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Lymphedema and Pain Management

Coping with Pain from Lymphedema

PAIN AND LYMPHEDEMA

Lymphedema is not simply a condition of swollen limbs with occasional infections from time to time. It is and can be an excruciatingly painful condition.

Pain is part of our bodies immediate survival defense mechanism. The signal from our nerves to our brains tells us when something has gone wrong, that there is an injury, inflammation, trauma, infection. Warning pain is a life saver, but chronic unrelenting pain is a debilitating experience, both mentally and physically.

Chronic, severe pain drains us of our mental and emotional ability to cope. Severe depression can come from unrelenting pain. It can and does put undue stress on our bodies and affects our ability to heal from either wounds or infections. Because of the stress it can decrease our immune system's ability to defend the body from disease.

What are the sources of this physical pain from lymphedema?

1. Compression of and to nerves from the swelling This may be especially true with the terrible pain often reported by patients with leg lymphedema. Remember, the sciatic nerve, one of our body's largest nerves runs down the back of the leg from the hip all the way down. Extensive fibrosis (hardening of the tissue) can cause compression of this nerve leading to pain. 2. Increased pressure and compression of nerves from fibrosis 3. Chronic inflammations that are all to often with lymphedema 4. Cellulitis, lymphangitis and other infections 5. Over exertion of areas of the body as it attempts to cope with the excess strain and weight over an oversized limb 6. Wounds and those weeping sores we all get from time to time

These are only some of the sources of pain associated with lymphedema. When our pain becomes chronic and severe, it needs to be treated. You may find it necessary to seek a referral to a pain clinic and learn different types of pain management.

Pain Management

Patients with lymphedema may experience pain caused by the swelling and pressure on nerves; loss of muscle tissue and function; or scar tissue causing shortening of muscles and less movement at joints. Pain may be treated with medications, relaxation techniques, and/or transcutaneous electrical nerve stimulation (TENS), however, the most successful treatment is to decrease the lymphedema.

www.nci.nih.gov/cancerinfo/pdq/supportivecare/lymphedema/patient


Pain in the lymphedematous arm following treatment of breast cancer - evaluation and treatment

NLN Newsletter

http://www.lymphovenous-canada.ca/paincan.htm


International Association for the Study of Pain

http://www.halcyon.com/iasp


Pain Terminology

International Association for the Study of Pain

http://www.iasp-pain.org/terms-p.html


COPING WITH PAIN

http://facial-neuralgia.org/coping/pain/pain.html

Pain management is unfortunately a constant for facial neuralgia patients and their families. Drugs and surgery are the usual forms of treatment for these conditions but these treatments are not always 100% effective and people must learn to cope with pain in their lives. There are many resources available on the Internet for the treatment of and coping with pain. Here are a few starting points.

PainNet. Probably the best net site in this field.

Wellness Web Pain Management Center Discussion of what pain is, how to cope, links to other pain sites.

Chronic Pain: Hope Through Research National Institute of Neurological Disorders and Stroke, presents an excellent general discussion of chronic pain, its causes, treatments and problems.

Chronic Pain Study Although commissioned by the Workers Compensation Board of Nova Scotia, this study presents an excellent discussion of chronic pain and its unique problems as opposed to acute pain.

Coping Skills Suggestions on coping with chronic pain from the Invisible Disabilities Association of Canada

National Chronic Pain Outreach Center Publishes a quarterly journal, LIfeline and serves as a clearing house for information on all kinds of chronic pain.

IASP Home Page.

International Association for the Study of Pain.

Virtual Pocket Dictionary of Pain Terms

COPING WITH PAIN OR CHRONIC ILLNESS

http://www.helphorizons.com/care/topic.asp?topic=22


AMERICAN ACADEMY OF PAIN MANAGEMENT

http://www.aapainmanage.org/


Pain.com

http://www.pain.com/frameindex.cfm

What is pain?

From CancerBacUp - UK

Series of Articles Regarding Pain

Pain is defined as an uncomfortable and unpleasant sensation and emotional experience that occurs when tissues in the body are damaged. Pain is felt when particular nerves within the nervous system are stimulated by pressure such as that caused by a tumour, by external things such as extreme heat or cold, or by damage to the surrounding tissue.

The nervous system is made up of the brain, the spinal cord, and a complicated network of nerves that thread throughout the body. The brain is the control centre for the entire body.

The brain uses the information it receives from nerves to co-ordinate our actions and reactions. Nerves carry nerve impulses back and forth between all the areas of the body and the brain. Nerves known as sensory nerves send messages from the body to the brain via the spinal cord inside the spine. Nerves known as motor nerves carry messages out from the brain to all the muscles and glands in the body.

Nerves are made up of nerve cells. Nerve cells are also known as neurons. Neurons are very thin. Some are very small, and some can be three feet long. They are all shaped a bit like flat stars that have been pulled at each end so that they have long fingers. The fingers of one nerve cell almost reach to the next neuron, but there is a gap between them.

When a nerve cell is stimulated - by heat, cold, touch, sound vibrations or some other message - it begins to create a tiny electrical pulse in the cell that travels the full length of the neuron. When the electrical impulse reaches the end of the cell, it triggers the release of chemicals that carry the electrical impulse to the next nerve cell. In this way messages can be sent from nerves anywhere in the body to the spinal cord and then up to the brain where the sensation is felt (perceived). In the same way messages can also be sent in the opposite direction from the brain to any part of the body.

Pain can be acute, which means that it is short term and caused by an injury such as a burn, cut, or sprain. Acute pain gets better after a short time as the injury heals, and is helpful in drawing attention to an injury. One example is, if you sprain your ankle, the pain prevents you walking on the injury, so it makes you rest and gives the sprain a chance to heal. If you have a headache caused by stress, it may make you think about ways of reducing stress, so that you don't get headaches.

In cancer, pain can be chronic, which means that the pain is constant, and is often not relieved by resting. It may need specialist treatment to control it.

Content last reviewed: 01 April 2003 Page last modified: 11 August 2004

link no longer valid


What causes pain?

http://www.janssen-cilag.com/bgdisplay.jhtml?itemname=pain_causes (or)

http://painresourcecenter.com/main_b_howpaindevelops.asp


Describing pain

http://painresourcecenter.com/main_e_howtodescribepain.asp


Painkillers

http://www.vaughns-1-pagers.com/medicine/painkiller-comparison.htm


Realistic Levels of pain control

http://www.medscape.com/viewarticle/587545


Facts about painkilling drugs

http://www.macmillan.org.uk/Cancerinformation/Livingwithandaftercancer/Symptomssideeffects/Pain/Factsaboutpainkillers.aspx


*Note before using any of these medicines, you should check with your physcian as many have are contraindictory for lymphedema patients*

Other helpful medicines

http://www.cancerbacup.org.uk/Resourcessupport/Controllingsymptoms/Pain/Otherhelpfulmedicines


Note before using any of these medicines, you should check with your physcian as many have are contraindictory for lymphedema patients

Other methods of pain control

http://www.nhs.uk/ipgmedia/national/macmillan%20cancer%20support/assets/controllingpain-otherwaystocontrolpain(cb).pdf


What you can do for yourself

http://www.ciap.health.nsw.gov.au/nswtag/publications/guidelines/PainManagement41202.pdf


Electroacupuncture is not effective in chronic painful neuropathies. Dec 2011

Wiley Online


High and low frequency TENS reduce postoperative pain intensity after laparoscopic tubal ligation: a randomized controlled trial. Jan 2009

Journal of Pain


Lymphedema may cause pain after surgery - Jan 2012

ABC


The Pain of Lymphedema - Nov 2010 Judith Nudelman, MD Clinical Assistant Professor of Family MedicineAlpert Medical SchoolBrown UniversityProvidence, R.I.

Washington Post

Acetaminophen

Why is this medication prescribed?

Acetaminophen is used to relieve mild to moderate pain and to reduce fever. It does not relieve the stiffness, redness, and swelling of arthritis.

This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information.

How should this medicine be used?

Acetaminophen comes as a tablet, chewable tablet, capsule, liquid, drops, and granules (to be dissolved in water) to take by mouth and a suppository to use rectally. Acetaminophen is available without a prescription. Follow the directions on the package label carefully. If your doctor prescribes it for you, the prescription label will tell you how often to take it. Follow the directions on the package or prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take acetaminophen exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

Do not crush, chew, or open the capsules: swallow them whole.

To insert an acetaminophen suppository into the rectum, follow these steps:

Remove the wrapper. Dip the tip of the suppository in water.

Lie down on your left side and raise your right knee to your chest. (A left-handed person should lie on the right side and raise the left knee.)4. Using your finger, insert the suppository into the rectum, about 1/2 to 1 inch in infants and children and 1 inch in adults. Hold it in place for a few moments.

Stand up after about 15 minutes. Wash your hands thoroughly and resume your normal activities. Adults should not take acetaminophen for pain for more than 10 days (5 days for children) without talking to a doctor. Acetaminophen should not be taken by adults or children for high fever, for fever lasting more than 3 days, or for recurrent fever without a doctor's supervision. Do not give a child more than five doses in 24 hours unless directed to do so by a doctor.

What special precautions should I follow?

Before taking acetaminophen,

tell your doctor and pharmacist if you are allergic to acetaminophen or any other drugs.

tell your doctor and pharmacist what prescription and nonprescription medications you are taking, especially carbamazepine (Tegretol), phenobarbital, phenytoin (Dilantin), rifampin (Rifadin, Rimactane), sulfinpyrazone (Anturane), and vitamins.

tell your doctor if you have or have ever had liver disease and if you have a history of alcohol abuse.

tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking acetaminophen, call your doctor.

if you drink 3 or more alcohol beverages every day, ask your doctor if you should take acetaminophen. You should not drink alcohol beverages while taking acetaminophen.

What special dietary instructions should I follow?

To prevent stomach upset, take acetaminophen with meals or milk.

What should I do if I forget a dose?

If your doctor prescribes acetaminophen on a regular basis, take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.

What side effects can this medication cause?

Although side effects from acetaminophen are not common, they can occur. Tell your doctor if this symptom is severe or does not go away:

upset stomach If you experience the following symptom, call your doctor immediately:

skin rash

What storage conditions are needed for this medicine?

Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication.

In case of emergency/overdose

In case of overdose, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911.

What other information should I know?

Before taking other nonprescription pain relievers or cold, cough, and allergy products, read their labels to be sure that they do not contain acetaminophen. An overdose of acetaminophen can have serious, life-threatening consequences.

Ask your pharmacist any questions you have about acetaminophen.

Last Revised - 01/01/2003

http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a681004.html


Acetaminophen

(a see ta MIH no fen) Anacin-3 Maximum Strength, Childrens Tylenol, Tylenol, Tylenol Caplet, Tylenol Caplet Extra Strength, Tylenol Extended Release, Tylenol Extra Strength, Tylenol Gelcap Extra Strength, Tylenol Suspension

What is the most important information I should know about acetaminophen?

• Use acetaminophen for up to 3 days for fever or up to 10 days for pain (or up to 5 days to treat a child's pain). If the symptoms do not improve, or if they get worse, stop using acetaminophen and see a doctor.

• Avoid alcohol during treatment with acetaminophen. Together, alcohol and acetaminophen can be damaging to the liver.

• Be aware of the acetaminophen content of other over-the-counter and prescription products. Care should be taken to avoid taking more than the recommended amount of acetaminophen per dose or per day. What is acetaminophen?

• Acetaminophen is a pain reliever and a fever reducer.

• Acetaminophen is used to treat many conditions such as headache, muscle aches, arthritis, backache, toothaches, colds, and fevers.

• Acetaminophen may also be used for purposes other than those listed in this medication guide. What should I discuss with my healthcare provider before taking acetaminophen?

• Do not take acetaminophen without first talking to your doctor if you drink more than three alcoholic beverages per day or if you have had alcoholic liver disease. You may not be able to take acetaminophen, or you may require a lower dose or special monitoring.

• Before taking acetaminophen, tell your doctor if you have kidney or liver disease. You may not be able to take acetaminophen, or you may require a dosage adjustment or special monitoring during treatment if you have either of these conditions.

• Acetaminophen is in the FDA pregnancy category B. This means that it is unlikely to be harmful to an unborn baby. Do not take acetaminophen without first talking to your doctor if you are pregnant.

• Acetaminophen passes into breast milk. It appears to be safe for use during breast-feeding but should be avoided if possible. Talk to your doctor before taking acetaminophen if you are breast-feeding a baby.

• If you are treating a child, read the package carefully and use a pediatric form of the medication if possible. Talk to a doctor first if the child is younger than 2 years of age.

How should I take acetaminophen?

• Take acetaminophen exactly as directed by your doctor or follow the instructions on the package. If you do not understand these instructions, ask your pharmacist, nurse, or doctor to explain them to you.

• Take each oral dose with a full glass of water.

• Acetaminophen can be taken with or without food.

• Wash your hands before and after using the rectal suppositories. Run the suppository under cold water or put it in the refrigerator for a few minutes before using it. Remove any wrapping from the suppository and moisten the suppository with cold water. Squat, stand, or lie down with one leg straight and the other bent, in a comfortable position that allows access to the rectal area. Use your finger, or the applicator if one is provided, to deposit the suppository as far as it will comfortably go into the rectum. Insert the narrow end first. Close your legs and lie still for a few minutes. If the applicator will be reused, take it apart and wash it with warm water and mild soap, then dry it completely. Avoid having a bowel movement for at least 1 hour after inserting the suppository.

• To ensure that you get a correct dose, measure the liquid forms of acetaminophen with a special dose-measuring spoon or cup, not with a regular table spoon. If you do not have a dose-measuring device, ask your pharmacist where you can get one. Shake the liquid well before measuring.

• Never take more acetaminophen than is directed. The maximum amounts for adults are 1 gram (1000 mg) per dose and 4 grams (4000 mg) per day. Taking more acetaminophen could be damaging to the liver. If you drink more than three alcoholic beverages per day, talk to your doctor before taking acetaminophen.

• Use acetaminophen for up to 3 days for fever or up to 10 days for pain (or up to 5 days to treat a child's pain). If the symptoms do not improve, or if they get worse, stop using acetaminophen and see a doctor.

• If you are treating a child, read the package carefully and use a pediatric form of the medication if possible. Talk to a doctor first if the child is younger than 2 years of age.

• Store acetaminophen at room temperature away from heat, moisture, and the reach of children. The rectal suppositories can be stored at room temperature or in the refrigerator. What happens if I miss a dose?

• If you are taking acetaminophen on a regular schedule, take the missed dose as soon as you remember. Wait the prescribed amount of time or as directed in the package labeling before taking another dose. Do not take a double dose.

• If you are taking acetaminophen on an as-needed basis, missing a dose is not usually a problem. Take the dose as soon as you remember, and do not take another dose for the amount of time prescribed or as directed in the package labeling.

What happens if I overdose?

• Seek emergency medical attention.

• Symptoms of an acetaminophen overdose include nausea, vomiting, diarrhea, abdominal pain, sweating, seizures, confusion, and an irregular heartbeat.

What should I avoid while taking acetaminophen?

• Avoid alcohol during treatment with acetaminophen. Together, alcohol and acetaminophen can be damaging to the liver.

• Be aware of the acetaminophen content of other over-the-counter and prescription products. Care should be taken to avoid taking more than the recommended amount of acetaminophen per dose or per day.

What are the possible side effects of acetaminophen?

• If you experience any of the following rare but serious side effects, stop taking acetaminophen and seek emergency medical attention or contact your doctor immediately:

    · an allergic reaction (difficulty breathing; closing of the throat; swelling of the lips, tongue, or face; or hives); 
    · liver damage (yellowing of the skin or eyes, nausea, abdominal pain or discomfort, unusual bleeding or bruising, severe fatigue); 
    
    · blood problems (easy or unusual bleeding or bruising). 

• Other, less serious side effects are not known to occur.

• Side effects other than those listed here may occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

What other drugs will affect acetaminophen?

• Be aware of the acetaminophen content of other over-the-counter and prescription products. Care should be taken to avoid taking more than the recommended amount of acetaminophen per dose or per day.

• Acetaminophen may cause false urine glucose test results. Talk to your doctor if you have diabetes and you notice changes in your glucose levels while taking acetaminophen.

• Other medications may interact with acetaminophen. Talk to your doctor and pharmacist before taking any prescription or over-the-counter medicines, including herbal products while taking acetaminophen. Where can I get more information?

• Your pharmacist has additional information about acetaminophen written for health professionals that you may read.

• Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

• Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist.

© 1996-2003 Cerner Multum, Inc. Version: 7.02. Revision date: 3/10/03.

http://www.drugs.com/acetaminophen.html

Nonsteroidal anti-inflammatory drugs (NSAIDs)

From MayoClinic.com Special to CNN.com NSAIDs (en-SEDS) are most effective for mild to moderate pain accompanied by swelling and inflammation. These drugs relieve pain by inhibiting an enzyme in your body called cyclooxygenase (si-klo-OX-suh-juhn-ays). This enzyme makes hormone-like substances called prostaglandins, which are involved in the development of pain and inflammation.

NSAIDs are especially helpful for arthritis and pain resulting from muscle sprains, strains, back and neck injuries or cramps.

Over-the-counter NSAIDs include:

Aspirin Ibuprofen (Advil, Motrin, others) Ketoprofen (Orudis) Naproxen sodium (Aleve) NSAIDs available only by prescription include:

Diclofenac potassium (Cataflam) Diclofenac sodium (Voltaren) Etodolac (Lodine) Flurbiprofen (Ansaid) Indomethacin (Indocin) Ketorolac (Toradol, Acular) Nabumetone (Relafen) Naproxen (Anaprox, Naprelan, Naprosyn) Oxaprozin (Daypro) Piroxicam (Feldene) Sulindac (Clinoril)

When taken as directed, NSAIDs are generally safe. But if you take more than the recommended dosage — and sometimes even the recommended dosage — NSAIDs may cause nausea, stomach pain, stomach bleeding or ulcers. Large doses of NSAIDs can lead to kidney problems and fluid retention. Your risk increases with age. If you regularly take NSAIDs, talk to your doctor so that he or she can monitor you for side effects.

NSAIDs have a so-called ceiling effect, or limit to how much pain they can control. This means that beyond a certain dosage, they don't provide additional benefit. If you have moderate to severe pain, exceeding the dosage limit may not help relieve your pain.

November 22, 2002

http://www.cnn.com/HEALTH/library/PN/00038.html


Non Steroidal Anti-Inflammatory Drugs

http://www.medinfo.co.uk/drugs/nsaids.html

Non Steroidal Anti-Inflammatory Drugs

http://www.medinfo.co.uk/drugs/nsaids.html

N S A I D Information

- - - - -

NSAID Use Increases Renal Failure Risk, Especially in Hypertension or Heart Failure

By Michelle Rizzo

NEW YORK (Reuters Health) Mar 31 - The risk of developing acute renal failure (ARF) is increased among nonsteroidal anti-inflammatory drug users compared to non-users in the general population, according to report from Spain. The risk is heightened in patients with hypertension or heart failure.

Dr. Consuelo Huerta, from Centro Espanol de Investigacion Farmacoepidemiologica, Madrid, and colleagues used the General Practice Research Database from the United Kingdom to assess the risk for nonfatal ARF associated with NSAID use in a nested case-control study.

As reported in the March issue of the American Journal of Kidney Diseases, the analysis included a total of 103 patients confirmed as idiopathic cases of ARF, compared with 5000 matched controls.

“We found that the incidence of nonfatal ARF was 1 per 10,000 person-years in persons with no prior history of renal impairment,” Dr. Huerta told Reuters Health. “This risk increased threefold among users of NSAIDs.” The risk declined after treatment was discontinued. Long-term and high daily doses were associated with slightly increased risks.

The investigators found that a history of heart failure, hypertension, diabetes, and hospitalizations in the previous year were associated with a greater risk for ARF. “The increased risk associated with NSAIDs was potentiated among patients with a history of hypertension or congestive heart failure,” Dr. Huerta explained.

The risk for ARF was increased with the use of selected cardiovascular drugs, especially diuretics. The relative risk of ARF with concomitant use of NSAIDs and diuretics was 11.6, and for NSAIDs and calcium channel blockers it was 7.8.

“Our study adds to the existing evidence that NSAIDs should be used with special caution in patients with a low circulating plasma volume and/or renal function already compromised, in particular patients with congestive heart failure or hypertension,” Dr. Huerta concluded.

Am J Kidney Dis 2005;45:531-539.

http://www.medscape.com/viewarticle/502303

- - - - -

Alert Center: NSAIDs and Cardiovascular Effects Updated April 4, 2005

Emerging information is creating debate about whether the benefits of COX-2 inhibitors (“coxibs”) outweigh their cardiovascular risks. In addition, possible adverse effects of standard NSAIDs on the cardiovascular system are under scrutiny. Physicians as well as patients are uncertain about the optimal use of these agents. This Alert Center provides links to articles and/or policy statements that update the evidence in this important therapeutic area. This Center is not intended to be a definitive source on the subject.

http://www.medscape.com/pages/editorial/public/alertcenters/coxib

- - - - -

Medscape Editorial Note, January 18, 2005 The Pulse of Current Cardiovascular Concern: Anti-inflammatory Medications CME Co-Chairs: Thomas F. Lüscher, MD, FRCP; Carl J. Pepine, MD; Faculty: Jeffrey S. Borer, MD; R. Preston Mason, MBA, PhD; Wayne A. Ray, PhD; Frank Ruschitzka, MD; Lee S. Simon, MD Disclosures

Release Date: December 22, 2004; As noted above, this activity is a symposium presented on November 8, 2004.

On December 17, 2004, the National Institutes of Health (NIH) announced suspension of the use of the COX-2 inhibitor celecoxib (Celebrex;Pfizer, Inc.) for all participants in a large colorectal cancer prevention clinical trial (Adenoma Prevention with Celecoxib [APC]). This action was based on an analysis by an independent Data Safety and Monitoring Board that showed a 2.5-fold increased risk of major fatal and nonfatal cardiovascular events for participants taking the drug compared with placebo.

However, according to a Pfizer spokesperson, data from another ongoing study assessing whether celecoxib can prevent colon cancer – the Prevention of Colorectal Sporadic Adenomatous Polyps (PreSAP) trial – “revealed no greater cardiovascular risk than placebo.”[1] The PreSAP trial used the same cardiovascular measures and the same Data Safety and Monitoring Board as the APC trial.

The NIH, which sponsors over 40 studies using celecoxib for the prevention and treatment of cancer, dementia, and other diseases, will conduct a full review of all supported studies involving this drug class.

On the basis of suspension of celecoxib in the APC study, the US Food and Drug Administration (FDA) issued a statement noting that although these findings were important, “at this point FDA has seen only the preliminary results of the studies. FDA will obtain all available data on these and other ongoing Celebrex trials as soon as possible and will determine the appropriate regulatory action.”[2]

Further information from the FDA about celecoxib is available on its Celecoxib Information Page: http://www.fda.gov/cder/drug/infopage/celebrex/default.htm

In addition, on December 23, 2004, the FDA issued an alert for healthcare providers regarding naproxen, in which it stated, “Based on emerging information from a long-term prevention trial, the risk of cardiovascular and cerebrovascular events may increase among patients taking naproxen. FDA will be analyzing all available information from these studies to determine whether additional regulatory action is needed.”

The Naproxen Alert, which includes prescribing information, is available at: http://www.fda.gov/cder/drug/InfoSheets/HCP/Naproxen-hcp.pdf

Further information from the FDA is available on its Naproxen Information Page: http://www.fda.gov/cder/drug/infopage/naproxen/default.htm

The FDA also approved a new label with upgraded warnings for valdecoxib (Bextra;Pfizer, Inc.). The FDA announced on December 9, 2004 that “a 'boxed' warning, strengthening previous warnings about the risk of life-threatening skin reactions and a new bolded warning contraindicating the use of Bextra in patients undergoing coronary artery bypass graft surgery, will be added to the label.”

The Bextra labeling announcement is available at: http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01331.html

Information from the FDA on nonsteroidal anti-inflammatory drug products (NSAIDs), including rofecoxib, celecoxib, valdecoxib, and naproxen, is available in a Public Health Advisory on NSAIDs, released December 23, 2004 and available at: http://www.fda.gov/cder/drug/advisory/nsaids.htm

A regularly updated comprehensive collection of information related to NSAIDs is available in the Medscape NSAID Alert Center

References Pfizer. Investor news release. December 17, 2004. Available at: http://www.pfizer.com/are/investors_releases/2004pr/mn_2004_1217.cfm US Food and Drug Administration. FDA statement on the halting of a clinical trial of the Cox-2 inhibitor Celebrex.

Available at: http://www.fda.gov/bbs/topics/news/2004/new01144.html

Naproxen sodium

How does it work?

Naproxen sodium belongs to a group of medicines called non-steroidal anti-inflammatory drugs (NSAIDs).

It works by blocking the action of a substance in the body called cyclo-oxygenase. Cyclo-oxygenase is an enzyme that is involved in the production of various chemicals in the body, some of which are known as prostaglandins. Prostaglandins are produced in response to injury or certain diseases and cause pain, swelling and inflammation. As naproxen stops the production of prostaglandins, it is effective at relieving pain and inflammation.

All the medicines in this group reduce inflammation caused by the body's own immune system and are effective pain killers.

What is it used for?

A form of arthritis affecting the joints of the spine (ankylosing spondylitis)

Abdominal pain associated with menstrual periods (dysmenorrhoea)

Acute gout

Disorders of the muscles and skeleton, such as tendon inflammation (tendinitis), sprains, strains, dislocations, fractures

Inflammatory disease of the joints (rheumatoid arthritis)

Osteoarthritis

Pain following childbirth

Pain following insertion of an intrauterine contraceptive device (coil or IUCD)

Pain following surgery

Pain relief in migraine

Warning!

This medicine may reduce your ability to drive or operate machinery safely. Do not drive or operate machinery until you know how this medicine affects you and you are sure it won't affect your performance.

This medicine is not recommended for use in children under 16 years of age.

If you have cirrhosis of the liver, heart failure or kidney disease, you are on a low sodium diet, or you are taking diuretic medicines, you should have your kidney function assessed before and during treatment with this medicine.

If you experience any disturbances in your vision during treatment with this medicine you should have an eye test. Use with caution in

Blood clotting disorders

Decreased kidney function

Decreased liver function

Elderly people

Heart failure

History of allergies

History of asthma

History of diseases of the stomach or intestines

People on a low salt (sodium) diet

Not to be used in

Allergy to aspirin or other medicines in this class (NSAIDs)

Bleeding from the stomach or intestines

People in whom aspirin or other medicines in this class (NSAIDs), cause attacks of asthma, itchy rash (urticaria) or nasal inflammation (rhinitis)

Peptic ulcer or a history of this. This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy.

If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.

Pregnancy and Breastfeeding

Certain medicines should not be used during pregnancy or breastfeeding. However, other medicines may be safely used in pregnancy or breastfeeding providing the benefits to the mother outweigh the risks to the unborn baby. Always inform your doctor if you are pregnant or planning a pregnancy, before using any medicine.

This medicine is not recommended for use in pregnancy, particularly in the first and third trimesters, unless considered essential by your doctor. Seek medical advice from your doctor.

This medicine passes into breast milk. It is recommended that mothers should avoid using this medicine while breastfeeding. Seek medical advice from your doctor.

Label warnings

Take this medication with or after food.

Side effects

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Because a side effect is stated here, it does not mean that all people using this medicine will experience that or any side effect.

Headache

Abdominal pain

Difficulty in sleeping (insomnia)

Swelling of the legs and ankles due to excess fluid retention (peripheral oedema)

Blood disorders

Abnormal reaction of the skin to light, usually a rash (photosensitivity)

Seizures (convulsions)

Balance problems involving the inner ear (vertigo)

Nausea and vomiting

Sensation of ringing, or other noise in the ears (tinnitus)

Inflammation of the liver (hepatitis)

Severe blistering skin reaction affecting the tissues of the eyes, mouth, throat and genitals.(Stevens-Johnson Syndrome)

Concentration difficulties

Ulceration or bleeding of the stomach or intestines

Hypersensitivity reactions such as narrowing of the airways (bronchospasm), swelling of the lips, throat and tongue (angioedema), itchy blistering rash or anaphylactic shock

Kidney disorders The side effects listed above may not include all of the side effects reported by the drug's manufacturer.

For more information about any other possible risks associated with this medicine, please read the information provided with the medicine or consult your doctor or pharmacist.

How can this medicine affect other medicines?

Naproxen may increase the blood levels of the following medicines, resulting in an increased risk of side effects: - lithium - methotrexate - phenytoin.

There may rarely be an increased risk of seizures if this medicine is taken with quinolone-type antibiotics such as ciprofloxacin.

Probenecid may increase the blood level of naproxen, resulting in an increased risk of side effects.

Naproxen may reduce the effectiveness of the following medicines for high blood pressure:

- diuretics such as furosemide (frusemide) - ACE inhibitors such as captopril - beta-blockers such as propranolol.

There may be an increased risk of kidney problems if this medicine is taken with any of the following:

- diuretics - ACE inhibitors - ciclosporin.

NSAIDs such as naproxen should not be taken within 8-12 days of taking mifepristone.

Naproxen should not be taken with any other NSAID, eg ibuprofen, as this increases the risk of adverse effects.

There may be an increased risk of bleeding if naproxen is taken with the following:

- blood-thinning or anticoagulant medicines such as warfarin - corticosteroids such as prednisolone.

This medicine may affect the results of certain laboratory tests, eg adrenal function tests. If you are due to have any blood tests, ask your doctor if you need to stop taking this medicine beforehand.

Other medicines containing the same active ingredients

Synflex

Last updated 8.7.2004 http://www.netdoctor.co.uk/medicines/100004608.html


Ibuprofen

Why is this medication prescribed? Ibuprofen is used to relieve the pain, tenderness, inflammation (swelling), and stiffness caused by arthritis and gout. It also is used to reduce fever and to relieve headaches, muscle aches, menstrual pain, aches and pains from the common cold, backache, and pain after surgery or dental work.

This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information.

How should this medicine be used? Ibuprofen comes as a tablet and liquid to take by mouth. It usually is taken three or four times a day for arthritis or every 4-6 hours as needed for pain. Follow the directions on the package or prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take ibuprofen exactly as directed. Do not take more or less of it or take it more often than directed by the package label or prescribed by your doctor. If you think that you need more medication to relieve your symptoms, call your doctor.

If you obtained ibuprofen without a prescription, do not take it for more than 3 days for fever or 10 days for pain without talking to a doctor.

If you are taking ibuprofen for pain and the painful area becomes red or swollen, call your doctor.

What special precautions should I follow? Before taking ibuprofen,

tell your doctor and pharmacist if you are allergic to ibuprofen, aspirin or other medications for pain or arthritis, or any other drugs tell your doctor and pharmacist what prescription and nonprescription medications you are taking, especially anticoagulants ('blood thinners') such as warfarin (Coumadin), aspirin, atenolol (Tenormin), carteolol (Cartrol), cyclosporine (Neoral, Sandimmune), digoxin (Lanoxin), diuretics ('water pills'), labetalol (Normodyne, Trandate), lithium (Eskalith, Lithobid), medications for arthritis or diabetes, methotrexate, metoprolol (Lopressor), nadolol (Corgard), phenytoin (Dilantin), probenecid (Benemid), and vitamins. Do not take aspirin or acetaminophen when using ibuprofen unless directed to do so by your doctor. tell your doctor if you have or have ever had liver, heart, or kidney disease; high blood pressure; any stomach problems; or any other gastrointestinal disease. tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking ibuprofen, call your doctor. if you are having surgery, including dental surgery, tell the doctor or dentist that you are taking ibuprofen. you should know that this drug may make you drowsy. Do not drive a car or operate machinery until you know how this drug affects you. if you drink 3 or more alcohol drinks every day, ask your doctor if you should take ibuprofen. You should not drink alcoholic beverages while taking ibuprofen. What special dietary instructions should I follow? Ibuprofen may cause an upset stomach. Take ibuprofen with food or milk.

What should I do if I forget a dose? If your doctor prescribes ibuprofen on a regular basis, take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.

What side effects can this medication cause? Although side effects from ibuprofen are not common, they can occur. Tell your doctor if any of these symptoms are severe or do not go away:

headache dizziness nervousness upset stomach stomach pain or cramps vomiting constipation diarrhea gas If you experience any of the following symptoms, call your doctor immediately:

bloody vomit bloody diarrhea or black, tarry stools ringing in the ears blurred vision swelling of the hands, feet, ankles, or lower legs skin rash itching What storage conditions are needed for this medicine? Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication.

In case of emergency/overdose In case of overdose, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911.

What other information should I know? Keep all appointments with your doctor and the laboratory. Your doctor may order certain lab tests to check your response to ibuprofen.

Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription.

Last Revised - 01/01/2003

http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682159.html

Chronic Pain Medicines

What drugs can treat chronic pain? Many medicines can decrease pain, including the ones listed below. Each one may have side effects. Some side effects can be serious. It's important to listen to your family doctor carefully when he or she tells you how to use your pain medicine. If you have questions about side effects or about how much medicine to take, ask your doctor or your pharmacist.

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Acetaminophen Acetaminophen (one brand name: Tylenol) helps many kinds of chronic pain. Remember, many over-the-counter and prescription pain medicines have acetaminophen in them. If you're not careful, you could take more acetaminophen than is good for you. Taking too much acetaminophen could cause liver damage. If you often have to take more than 2 acetaminophen pills a day, tell your doctor.

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Nonsteroidal Anti-inflammatory drugs (NSAIDs) Other drugs that help with pain are called nonsteroidal anti-inflammatory drugs, or NSAIDs. Examples include aspirin, ibuprofen (two brand names: Motrin, Advil) and naproxen (two brand names: Aleve [over the counter], Naprosyn [prescription]). These medicines can be taken just when you need them, or they can be taken every day. When these medicines are taken regularly they build up in the blood to levels that fight the pain of inflammation (swelling) and also give general pain relief. Many of these medicines are available in low-dose forms without a prescription.

If your doctor wants you to take an NSAID, always take it with food or milk because the most common side effects are related to the stomach. If you are taking other pain medicines, don't take NSAIDs without first talking to your doctor.

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Narcotics Narcotics can be addictive, so your family doctor will be careful about prescribing them. For many people with severe chronic pain, these drugs are an important part of their therapy. If your doctor prescribes narcotics for your pain, be sure to carefully follow his or her directions. Tell your doctor if you are uncomfortable with the changes that may go along with taking these medicines, such as inability to concentrate or think clearly. Do not drive when taking these medicines.

When you're taking narcotics, it's important to remember that there is a difference between “physical dependence” and “psychological addiction.” Physical dependence on a medicine means that your body gets used to that medicine and needs it to work properly. When you don't have to take the pain medicine any longer, your doctor can help you slowly and safely decrease the amount of medicine until your body no longer “needs” it.

Psychological addiction is the desire to use a drug whether or not it's needed to relieve pain. Using a narcotic this way can be dangerous and may not help your pain. If you have a psychological addiction to a narcotic, your doctor may give you another drug to help with your psychological problems. Or your doctor might recommend that you talk to a counselor. Your doctor might also change the medicine that you are addicted to by lowering the dose, changing to another drug or stopping the medicine altogether.

Narcotic drugs often cause constipation (difficulty having bowel movements). If you are taking a narcotic medicine, it's important to drink at least 6 to 8 glasses of water every day. Try to eat 2 to 4 servings of fresh fruits and 3 to 5 servings of vegetables every day. Be sure to tell your doctor if constipation becomes a problem for you. He or she may suggest taking laxatives to treat or prevent it.

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Other medicines Many drugs that are used to treat other illnesses can also treat pain. For example, carbamazepine (one brand name: Tegretol) is a seizure medication that can treat some kinds of pain. Amitriptyline (one brand name: Elavil) is an antidepressant that can also help with chronic pain in many people. Your doctor may want you to try one of these medicines to help control your pain. It can take several weeks before these medicines begin to work well.

Remember – if you are taking any pain medicine, be sure to ask your doctor or pharmacist before you take any other medicine, either prescription or over-the-counter.

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Are drugs the only way to treat chronic pain? No. Many other treatments can also decrease pain. They can actually change the body's chemicals that produce pain. Almost anything we do to relax or get our minds off our problems may help control pain. It's important to add relaxing activities to your daily life, even if you are already taking medicine for pain. You might have to use stress reduction methods for several weeks before you notice a decrease in pain. Your doctor can give you tips about stress reduction and relaxation methods.

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Source Treatment of Nonmalignant Chronic Pain (American Family Physician March 1, 2000, http://www.aafp.org/afp/20000301/1331.html)

Reviewed/Updated: 03/03

This article provides a general overview on this topic and may not apply to everyone. To find out if this article applies to you and to get more information on this subject, talk to your family doctor.

http://familydoctor.org/122.xml


Prescription Pain Relievers

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:

codeine hydromorphone (Dilaudid) levorphanol (Levo-Dromoran) methadone (Dolophine) morphine oxycodone (in Percodan) oxymorphone (Numorphan)

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.

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. Related Articles: Pain Control: Dispelling The Myths Pain: What Is It? How To Relieve Pain Without Medicine Nonprescription Pain Relievers

Dealing with Pain, sponsored by the Connecticut Division, Inc., of the American Cancer Society and the Yale Comprehensive Cancer Center, New Haven, Connecticut, was the basis of the first edition of Questions and Answers About Pain Control: A Guide for People with Cancer and Their Families. Since that time, new advances in pain control have taken place. This guide reflects many of those advances. We wish to thank the many reviewers, people who work with cancer patients daily, for their helpful comments and their assistance in revising Questions and Answers About Pain Control.

http://www.hospicenet.org/html/prescription.html


Daily Living: Understanding The Risks Of Common Painkillers

At some point, most people dealing with Chiari or syringomyelia have reached into their medicine chests for an over-the-counter painkiller to help them get through the day. And if they're like 30 million other people in the world, they chose an NSAID, or non-steroidal anti-inflammatory.

NSAID's are a widely used group of drugs that have analgesic, anti-inflammatory and antipyrectic action. They are very similar to aspirin and are used extensively in treating everything from post-operative pain, arthritis, inflammation, back pain, sciatia, and migraines to pain associated with menstruation. There are many brand names in the NSAID family, including: Advil (ibuprofen), Aleve (naproxen), Excedrin IB, Celebrex (Cox-2), Haltran, Naprosen, and Vioxx to name a few.

Despite the drugs' popularity, many users are unaware of the side effects that NSAID's can cause and the serious risks using them every day can entail. It it well documented in the medical literature - but not commonly discussed in the doctor's office - that daily use of NSAID's can result in gastro-intestinal problems, lead to sudden bleeding, and cause life-threatening health problems. It's a little known fact that thousands of people die every year from complications due to NSAID use.

A recent study, published in the August, 2004 issue of the journal Gastroenterology, drives home the risks of using these “everyday” type drugs. The study examined the rates of ulcer formation in 1,615 osteoarthritis patients who took a standard daily dose of either a placebo, low-dose aspirin, rofecoxib (Vioxx) combined with aspirin, or ibuprofen, over a 12 week period.

The trial was administered to a select group of patients, aged 50 and over, with a confirmed diagnosis of osteoarthritis. Each patient had to meet strict health standards and be without ulcers or erosive esophagitis (verified by endoscopy) to be included in the study. The trial was conducted by Loren Laine of the University of S. California School of Medicine, and a team from Merck Research Laboratories in West Point, Pennsylvania, led by Eric S. Maller.

The patients were randomly split into four groups and given the average daily dosage of each specific drug, with one group taking a placebo, one group taking 81 mg of enteric-coated aspirin a day, one group taking 25 mg rofecoxib combined with the aspirin every day, and one group taking 800 mg of ibuprofen a day. Repeat endoscopies were performed at 6 weeks and 12 weeks. Patients who developed ulcers were discontinued from the study and received ulcer treatment.

The results were striking and clearly show the inherent risk of using NSAID's on a daily basis. Low-dose aspirin did not significantly increase ulcer incidence; in fact, after 12 weeks, only 27 of the patients had ulcers greater than 3mm. But with the addition of 25 mg. of Vioxx, the number jumped to 58. In the ibuprofen group, 62 people - about 15% - developed ulcers after only 12 weeks of use.

A peptic ulcer is a sore that forms in the lining of the stomach or the beginning of the small intestine, the duodenum. Ulcers can cause a gnawing, burning pain in the upper abdomen, accompanied by nausea, vomiting, a loss of appetite and weight loss. NSAID's work by affecting chemicals in the body that cause inflammation, the prostaglandins. Unfortunately, this same group of chemicals is also involved in the activity of the stomach. Thus, NSAID's interfere with the stomach's ability to protect itself from the acid used to digest food and tend to cause indigestion, and in some cases, even ulcers.

Normally the stomach has three defenses against digestive juices: the mucus that coats the stomach lining to protect it from acids, the chemical bicarbonate which neutralizes these acids, and blood circulation to the stomach lining that aids in cell renewal and repair. NSAID's hinder all of these protective mechanisms, and with the stomachs defensives down, the natural digestive juices frequently cause the problems seen in this study.

It should be noted that the harmful effects of NSAID's can occur quickly. In this study, most of the increase in the number of erosions actually had occurred by the week 6 check-up. It should also be noted that while aspirin caused less problems than ibuprofen, it did cause significantly more problems than the placebo.

Although NSAID's can work well as pain-relievers, their benefits should be carefully weighed against their side effects. The finding in this study is in line with other estimates which state that 15%-30% of long term NSAID users develop peptic ulcers. That's a significant number when you consider that peptic ulcers can involve life-threatening complications, such as bleeding and perforation.

The risks of NSAID's don't stop with ulcers either. NSAID's can affect medical conditions such as asthma and high blood pressure, and can even impact the liver and kidneys. In fact, just before this issue was posted, Merck voluntarily pulled their blockbuster drub, Vioxx, off the market due to concerns about side effects involving the heart (see Merck Pulls Vioxx Off The Market)

Despite the lack of awareness regarding the risks of NSAID's, the research is clear. Given this, it is important to discuss NSAID use - especially daily, long-term use - with your doctor, so that together you can evaluate the potential benefits and risks and make an informed, intelligent healthcare decision.

– Julie Carter

Sources:

Ulcer Formation With Low-Dose Enteric-Coated Aspirin and the Effect of COX-2 Selective Inhibition: A Double-Blind Trial. Laine L. et al. Gastroenterology, August 2004; 127; 395-402

Digestive Diseases A-Z: NSAIDs and Peptic Ulcers

National Digestive Diseases Information Clearinghouse

NIH Publications No. 02-4644, February 2002

See also:

ACPA Resource Guide To Chronic Pain Medication & Treatment

http://theacpa.org/uploads/ACPA_Resource_Guide_2012_Final%20010912.pdf

Lymphedema treatment decreases pain intensity in lipedema.

Dec 2011

Szolnoky G, Varga E, Varga M, Tuczai M, Dósa-Rácz E, Kemény L.

Source

Department of Dermatology and Allergology, University of Szeged, Hungary. szolnoky@dermall.hu

Abstract

Lipedema is a disproportional obesity featuring light pressure-induced or spontaneous pain. On the basis of our clinical observations, lymphedema therapy, as practiced in our clinic, reduces the perception of pain beyond leg volume reduction. We therefore aimed to measure pain intensity prior and subsequent to treatment. 38 women with lipedema were enrolled in the study with 19 patients undergoing treatment and 19 serving as the control group using exclusively moisturizers. Treatment consisted of once daily manual lymph drainage (MLD), intermittent pneumatic compression (IPC), and multilayered short-stretch bandaging performed throughout a 5-day-course. Pain was evaluated with a 10-item questionnaire, a pain rating scale (PRS), and the Wong-Baker Faces scale. Treatment resulted in a significant reduction of pain with a decrease in mean scores of all three measures. In the control group, only PRS showed significant decrease. Our study results indicate that this treatment regimen not only reduces leg volume and capillary fragility, but also improves pain intensity in patients with lipedema.

PubMed

The Pros and Cons of Other Anti-Inflammatory Drugs

All pain relievers have risks as well as benefits. Get the pros and cons of anti-inflammatory medicines here.

Medicine Net

http://www.medicinenet.com/script/main/art.asp?articlekey=50398

The Pros and Cons of Older Anti-Inflammatory Drugs

http://www.medicinenet.com/script/main/art.asp?articlekey=50398&page=2

The Pros and Cons of Other Analgesics

http://www.telegraph.co.uk/health/3314136/Pros-and-cons-of-painkillers.html

External Links

Managing chronic pain with spinal cord stimulation. Jan 2012

http://onlinelibrary.wiley.com/doi/10.1002/msj.21289/abstract;jsessionid=E7D934A4F4F2C24C394550DDC86E490E.d02t03

Comparison of central versus peripheral delivery of pregabalin in neuropathic pain states. Jan 2012

http://www.molecularpain.com/content/8/1/3/abstract

Pain in the ICU: A Psychiatric Perspective.

http://jic.sagepub.com/content/early/2012/01/04/0885066611432417.long

Chronic Pain in Older Adults.

http://www.ncbi.nlm.nih.gov/pubmed/22229962

Lymphedema People Internal Links

Lymphedema People Resources

lymphedema_and_pain_management.txt · Last modified: 2012/10/16 14:40 (external edit)