Sunday, September 30, 2007

Narcotics for pain control: When is enough too much?

Ask 100 cancer patients what they fear most, and I’m sure almost all will say the same thing: pain. What do people think of when they think about cancer? Pain. So what is one of the most important things I can do for my patients? Control their pain.

There are many ways to control pain. Sometimes, when the medicines we use to treat cancer shrink the size of the tumor, the pain is eased as well. Sometimes medicines that are approved by the FDA for treating pain can also treat the cancer. A great example of this is Quadramet, an injectible radioactive drug, approved to treat bone pain in patients whose breast or prostate cancer has spread to bones, that we are using in a clinical trial to treat bone cancer, osteosarcoma.

Much more common, though, is the use of narcotics to treat cancer pain. But like almost every medicine, these drugs come with side effects. Feared ones. The two biggest fears among patients? That they may become addicted or they may die.

Let’s talk about addiction.

I’ll tell you about my patient, Q (not her real initial, given the sensitive nature of her story). When Q was diagnosed with osteosarcoma, the cancer had already spread throughout her lungs. She completed the usual course of chemotherapy and had a major operation to remove the tumor in her leg, but when it was all done, she was in pain and still had cancer in her lungs. Throughout her course, we were giving her oxycodone and OxyContin to control her terrible pain. After experimental treatment and truly heroic lung surgeries, however, she achieved a remission.

But as the pain lingered on, so did the use of oxycodone and OxyContin.

Soon she experienced one of the problems most narcotic patients go through – tolerance. She needed more and more medicine to achieve the same degree of pain control, because her body “got used to” the drugs.

Next she experienced another of the common problems with narcotics – dependence. Her body got so used to the drugs that attempts to take them away caused symptoms: sneezing and yawning weren’t so bad, but chills and diarrhea and pain? Those were terrible. So to ward them off, she took more painkillers.

Tolerance and dependence are normal reactions of a normal healthy body to chronic narcotic use. Tolerance and dependence are not the same as the dreaded “A” word – addiction.

Most people who use narcotics correctly never get addicted. Unfortunately, Q became addicted. Addiction is a psychological dependence on the drug… a strong feeling of NEEDING the drug. Dependence and tolerance are biological, they relate to how the body processes the drug, and can be easily managed. Addiction is an altogether different matter. Managing and dealing with addiction is NOT easy for either the person addicted or for their family members. Recovery from addiction is possible, but it is all too often a long and difficult process.

But imagine a world without pain medicines – a world where people suffer through physical pain without any relief. Awful, isn’t it? Unfortunately, as reported in the New York Times on September 10, 2007, this situation is all too real for many of the world’s poorest people. Their governments, so concerned about protecting people from addiction, have all but banned the use of these drugs. This has left cancer patients, and many others, to die a slow, painful, and horrifying death. They die with a pain that is altogether preventable, but is not because of government fear of addiction.

But addiction is a real danger, even when these drugs are used properly. OxyContin made a big splash when it was introduced, because its manufacturer, Purdue Pharma, claimed that, because it was a slow release formulation, it was not addictive. This is not true, and Purdue Pharma paid a hefty price for misleading physicians and consumers.

Death is also a risk, especially if these drugs are used incorrectly. Within the last two weeks, the Food and Drug Administration issued warnings after several patient deaths were linked to improper use of Fentora, a formulation of a powerful narcotic called Fentanyl, that is absorbed through the lining of the mouth.

So should we fear narcotics? Should they be banned like they are in parts of Sierra Leone (as reported by the New York Times)? Certainly not. No one should have to suffer like this woman.

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But we do need to respect them. These drugs need to be used properly. They need to be used carefully. And patients need to be warned that tolerance and dependence are expected, but that they are NOT signs of addiction.

And we need to remember that addiction is treatable. I just saw Q for a routine follow up appointment 2 weeks ago. After several inpatient detox stays, she has kicked her narcotic habit (she had graduated from OxyContin to heroin) and she was back in college. What an inspiration Q is! First she beat cancer, then she beat addiction. I’m sure she’ll beat whatever other challenges life throws at her on her way to the top!


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