Types of painkillers
This page tells you about the main groups of drugs used to treat cancer pain. There is information about
Opioids (pronounced oh-pee-oyds) were first made from the juice of the opium poppy. But many are now manmade in a laboratory. There are different types of opioid painkillers. Some are used for mild or moderate pain and others for severe pain.
Opioids for severe pain include
- Fentanyl and Alfentanil
These are commonly used to treat cancer pain. You can only get them on prescription from your doctor. Used properly, these drugs do not have many side effects.
Opioids for mild to moderate pain include
Some types are available over the counter.
You may worry that you will become addicted to morphine and other opioid drugs. This is a common fear, but it is unlikely you will get addicted to painkillers if you are taking them for cancer pain. You are usually started on a weaker opioid, and then move on to a stronger one if needed. Sometimes you might need very high doses of these drugs to control your pain. It is quite safe to take high doses if you need them. Your nurse and doctor will keep a close watch for side effects.
Your doctor or nurse may prescribe non opioid drugs to take alongside opioids to give you the best pain relief possible.
There are lots of different preparations of morphine that can be given in different ways, including
- An immediate release liquid or tablet that you take every 2 to 4 hours
- Slow release tablets, capsules or powders that you take every 12 or 24 hours
- A liquid that can be injected into a vein or given through a drip
- A liquid that can be given through a small needle under the skin
- Suppositories inserted into your back passage
- Tablets you dissolve under your tongue (transmucosal tablets)
- Patches you stick on to the skin (transdermal patches)
When you start taking morphine, you will normally be given the more short acting immediate release type. You may take it every 2 to 4 hours. That way your dose can be adjusted quickly and easily until your pain is controlled. Your doctor or nurse will give you instructions on how much morphine to take and when to take it. Their instructions will allow you some flexibility so that you can take enough to control your pain.
If the dose you are taking is not enough for you, you will probably find that your pain comes back before the next dose of morphine is due. It is important to keep a note of how much morphine you take and when. Then your doctor or nurse can work out how much you need every 24 hours.
Once your doctor or nurse knows how much morphine you need to control your pain, they can give you slow release tablets containing enough morphine to control your pain for 12 or 24 hours. There are several types of slow release tablets and they are also called sustained release morphine. The morphine is released slowly from the tablet and controls your pain for long periods. This is more convenient than taking tablets every 4 hours.
Remember that you must take slow release tablets regularly or they won't work. When you start taking them, it can take up to 48 hours for the dose to steady in your bloodstream. They are not the sort of tablets that you can take now and again.
You should also have a supply of the immediate release type morphine to take, in case you have any extra pain while you are taking slow release tablets. The extra pain may be breakthrough pain or incident pain. Incident pain is the type of pain that comes on quickly when you do things such as have a dressing changed or change position. You should keep a note of what you take so that you can tell your doctor and nurse. If you frequently need extra doses, you may need a higher dose of the slow acting tablets.
With morphine, you often have other drugs that help to reduce pain. For example, you may also have an anti inflammatory drug to help control bone pain or to reduce swelling that is adding to the pressure caused by the cancer.
Diamorphine is a form of morphine that is very easy to dissolve in very small amounts of water. So it may be used when morphine needs to be given by injection, especially in a syringe driver. This is a battery operated or clockwork pump. It gives liquid from a syringe through a small fine tube placed just under the skin. The pump can give small amounts continuously. So it is used when good regular pain control is needed for people who have sickness or find it difficult to swallow tablets. It may be used for people who are terminally ill, but being cared for at home. A nurse changes the syringe every 24 or 48 hours.
Fentanyl is a manmade (synthetic), slow release opioid. You can have it as a patch (called Durogesic) stuck onto your skin that releases the drug slowly. So you don't have to take any tablets or have any injections. When you start fentanyl, it can take up to 72 hours to get the right level of drug in your bloodstream. So your doctor will ask you to carry on taking your previous painkillers for a while.
While you have a fentanyl patch, you should also have a supply of the immediate release type morphine or oxycodone to take, in case you have any extra pain. When you've had a fentanyl patch, it takes up to 72 hours to get the fentanyl out of your system once you stop using it. So any other painkiller you move onto will need to be phased in gradually as the fentanyl is phased out.
A small study has shown that fentanyl may not be absorbed as well in people who have had severe weight loss (cachexia). So in this situation, doctors may prescribe a different type of drug.
Fentanyl is also available as a lozenge that you dissolve under your tongue. It is called Actiq. It works very quickly and gives fast pain relief. It is helpful for pain that comes on quickly, such as when you need to have a dressing changed or move around. This type of pain is called incident pain.
Fentanyl is also available as a tablet that you put between your gum and cheek. It slowly dissolves. The tablets are called Effentora and Abstral. It is available as a nasal spray called PecFent. The tablet and the nasal spray are for breakthrough pain.
Alfentanil is a type of fentanyl. It is also called Rapifen. It dissolves in water and so may be used when you need fentanyl to be given by injection, especially in a syringe driver. This is a battery operated or clockwork pump. It gives liquid from a syringe through a small fine tube just under the skin. The pump can give tiny amounts continuously. So it is used when good regular pain control is needed for people who have sickness or find it difficult to swallow tablets. It can be used for people who are terminally ill, but being cared for at home.
Alfentanil is also available as a lozenge that you dissolve under your tongue. It works very quickly and can be used for breakthrough pain.
Buprenorphine is a medium to strong opioid painkiller. You can have it as stick on patches, similar to fentanyl. They are called Transtec and are useful if you find swallowing pills and medicines difficult. It takes at least 24 hours for the right level of the drug to build up in your bloodstream when you start the patches. And if you are using the 7 day patch called BuTrans, it can take up to 3 days for the right level to build up when you first start them. So you may need to continue with your other painkillers during this time, so follow your doctor's advice.
While you have one of these patches, you should also have a supply of the immediate release type morphine or oxycodone to take, in case you have any extra pain. It takes a few days to get the drug out of your system when you stop taking it.
Buprenorphine is also available as a tablet called Tephine that you dissolve under your tongue and have every 6 to 8 hours.
This opioid can be useful if you have both bone and nerve pain. Particularly if morphine has not helped your pain or has given you unpleasant side effects. Oxycodone is available as an injectable liquid, a liquid that you drink or as capsules to swallow. These preparations are called OxyNorm. There is a slow release tablet called OxyContin. You should have a supply of the immediate release type oxycodone to take, in case you have any extra pain while you are taking the slow release tablets.
Hydromorphone is a strong opioid. It is also called Palladone and is available as
- Immediate release capsules
- Slow release capsules that you take every 12 hours (Palladone SR)
- An injectable liquid
While you are taking slow release tablets you should also have a supply of the immediate release type hydromorphone, in case you have any extra pain.
Methadone is a strong opioid. It works very well at controlling nerve pain. It is available as
- A liquid that you swallow
- An injectable liquid
Codeine is a weak opioid and is usually the first choice of drug if non opioid drugs are not enough to control your pain. A number of tablets combine codeine and paracetamol, for example co-codamol or co-dydramol.
Tramadol is a weak opioid and is available as
- Tablets or capsules (Tramacet or Zamadol)
- Slow release tablets or capsules that you take every 12 hours (Dromadol, Nobligan or Tradorec)
- Tablets that dissolve on your tongue (Zamadol melt)
While you are taking slow release tablets you should also have a supply of the immediate release type tramadol, in case you have any extra pain. The maximum dose of tramadol you can have in 24 hours is 400 mg.
There is information about the side effects of opioids in this section.
These include drugs such as paracetamol and anti inflammatory drugs. Anti inflammatories are often called non steroidal anti inflammatory drugs (NSAIDs for short). These drugs are very good for relieving bone and muscle pain. They can help improve pain relief when you take them with stronger painkillers.
There are many different non steroidal anti inflammatory drugs. They include
You can have these drugs in different ways including
- As a liquid or tablet every 4 to 8 hours
- As slow release tablets that you take every 12 hours
- As an injection
- As a suppository (into your back passage)
Some of these drugs are available without a prescription, but always ask your doctor for advice on when and if to take them. They can irritate your stomach lining and you shouldn't take them if you have any history of stomach ulcers or stomach bleeding. They can also slow the time it takes for your blood to clot and so you should not take them with other drugs that slow your blood clotting, such as warfarin. Some can have an effect on how your kidneys work.
There is information about the side effects of these drugs in this section.
Your doctor may give you other drugs to help relieve your pain. These are sometimes called co analgesics or adjuvant analgesics because they are given alongside other painkillers (analgesics). They can mean that you can take a lower dose of opioid painkillers than you otherwise would. So you are less likely to have side effects. Co analgesics include
- Anti depressants
- Drugs to prevent fits (anti convulsants)
- Local anaesthetics
Steroids reduce swelling. These are useful for pain control because swelling around a tumour increases pressure on surrounding tissues and so may increase pain. Steroids are made naturally in the body and can also be made artificially and used as drugs. Doctors prescribe steroids for many different reasons and for many different illnesses and conditions. They can be tablets or injections. In cancer care, you are most likely to have either prednisolone or dexamethasone.
Cancer that has spread to the bone can cause pain. This can be a problem in advanced cancer, especially with breast cancer, prostate cancer and myeloma. Bisphosphonates are a group of drugs that may help to
- Control bone pain and so lower the amount of painkillers you need to take
- Slow down or prevent damage caused by cancer spread to the bones
We have a section that tells you about bisphosphonates.
Some types of anti depressant can help to relieve nerve pain that is not controlled by other painkillers. They can also help with depression that may be caused by long term chronic pain.
This group of drugs is usually used to control fits (seizures). But they can often help to relieve burning or tingling pain (nerve pain). The anticonvulsant drugs used include gabapentin (Neurontin), topiramate (Topamax), lamotrigine (Lamictal) and pregabalin (Lyrica).
These drugs are used for pain problems in a specific part of the body.
Some local anaesthetic drugs can relieve pain from mouth ulcers. Your doctor may suggest gel that forms a protective coating over the ulcer such as Gelclair (Orabase). Or they may suggest mouthwashes such as benzydamine (Difflam), Gelclair, MuGard or Caphosol. These drugs coat the lining of your mouth and can relieve pain from mouth ulcers caused by chemotherapy or pain caused by radiotherapy.
Local anaesthetic can be given by injection or infusion into the spine to help relieve severe back pain. This type of infusion is called an epidural or spinal anaesthetic.
There is information about the side effects of co analgesics in this section.
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