Pain Control: An Interview with Robin Matthews

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Robin Matthews is a Family Nurse Practitioner at Seattle Cancer Care Alliance. Robin graduated from Columbia School of Nursing, in New York, with an M.S. in 2009. Robin has been working with Sickle Cell patients at SCCA since November 2011.

Q: What are the top five pain medications for pain ranging by pain level?
Robin: For fast-­‐acting medications, the most common are oxycodone and hydromorphone for severe pain; hydrocodone (as in Vicodin or Norco) is sometimes used for moderate pain. For long-­‐acting medications, OxyContin and MS Contin (long-­‐acting morphine) are the most common, with methadone coming in third. A very small number of people may use a fentanyl patch as their long-­‐acting medication. In the area of non-­‐opioids, ketorolac (Toradol) is frequently used in the hospital/ER setting; acetaminophen and ibuprofen are also commonly used.

Q: What are the side effects of these medications?
Robin: For opioids (morphine, oxycodone, hydromorphone, hydrocodone, fentanyl, methadone), the biggest concern is respiratory depression, or decreased drive by the body to breathe, which can lead to death. Other common side effects are sedation, nausea/vomiting, constipation, and itching. Another side-­‐effect is opioid-­‐induced hyperalgesia, which is the body becoming more sensitive to painful stimuli and even to non-­‐painful stimuli, so that a person might feel pain from something that wouldn’t normally cause pain.

Q: What is the possible addiction risk for each drug?
Robin: We know that with repeated dosing, the human body becomes tolerant to opioids, requiring higher doses to achieve the same effect. After a certain point, the body becomes physically dependent on the medication, meaning that a person will experience withdrawal symptoms if the medication is abruptly stopped (for opioids, withdrawal symptoms include shakiness, abdominal cramping/diarrhea, muscle aches). It is important to distinguish physical dependence from addiction.
Features of addiction include drug-­‐seeking behavior, obsessive thinking, drug cravings, continued substance use despite harm, and loss of control over substance use. Each person has a different risk for developing addiction to opioids, as the person’s genetics, environment and life experiences will affect their chance of becoming addicted. The chance of becoming addicted to opioids is more related to the person than to the drug.

Q: What are the most used medications?
Robin: For long-­‐acting medication, OxyContin is used a bit more than MS Contin; methadone is used less than each of these; fentanyl patch is used much less. For short-­‐acting medication, oxycodone and hydromorphone are used about equally. Short-­‐acting morphine is sometimes used. Hydrocodone (as in Vicodin or Norco) is used occasionally.

Q: What forms do these medications come in (e.g., pill, IV)?
Robin: Morphine is available as a short-­‐acting and long-­‐acting oral, IV or Intramuscular/Subcutaneous (IM/SC) form. Hydromorphone is available as short-­‐ acting oral, suppository, IV, IM/SC form. Fentanyl is available as a transdermal patch, oral lozenge (“lollipop”), or IV. Oxycodone is available as short-­‐ acting and long-­‐acting oral (it may also be compounded with Tylenol as in Percocet).
Hydrocodone is available as short-­‐acting oral (often compounded with Tylenol as in Vicodin or Norco, may also be compounded with ibuprofen as in Vicoprofen). Methadone is available as long-­‐acting oral tablet or solution and is also available in IV form but used rarely.

Published in February 2013 newsletter. Written by Karsten Weathersby