. Interpatient variability e. Genetic polymorphism exists most commonly with CYP2D6, leading to some patients being classified as poor metabolizers.
This may result in increased levels of a poorly metabolized parent compound, or decreased levels of an active metabolite. The same problem could arise if codeine is administered with a drug that inhibits CYP2D6. A further discussion of the CYP system and the interaction of medications can be found in Bernard [ ].