Opioids for Cancer Pain

Opioids are a type of medicine used to relieve moderate to severe pain. They may also be called opiates or narcotics, and are a type of analgesic (painkilling) drug. Opioids work in the brain and other parts of the body by attaching to pain receptors to block the feeling of pain. Some people with cancer need opioids for cancer-related pain.

Your cancer care team may prescribe opioids for increasing or severe pain. Cancer-related pain can be caused by the cancer itself or by cancer treatments.

How to use opioids safely

Opioids should be prescribed and used with great care for several reasons:

• Some pain medicines may interfere with other medications.
• Pain medicines may affect people differently. Because of this, some cannot be given to older adults, young children, or certain people being treated for other medical conditions.
• While opioids are good at managing pain, they can be misused or abused.

However, it's important to know that not everyone who uses opioids will become addicted or misuse them. Opioids can be safely taken when used responsibly and as prescribed.

Your cancer care team will discuss safety precautions and answer questions or concerns you may have.

If you are taking opioids, here are some important tips:

• Store your medications securely, such as in a locked box.
• Only take opioids as instructed by the provider who prescribed them.
• If you see more than one doctor, make sure they know all the medications you are taking. Opioids can interact with other medications, so it’s important for each doctor to know everything you’re taking.
• Don’t share your medication with anyone.
• If you drink alcohol or take tranquilizers, sleeping pills, antidepressants, antihistamines, or any other medicines that make you sleepy, talk to your doctor before starting opioids. Taking opioids (even small doses) while drinking alcohol or taking tranquilizers can cause serious problems. Combining opioids with these substances can lead to overdoses and symptoms like weakness, trouble breathing, confusion, and anxiety.
• If you have leftover or expired opioid medication, you should dispose of them safely. The FDA Safe Disposal site has more information and lists locations near you where you can safely return your unused medications. You might also be able to return them to your local pharmacy.

Your cancer care team might ask you questions before prescribing opioids. They might ask who you live with, if anyone has a history of addiction, if children are in the home, or how your medications are stored. A low dose of opioids might be prescribed first and then changes can be made based on how you’re feeling. While taking opioids, you might need to have urine or blood tests to check opioid levels.

Risk of opioid overdose

Taking too many opioids can slow a person’s breathing or even stop their breathing altogether. Other signs of opioid overdose include:

• Small, pinpoint pupils
• Loss of consciousness
• Choking or gurgling sounds
• Pale, blue, or cold skin

Naloxone (Narcan) is a medicine that blocks the effects of opioids in case of an overdose. Your cancer care team might suggest having naloxone (Narcan) available while you are taking opioids, especially if you are taking a high dose of opioids or are at a higher risk of overdose.

Some things that can increase a person’s risk of opioid overdose include:

• Certain medical conditions that affect breathing, like sleep apnea or chronic obstructive pulmonary disease (COPD)
• Taking benzodiazepines (such as Ativan, Xanax, or Valium) with opioids
• Having a history of overdose
• Using illegal drugs
• Taking medication for opioid use disorder (such as Methadone or Suboxone)
• Are over the age of 65 and have a non-opioid substance use disorder such as alcohol, or have a mental health disorder

Your doctor might prescribe Narcan to have on hand or direct you to where you can get it. All 50 states allow Narcan to be sold over the counter without a prescription. It comes as a nasal spray.

If you decide to keep Narcan on hand in case of an emergency, make sure whoever you live with knows where it is and how to use it. Your doctor, nurse, or pharmacist can show you.

Common opioids used for cancer pain

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

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

Opioids come in long-acting and short-acting forms.

Opioids that are called extended release (ER), long-acting (LA), controlled release (CR), and sustained release (SR) are all long-acting forms. This means they release a little bit of the medication over a longer period. They are often taken once or twice a day to treat chronic pain.

Immediate release (IR) opioids are short-acting forms and release their medicine quickly over a shorter period of time. These opioids are used to treat breakthrough pain. They might be taken several times a day depending on pain level.

There are pros and cons to long-acting and short-acting opioids. While long-acting opioids take longer to work, they provide relief for much longer. While short-acting opioids work quickly, they don’t provide relief for as long. A short-acting opioid might be used with a long-acting opioid to give steady relief.

Sometimes, the same opioid is used to treat both chronic and breakthrough pain. For example, morphine comes in different forms. Morphine sulfate immediate release (MSIR) is a short-acting form of morphine. Morphine sulfate controlled release (MS Contin) is a long-acting form of morphine. Someone might be prescribed both MSIR and MS Contin. It is important to know which you are taking and how often.

Common opioid and non-opioid drug combinations

Some opioids are combined with non-opioids in one medication for better pain relief.

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

Oxycodone

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

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

Hydrocodone

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

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

If you’re taking a combination pain medicine, be sure you know what drugs are in each because some can interact with each other and might damage your organs. For example, both Tylenol and Percocet have acetaminophen in them. There is a limit to how much acetaminophen you should take in a day, so it’s important to know how much total acetaminophen you are taking.

How to get pain relief with opioids

Talk to your cancer care team if your medications aren’t relieving your pain. It may take a few adjustments to find the combination that works best for you. Do not change how much or how often you take pain medication without talking to your care team first. If changing the dose or frequency doesn’t work, they may prescribe a different medication or add a new one to what you’re already taking.

Learn more about developing a pain control plan with your cancer care team.

Opioid tolerance

Some people need to increase the dose of their pain medicine over time to get the same relief as they did before at a lower dose. This may be because the pain has increased, or you have developed a drug tolerance. Drug tolerance occurs when your body gets used to the opioid you’re taking. Many people don’t develop a tolerance to opioids. But if you do develop drug tolerance, usually small increases in the dose or a change in the kind of medicine will help relieve the pain.

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

Side effects of opioids

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

Many side effects from opioid pain medicine can be prevented. Some of the mild ones such as nausea, itching, or drowsiness, often go away on their own after a few days as your body adjusts to the medicine. If you're having any side effects, let your doctor or nurse know and ask for help managing them.

Here are a few of the more common side effects:

Drowsiness or sleepiness

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

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

Here are some ways to handle sleepiness:

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

Constipation

Opioids cause constipation in most people, but it can often be prevented or controlled. Opioids slow the movement of stool through the bowels, which allows more time for water to be absorbed by the body. The stool loses water and becomes hard. When you start taking opioids, your doctor might also suggest taking a laxative, stool softener, or other treatment to help keep your stool soft and your bowels moving. See Constipation for more information.

Nausea and vomiting

Nausea and vomiting caused by opioids usually goes away after a few days of taking the medicine. See Nausea and vomiting for more information.

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

When you no longer need opioids

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