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Medical Author:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Medical Editor:

William C. Shiel Jr., MD, FACP, FACR

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Most medications have a maximum dose. Usually, the maximum dose is one that you cannot exceed without suffering harm to the patient. In the case of most pain medications, taking more than the maximum dose will not increase the pain relief but may cause toxic side effects such as stomach ulcers, kidney damage, liver damage, chemical imbalance in the bloodstream, or death.

Strong opioid medications are slightly different in this regard, and this is fortunate for people who suffer from severe pain. With strong opioids, the dose depends on the amount of pain. These medications should not mixed with acetaminophen or other non-opioid drugs when used to treat chronic pain. People with intense pain can take very high doses of opioids without experiencing side effects. Some people with intense pain receive such high doses that the same dose would be fatal if taken by someone who was not suffering from pain. In the pain patient, that same high dose can control the pain and still allow the person to be wide awake enough to do his or her activities of daily living.

Long-acting opioid: The best way to treat chronic, severe pain is by keeping it under control all the time. The doctor can do this by using a long-acting opioid to keep the pain under control and a short-acting opioid to deal with those few times during the day when the pain breaks through. So, if a patient is on morphine, he would would receive a slow-release tablet that would keep the pain under control most of the time, and a short-acting tablet or liquid for those times when the pain breaks through.

Some opioids are not recommended for chronic pain.

• Demerol (meperidine), which is used often for acute pain after surgery, is a poor drug for chronic pain. It is not absorbed well when taken by mouth, and it causes dysphoria (feeling truly lousy) and seizures if used for more than a few days.
• Talwin (pentazocine) is also not appropriate for chronic pain, because it has a ceiling effect. There is a maximum dose, after which raising the dose gives no further pain relief. It also causes withdrawal symptoms when given to someone who is also taking another opioid.
• The opioid/acetaminophen or opioid/NSAID combination drugs are acceptable for short-term use, but acetaminophen is poisonous to the kidneys and liver when used for a long time or in high doses. Many NSAIDs are toxic to the kidneys and stomach when taken for a long time or in high doses.

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