fact sheet 3 - emerging solutions in pain · 2012-06-18 · patient education series....

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Managing Side EffectsChronic pain can affect you in many ways,1 making it diffi cult to enjoy life and do the things you need and love to do. Fortunately, today there are many different medications available that effectively treat pain.2 Although it may not be possible to completely eliminate your pain, an individualized treatment plan created specifi cally for you by you and your healthcare professional may signifi cantly reduce your pain and enable you to return, sometimes in a modifi ed way, to doing many normal activities.2,3 Your healthcare professional may be a physician, a physician’s assistant, or a nurse practitioner. He or she may work in a small practice or as part of a large group. Your healthcare professional may also be part of a larger pain management team working to help you manage your pain. This team of healthcare professionals may include physicians, specialists, nurses, therapists, and pharmacists.

Pain medications will likely be the main part of the treatment plan, which may also include other methods for relieving pain, for example, exercise, massage, and acupuncture.2,3 Medications can help relieve symptoms to make you more

comfortable and improve your ability to function.2 Being able to do things again, even in a limited fashion, will also help improve your physical, emotional, and psychological well-being.3 More information about the different types of pain medications is available in Fact Sheet 2 of the Emerging Solutions in Pain Patient Education Series. Unfortunately, in addition to all the potential benefi ts pain medications have to offer, they also have the potential to cause side effects or risks.2

The side effects that can be caused by pain medications may be mild and simply unpleasant, or they can be serious and potentially life-threatening.2 For this reason, you should tell your healthcare professional immediately if you are feeling or

experiencing something unusual. The good news is that many potential side effects which are caused by pain medications are often avoidable, and can be managed with help from your healthcare professional.2

Medications can help relieve symptoms to make you more comfortable and improve your ability to function.

Many potential side effects which are caused by pain medications are often avoidable, and can be managed with help from your healthcare professional.

Fact Sheet 3

Patient Tool Kit 2008Patient Tool Kit 2008

Fact Sheet 3

2 • Fact Sheet 3: Managing Side Effects

Start by talking to your healthcare professionalThe best way to avoid and/or manage medication side effects is to talk to your healthcare professional. To provide the best guidance, your healthcare professional needs to know about all the medications you are taking. This includes over-the-counter (OTC) and prescription pain medications, herbal remedies, nutritional supplements, and vitamins. You can start the conversation by putting all the medications you take—including the ones you may not think of as

medications, like herbal remedies, nutritional supplements, and vitamins—in a bag and bring them with you to your next offi ce visit. This is very important because medications can interact with one another and cause side effects.2

It is also important to tell your healthcare professional honestly about your intake of caffeine, alcohol, and tobacco, and about any illegal drugs you may be using including marijuana,2 even if you only use them occasionally. For more information about talking with your pain management team, see Fact Sheet 13 of the Emerging Solutions in Pain Patient Education Series.

Side effects with OTC pain medicationsOTC pain medications, such as acetaminophen and nonsteroidal anti-infl ammatory drugs (NSAIDs) such as aspirin and ibuprofen, rarely cause life-threatening side effects. But serious side effects can occur. Acetaminophen can cause liver and/or kidney damage, and this problem is more likely to occur if you drink a lot of alcohol or if you already have liver or kidney problems.2

NSAIDs, such as aspirin and ibuprofen, cause your stomach to produce more acid while also reducing the protective lining of your stomach.2 People who take NSAIDs for long periods of time,

or who take high doses of NSAIDs, are at an increased risk for gastrointestinal problems including upset stomach, ulcers, and bleeding. Drinking alcohol can also increase this risk.6 NSAIDs can also cause kidney and liver damage, and other health conditions such as high blood pressure. Taking NSAIDs if you are also taking a diuretic (also called a water pill) can also be dangerous.2 All medications should be taken as directed or by following the recommended dosage on the product’s label.


Acetaminophen can cause liver and/or kidney damage, and this problem is more likely to occur if you drink a lot of alcohol or if you already have liver or kidney problems.


If you are taking an OTC medication for your pain, tell your healthcare professional right away. He or she will know whether it is safe for you, and if so, what dose is right for you and how long you should take it.

To help protect your gastrointestinal tract from harm, your healthcare professional may suggest a protective medication such as a proton pump inhibitor (PPI), like Prilosec OTC®*, or an H2-receptor antagonist, like Zantac®*, to help prevent certain NSAID-related gastrointestinal side effects.2 These medications are available OTC, but consulting with a healthcare professional prior to their use is strongly suggested.

Side effects with prescription NSAIDsAnother type of NSAID, called a cyclooxygenase (COX)-2 inhibitor (Celebrex® * for example), is a non-opioid that is available only by prescription.2 Stomach problems may occur with their use. The COX-2 inhibitors may also cause kidney and cardiovascular problems, especially if taken for long periods of time or in doses not recommended.2 Together, you and your healthcare professional can decide whether a COX-2 inhibitor is right for your particular pain. A potentially dangerous symptom connected with NSAIDs involves asthma and nasal polyps. Anyone who has any history of asthma associated with use of an NSAID should avoid their use.

* The brand names that appear in these fact sheets are listed for information only. No endorsement is implied.

Side effects with opioidsOpioids are the most widely prescribed treatment for people with moderate-to-severe pain.4 Like all medications, opioids do have side effects. Your healthcare professional may be able to anticipate some of these side effects that may be more likely to occur because of your age, gender or race, and offer steps to help you avoid them.5

For example, people over 70 years of age are more likely to get side effects from taking opioids.5

If you are over 70 years old and your healthcare profes-sional prescribes an opioid for your pain, he or she may prescribe a lower dose or give you a longer break between doses. Men and African Americans are more likely than women and Caucasians to feel nauseous from taking opioids.5


Opioids are the most widely prescribed medications for people with moderate-to-severe pain.


The most common side effects of opioids, and how your healthcare professional may prevent and/or treat them, are:

• ConstipationConstipation is the most common side effect from long-term opioid use. To help prevent or reduce constipation, your healthcare professional may recommend that you drink more water and increase the amount of fi ber in your diet.5 He or she may also recommend you get more physical activity and try to go to the bathroom regularly. Your healthcare professional may prescribe a stool softener or a laxative to treat your constipation. If constipation remains a problem for you, your healthcare professional may suggest a pain medication patch, which may cause less constipation than oral opioids.5

• NauseaMany people who feel nauseous from taking opioids fi nd that this unpleasant feeling goes away over time. If you become very sick to your stomach and begin vomiting, your healthcare professional may prescribe a medication to help calm your stomach. Medications that are used for treating nausea caused by opioids include antihistamines, antipsychotics, prokinetic agents, and serotonin antagonists.5 These medications must be taken as directed.

• Tiredness and diffi culty thinking clearlyOpioids relieve pain by affecting your central nervous system or CNS—particularly your brain.2 As a result, they can cause some unwanted side effects in your brain including tiredness and diffi culty thinking clearly. These side effects tend to occur when you fi rst start taking an

opioid, and when your healthcare professional increases your opioid dose. To help prevent or treat these side effects, your healthcare professional may consider stopping any other medications you may be taking that have the potential to cause the same problem if they are not as necessary as your pain medication. He or she may also decide to prescribe a stimulant medication or antipsychotic to treat the problem.5 When you fi rst start taking an opioid for pain, it may be a good idea to avoid driving, and to take extra care to avoid falling, until you get use to having the medication in your system.2

When you fi rst start taking an opioid for pain, it may be a good idea to avoid driving, and to take extra care to avoid falling, until you get use to having the medication in your system.



• RashYou may think of a rash as an allergic reaction, but if you get a rash while taking opioids, it is probably an adverse reaction.5 Rash occurs most often in people receiving opioid treatment via an injection. If an opioid-related rash occurs, your healthcare professional may treat it with an antihistamine. Some individuals may get itchiness associated with opioids without a distinct rash. This can also be treated with antihistamines. Anyone developing a real rash should discontinue the medication and see their physician to make sure it is not an allergic reaction. If the problem persists, he or she may exchange the opioidyou are taking for a different one (called opioid rotation), reduce your opioid dose, or recommend the use of cold compresses or skin moisturizers.5

• Other possible side effectsIn rare cases, opioids can also cause more serious, life-threatening effects such as diffi culty breathing or slow, shallow breathing.2,4 One of the most feared adverse effects associated with opioids is the clinically signifi cant respiratory depression.

However, similar to sedation, tolerance to respiratory depression develops over a period of days to weeks. Respiratory depression rarely occurs if opioids are titrated according to individual patient response. The longer the patient receives opioids, the wider the margin of safety. So, fear of respiratory depression in patients who have been taking opioids for longer than one week should not pose a signifi cant barrier to prescribing an

adequate dose of the opioid. When respiratory depression occurs in an opioid-tolerant or an opioid-naïve individual, it is usually preceded by increased sedation. However, if appropriate steps are taken to address persistent sedation, then respiratory depression is uncommon in patients receiving long-term opioid therapy.7 However, methadone specifi cally can cause delayed-onset respiratory depression because the levels can increase over time, even if the dose is held steady. For this reason, special care is needed when treating a patient with methadone.

Avoid opioids in patients with a history of sleep apnea and it may be useful to inform family members to notify a healthcare professional if the patient appears sedated. If you experience diffi culty breathing while you are taking an opioid, call 911 immediately and then call your healthcare professional.

If, at any time, you experience diffi culty breathing or any other life-threatening event, call 911 immediately.



Another side effect of opioids is called subacute overdose.4 It is most likely to occur when your healthcare professional is increasing the dose of certain types of opioids such as methadone or levorphenol. Subacute overdose is like a small overdose. Signs include increasing tiredness, diffi culty breathing or slow, shallow breathing, fast or slow heartbeat, or feeling extremely dizzy or confused. If your healthcare professional believes you may be experiencing a subacute overdose, he or she may withhold a dose or two to correct the problem, and then resume increasing your dose more gradually. If, at any time, youexperience diffi culty breathing or any other life-threatening event, call 911 immediately. It is important to have family members and friends be aware of these side effects, and understand what to do if they occur.

Follow these helpful tipsRegardless of which types of pain medications you are taking, by following your healthcare professional’s recommendations, and these tips, you will give your pain medications the best chance to work so you can feel less pain—and return to a better quality of life.

1. Bring all the medications you are currently taking to your healthcare professional so he or she can see exactly what you are taking and know how they may be interacting with each other and with any new medications he or she may prescribe. (Remember, this includes all OTC and prescription medications, herbal remedies, nutritional supplements, and vitamins.)

2. Be honest and open with your healthcare professional about any illegal drugs you may be using, including marijuana, even if you only use them occasionally.

3. Tell your healthcare professional how many caffeinated and alcoholic beverages you drink each day, and about your use of tobacco including cigarettes, cigars, pipes, smokeless tobacco, and the nicotine patch.

4. Do not start taking any new medications, including OTC medications, herbal remedies, nutritional supplements, or vitamins, without fi rst asking your healthcare professional whether it is safe.

5. Take all your medications as directed by your healthcare professional.

6. Call your healthcare professional right away if you have any signs or symptoms of side effects from your medications or any other unusual response.

7. Call 911 immediately if you experience diffi culty breathing.

Do not start taking any new medications, including OTC medications, herbal remedies, nutritional supplements, or vitamins, without fi rst asking your healthcare professional whether it is safe.



Although it may not be possible for your pain to resolve completely, with commitment and persistence, you can overcome your pain and lead a happy, productive, and fulfi lling life.

There are other fact sheets available in this educational series. Please discuss which may be suitable for you with your healthcare professional.

For additional information about managing pain medication side effects, visit these resources:

• The American Society of Anesthesiologistshttp://www.asahq.org/patientEducation/managepain.htm

• Familydoctor.orghttp://familydoctor.org/online/famdocen/home/common/pain/treatment/122.html

• The National Cancer Institutehttp://www.cancer.gov/cancertopics/paincontrol

• The National Library of Medicine/The National Institutes of Healthhttp://www.nlm.nih.gov/medlineplus/painrelievers.html

References

1. Loeser JD. Pain and suffering. Clin J Pain. 2000;16(2 Suppl):S2-S6.

2. ACPA Medication & Chronic Pain. Supplement 2007. Rocklin, CA: American Chronic Pain Association. Accessed May 25, 2007 at: http://www.theacpa.org/documents/ACPA%20Meds%202007%20Final.pdf

3. Marcus DA. Treatment of nonmalignant chronic pain. Am Fam Phys. 2000;61(5):1331-1338,1345-1346.

4. The Agency for Health Care Policy and Research. Management of Cancer Pain. Clinical Guidelines Number 9. AHCPR Publication No. 94-0592. March 1994. Accessed December 31, 2007 at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.18803

5. Swegle JM, Logemann C. Management of common opioid-induced adverse effects. Am Fam Phys. 2006;74(8):1347-1354.

6. Pain relievers: Understanding your OTC options. Accessed July 30, 2007 at: http://familydoctor.org/online/famdocen/home/otc-center/otc-medicines/862.printerview.html

7. Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. Mosby 2010.


fact sheet 3 - emerging solutions in pain · 2012-06-18 · patient education series....

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