Short acting potent opioids, such as Percocet, and ultrashort acting narcotics, like Actiq are particularly hard to justify for the management of chronic pain, because they only act for a short period of pain on a pain that is of longer duration. Short-acting narcotics often are used for the acute treatment of migraine headache that is moderate to severe in intensity. Orally self-administered narcotics that are commonly prescribed include codeine (typically prescribed with acetaminophen; eg, Tylenol #3), hydrocodone (typically prescribed with acetaminophen; eg, Lortab, Vicodin), meperdine (eg, Demerol), and oxycodone (either alone – eg, Oxy IR– or with acetaminophen – eg, Percocet). More potent short-acting narcotics include hydromorphone (Dilaudid) and morphine.

Self-administered short-acting narcotics also are available in an intranasal formulation (butyrophenone: Stadol) and a “lollipop” (hydromorphone: Actiq). Intranasal Stadol is notoriously addictive, and patients who are naive to narcotic therapy typically experience bothersome side effects with its use (even including hallucinations and delusional thinking).

All of the short-acting narcotics have the potential for promoting physical dependence, psychological addiction, or both. These drugs are meant for intermittent or short-term use, and – along with the dependence/addiction potential – extended use tends to lead rapidly to tolerance (ie, higher and higher doses of the opioid are required to produce an ever diminishing clinical response).

There is a potential role for migraines for ultrashort acting narcotics  – to abort an incipient attack. However, it is tricky to find the right moment to intervene and, if treated too early, repeated doses would be required, with all the ill effects that it would entail.

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This trial raised more questions than it answers. It does not prove that Cymbalta is uniquely beneficial for oxaliplaitn induced neuropathy and toxicity was significant. It was a comparison against placebo, not another analgesic or anti-depressant. Clearly, comparative studies are needed before it can be considered standard of care.

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Generally, narcotics are not the only modality that can be used to treat pain. Adjuvant therapies together with narcotics can be very helpful. For example, steroids and non-steroidal anti-inflammatory drugs, such as ibuprofen(Advil) can reduce the inflammation associated with tumors pressing on tissues, and certain anti-depressants and anti-seizure drugs can modify how the brain perceived pain and lessen it. There are also procedures, such as nerve blocks, that can be helpful  when pain is localized.

Cancer pain can require very high doses of narcotics. Guidelines provide guidance and in some case, recommend a specialty pain management consultation. A diagnostic re-evaluation is often indicated to exclude cancer progression. If there is progression, the best pain management is successful treatment of the underlying disease. It may sometimes be possible to switch to a different narcotic, which reduces tolerance and allows a lower dose, or decrease  total narcotic dose by using adjuvant analgesics, steroids or neuro-modifiyng drugs discussed above, but there remain situations in which very high doses are required despite all efforts. Intravenous patient controlled analgesia(PCA) with outpatient medication via a pump, or intrathecal catheters present other options.

Risk of addiction in cancer patients is very low, around 2% (Friedman et al), but several instruments can reduce it even farther:  CAGE questionnaire, Cyr-Wartman Screen, Skinner Trauma Screen, Screener and Opioid Assessment for Patients. It is important to understand the distinction between addiction, a psychological syndrome, and habituation, which is the body getting used to  narotics and requring higher doses. Habituation can be easily treated; addiction is much more difficult to treat. Unfortunately, overrated fear of addiction or unwarranted anxiety about attracting the attention of the DEA, sometimes leaves patients with inadequate pain control.

Failure to provide adequate pain control to cancer patients is a deviation from the standard of care and can be  grounds for a malpractice suite, or it can play a role in increasing recovery. The use of national guidelines or local state policies can be helpful to both plaintiff and defense. State pain policies can shield  practitioners who have complied with the state policy, or a damn physician who have not. Some state policies are so restrictive that they automatically put the defendant at a disadvantage. An expert who is familiar with the use of guidelines and local policies can prove invaluable in the litigation of cases the involve standards of pain management.

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