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Medical Author:

John P. Cunha, DO, FACOEP

John P. Cunha, DO, FACOEP

John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.

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Medical Author:

Standiford Helm Ii, MD

Standiford Helm Ii, MD

Dr. Helm has been practicing interventional pain management since 1982. Dr. Helm is a diplomate of the American Board of Anesthesiology with subspecialty certification in Pain Medicine and of the American Board of Pain Medicine. Dr. Helm is a Fellow of Interventional Pain Practice (FIPP), the only certifying agency which tests the ability to perform interventional pain procedures. Dr. Helm is also an examiner for FIPP.

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Medical Editor:

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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For severe pain, prescription narcotics are available.

• The advantage of prescription narcotics is there is no maximum dose.
• In high doses, however, they can affect breathing. In some cases, narcotics can lead to death if the person stops breathing. Medications taken by mouth are less likely to affect breathing.
• A doctor must supervise the adjustment of the dosage.

Narcotics, like all pain medications, can be used for both acute and chronic pain.

• Acute pain is pain which expected to occur after some event, such as an injury or surgery and that goes away after healing.
• Chronic pain is pain which persists after the expected healing time.

Narcotics are also divided into categories, called Schedules, by the government. Hydrocodone compounds, such as Vicodin, are Schedule III; many other narcotics are in Schedule II. For the patient, a major difference is that a physician can call or fax in a Schedule III prescription to the pharmacy, whereas a Schedule II medication requires a tamper proof prescription that the patient must deliver directly to the pharmacy.

Narcotics can be classified as either immediate release, with an effect lasting several hours, or sustained release, with effects lasting anywhere from eight hours to three days. Physicians use the sustained release forms primarily for chronic pain, where there is a continual need for pain relief. The intent is that by providing constant relief, the person suffering from chronic pain can focus on living their life (maintaining function) rather than constantly worrying about taking the next pill. In this way, physicians hope to minimize the occurrence of addiction.

Immediate release medications are used in the chronic pain setting to treat breakthrough pain, or short-lived (up to about an hour) pain that occurs because of increased activity or sometimes for no reason at all. Breakthrough episodes, if they do occur, can occur up to three to four times per day. There are many commonly prescribed immediate release medications, including preparations of morphine, oxycodone, hydromorphone,  meperidine, oxymorphone and fentanyl. Most of these medications are pills. Fentanyl comes in two preparations, Actiq and Fentora, which allow it to be absorbed into the blood stream through the lining of the mouth or the skin. Actiq and Fentora have the advantage of vary fast onset and have been approved by the FDA for cancer breakthrough pain.

The following are five commonly prescribed sustained release narcotic medications:

• morphine (MS Contin, Avinza, Kadain, Oramorph)
• oxycodone (OxyContin, Roxicodone, M-oxy, ETH-Oxydose, Oxyfast, OxylR)
• fentanyl (Duragesic, Fentanyl Patch)
• oxymorphone (Opana)
• methadone (Methadose)

Meperidine (Demerol) is not a very effective oral pain medication and should not be used as such. With all opioids, the major side effects are sedation, nausea, and constipation. Anyone taking narcotics should treat possible constipation, by maintaining a high fluid intake, a high fiber diet, and using stool softeners.

The purpose of prescribing opioids for chronic pain is to allow someone who is in pain to function more normally. If someone is too sedated from the opioids to function, then the medications being prescribed should be re-evaluated or possibly a pump should be used to deliver the medications into the intrathecal space (into the cerebrospinal fluid that surrounds the brain and spinal cord).

Most people using chronic opioid therapy do drive. Consult the prescribing physician before taking pain medication and driving, operating heavy machinery, or performing any job that may put the patient or others in danger. If someone taking opioids is involved in a traffic accident, they can be charged with driving under the influence.

Another sustained release nonnarcotic pain medication is tramadol (Ultram ER). It is not placed in a Schedule by the FDA, because the FDA does not believe there is significant abuse potential with this drug. It also has the advantage of being used once per day. While it is a less strong analgesic than the "scheduled" narcotics, it is very useful in some chronic pain patients who do not require stronger analgesics and also in patients who have a history of substance abuse whose physicians wish to avoid scheduled medications.

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