Advanced Prostate Cancer

ACPA General Pain Management

What is chronic pain?

Chronic pain is pain that continues a month or more beyond the usual recovery period for an injury or illness or that goes on for months or years due to a chronic condition. The pain is usually not constant but can interfere with daily life at all levels.

What is a multidisciplinary pain management program (MPP)?

A MPP offers a variety of skills taught by trained staff to help a person better manage his or her pain. These programs may not offer a cure, but they can help to improve the quality of life and at the same time reduce the overwhelming control that pain can have of daily life. Visit the section titled Choosing a Multidisciplinary Pain Program on our web site.

I don’t understand why my doctor is asking me to take a new medicine. How can I find out more about what it is for and ways it might effect me?

A MPP offers a variety of skills taught by trained staff to help a person better manage his or her pain. These programs may not offer a cure, but they can help to improve the quality of life and at the same time reduce the overwhelming control that pain can have of daily life. Visit the section titled Choosing a Multidisciplinary Pain Program on our web site.

How do I find out more information about my pain problems?

Most chronic pain conditions have an organization that is designed to provide specific information about cause, treatment, and research. The Resources section of this site can link you to many of them.

How can I find a doctor who specializes in pain management?

As a start, you can visit the following sites:

How can I make my family understand how much pain I’m in?

There is no way for another person to feel your pain. It is more important for them to understand what their role is in helping you manage the pain. The ACPA Family Manual is an excellent resource for family members. It can help them realize that, while family members don’t feel the physical pain, their lives are affected in much the same way as that of the person with pain. Throughout the book they may read what others who live with a person with pain have to say and learn how to cope with the changes in their life and yours.

Is my pain all in my head?

This question is often asked by people who have been told that they will have to learn to live with their pain. At times, it is difficult to pin down a specific physical cause for the pain. But that does not lessen the suffering. When we experience any pain, it is in both our bodies and minds. We cannot separate the physical and psychological affects any situation has on us.

Addiction, Dependence and Tolerance

I’ve been told that there is a difference between physical dependence and addiction to pain medications, but I don’t understand. Can you explain the difference to me?

It’s very common for people to be confused about the difference between physical dependence and addiction. The main difference is that addiction includes a psychological (or mental) craving for the medication that can lead to self-destructive behavior. Physical dependence only means that your body needs the medication and you have symptoms when you do not take it. People become physically dependent on many kinds of medicines, including insulin, antidepressants, and others. It is a normal part of using some medications.

When you use a pain medication, after a while your body becomes used to having that chemical on a regular basis. Your body needs that medication to function normally. If you stop taking it or lower the dose, your body reacts badly, with physical withdrawal symptoms like headaches, nausea, shakes, and other more serious problems. This is physical dependence, and it is not at all the same as addiction.

Addiction is a psychological problem that causes people to lose control over their use of a medication. People with this problem sometimes think the drug is the most important thing in their lives. They might raise their dosage or continue using the medication without their doctors’ permission, or seek other sources of medication that their doctors don’t know about. They take the medication even when they know it is not good for them, and they might do risky and irresponsible things to get the medication.

Depending on the type of medication you use, physical dependence might be unavoidable. Talk to your health care professional if you are concerned about dependence or if you feel you might need to increase or decrease your dosage.

Addiction is avoidable. If you think that you might be taking a pain medication that you do not need for pain, talk to your doctor about safely reducing the dose. Also, if you become preoccupied with the medication, thinking about how soon you can take more or worrying excessively that you might run out, that can be a warning sign to talk to a health care professional about changing your treatment.


Why did my doctor give me an antidepressant for my pain? I’m in pain, not depressed! Can’t he see that the only problem is my pain? I need help now!

It is a little confusing, but a number of antidepressants have actually been found to help ease chronic pain. The effect these medicines have on pain is separate from their effect on mood. There are many things about chronic pain that we do not understand. However, it seems that imbalances in chemicals involved in pain perception and transmission may play a role. In low doses antidepressants seem to adjust these chemicals. As a result, they are a common and useful way to treat chronic pain. As with all medicines, unwanted side effects can occur. For this reason you should always talk with your doctor about how well the medicine is working in your body and any side effects you may have.


  • Dworkin, R. H., O’Connor, A. B., Backonja, M., Farrar, J. T., Finnerup, N. B., Jensen, T. S., et al. (2007). Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain, 132(3), 237-251.
  • McCleane, G. (2008). Antidepressants as analgesics. CNS Drugs, 22(2), 139-156.
  • Moulin, D. E., Clark, A. J., Gilron, I., Ware, M. A., Watson, C. P. N., Sessle, B. J., et al. (2007). Pharmacological management of chronic neuropathic pain–consensus statement and guidelines from the Canadian pain society. Pain Research & Management, 12(1), 13-21.


What is biofeedback and how can it help me with pain management?

Biofeedback is a method used to raise a person’s awareness of physical processes that the body usually controls on its own. A computer is used to take measurements of your body’s functioning. It tracks things like blood pressure, heart rate, skin temperature, sweat gland activity, or muscle tension. The computer also shows you the information it is gathering in real-time as a picture or a sound. You can then use the feedback from the computer to build skill in controlling your body’s state in ways that may be helpful. For instance, muscle tension can be a problem for people with chronic pain. Learning to relax specific muscles can be helpful. Learning to do this may be easier if you have computer feedback about the tension in that area. Similarly, we know that anxiety can make pain feel worse. So, a person with pain might use biofeedback to learn to control physical aspects of anxiety. This, in turn, may help decrease the problems with physical pain.

Basically, biofeedback is a way to learn helpful skills. Ideally these skills allow people with pain to become actively involved in their own treatment. While biofeedback may be helpful, it is important to know that it requires special technology. As a result, it can be costly. Depending on which skills you and your care provider think you need there may be less expensive ways of learning the same thing.


  • Cooperstein, M. A. (1998, November). Biofeedback Technology: A Prospectus. Pennsylvania Psychologist Quarterly, 58(9), 17,27.
  • Corrado, P. E. (1998). The effect of biofeedback training on locus of control in chronic pain patients. ProQuest Information & Learning). Dissertation Abstracts International: Section B: The Sciences and Engineering, 58 (9-B), 5110.
  • Feliu, M. H. (2005). Neurobehavioral rehabilitation: A program design. ProQuest Information & Learning). Dissertation Abstracts International: Section B: The Sciences and Engineering, 65 (10-B), 5429. (Electronic; Print)
  • Hernandez, A. F. (1999). Effectiveness of a biofeedback protocol in the management of pediatric and adolescent headaches. ProQuest Information & Learning). Dissertation Abstracts International: Section B: The Sciences and Engineering, 60 (3-B), 1301.
  • Trifiletti, R. J. (1984). The psychological effectiveness of pain management procedures in the context of behavioral medicine and medical psychology. Genetic Psychology Monographs, 109(2), 251-278.
  • Uslan, D. (2003). Rehabilitation counseling. In L. A. Jason, P. A. Fennell & R. R. Taylor (Eds.), Handbook of chronic fatigue syndrome. (pp. 654-690). Hoboken, NJ, US: John Wiley & Sons Inc.

FDA Regulation (REMS)

What do you think is going to happen to people like myself that depend on opiates just to get through a day because of what might happen with REMS (Risk Evaluation and Mitigation Strategies)? I’m worried what restrictions the FDA will place on these medications making them more difficult for people with pain to obtain.

The United States Food and Drug Association (FDA) is responsible for ensuring that human and veterinary drugs, medical devices, and cosmetics are both safe and effective. The FDA is requiring the development of risk evaluation and mitigation strategies (REMS) for many long acting pain medications. The drugs that will be required to have REMS programs include brand and generic formulations of fentanyl (Duragesic), methadone (Dolophine), morphine (Avinza, Kadian, Oramorph, MS Contin), oxymorphone (Opana), and oxycodone (Oxycontin)1. The FDA has the authority to mandate these REMS programs2. They are designing them to allow people continued access to their medications and address issues with medication abuse3.

As abuse of these drugs has increased the need for such programs is clear. REMS programs will help to provide all medical staff and patients with proper education on the risks and benefits of these drugs. The FDA is accepting input from everyone involved including doctors, pharmacists, manufacturers, and the general public.

REMS programs will include training for doctors, nurses, and pharmacists about how to correctly prescribe and inform people about these drugs. Patient education will include proper counseling, and written drug guides1. The FDA is also considering programs to limit product availability to patients who are registered with the FDA4.

Initial reactions to these changes are often negative. However, these programs will not prevent people from receiving their medication as needed. When done responsibly opioid prescribing already includes many of the potential REMS changes. The FDA is hoping that these changes will help to ensure responsible use of opioids and patient safety. As the development process continues, individuals with chronic pain should express their opinions in an effort to help guide the creation of a REMS program that will help limit abuse while allowing individuals access to opioids for the treatment of their pain.

Meetings to date:
2007: FDA Amendment Act
February 6, 2009: FDA announces decision to require REMS
February 10, 2009: Stakeholders Meeting: 99 representative from:

  • American Society of Anesthesiologists
  • American Pharmacist Association
  • Drug Enforcement Agency
  • American Pain Society
  • Lance Armstrong Foundation
  • American Society of Pain Educators
  • American Chronic Pain Association
  • Substance Abuse and Mental Health Services Administration
  • National Institute of Drug Abuse
  • American Academy of Pain Management
  • American Academy of Neurology
  • Patient Advocates

March 3, 2009: Industry Meeting: Pharmaceutical Manufacturers
May 27-28, 2009: Public Meeting
July 14, 2009: Meeting with American Pharmacist Association Representatives

For Updates and Future Meetings access

**The FDA has not approved any REMS programs, the details of this article are based on proposals and will be updated as new information is available**

Medication Dosage and Use

I’ve been prescribed narcotics because of chronic pain, and the bottle says I should avoid operating heavy machinery and driving when I take them. Can you tell me why? Is there anything else I should avoid, like herbal supplements?

Narcotic pain medications (also known as opioids) tend to make people dizzy and drowsy. That is why people taking them are warned not to do things that could be dangerous if you were not 100% alert. Many people who use narcotic medications for chronic pain report that these side effects lessen or go away after a few days or weeks on the medication. However, even if you feel alert, driving might not be safe or legal in your area. Consult your health care team about whether you should restrict your activities while taking narcotics.

You should avoid other things that can make you sleepy or dizzy while taking this medication. Sleeping pills, tranquilizers, muscle relaxants, antihistamines, and even alcohol can make the side effects worse. Even if you usually do not have these side effects, you can get them when you add another medication or alcohol to your routine. Also remember that even over-the-counter medications and herbal supplements might cause these problems when taken with narcotic medications.

In particular, the herbal supplements kava and valerian should not be used with narcotic medications. Kava is typically used as a pain reliever, muscle relaxant, anti-anxiety treatment, or anticonvulsant. Valerian has similar uses as a mild sleep aid, pain reliever, and muscle relaxant. Both of these supplements can intensify the drowsiness and dizziness of narcotic medications.

Tell your doctor about all medications and herbal supplements you take, including over-the-counter medications and vitamins. Read the labels of your medications and consult your health care team if you have concerns. If you have any side effects, be sure to tell your doctor—you might just need a different dose of the medication.

Three days ago, my daughter was prescribed an antibiotic for an ear infection. She is very small for her age, and I’m hesitant to give her the whole dose because I don’t think the healthcare provider considered her weight when determining the dose. I’ve been breaking the pill in half and she seems better. Did I do the right thing?

In a word, no. Antibiotics work by killing the bacteria that cause infection. If you take less than was prescribed, all the bacteria might not be killed. The surviving bacteria can become resistant to the drug, and it might not work the next time your daughter needs it. With antibiotics, it is very important to take the full dose and finish all the medication exactly as prescribed. Also, breaking pills can sometimes be dangerous.

Health care professionals are taught to consider both age and weight when prescribing medication. However, if you feel the doctor might have made a mistake, you should call the doctor’s office or ask your pharmacist to make sure that the dosage is in a safe and effective range. Pharmacists are a great source of information about medication safety.

It is good for you to be aware of the potential drawbacks of your child’s medications, but you must also be open with your child’s health care team about your concerns. If you don’t feel comfortable giving a drug to your child, please discuss those concerns with the medical team so that you can decide on a safe course of action.

I have a difficult time swallowing large pills, and in the past, I’ve crushed the pills up and mixed them into food to make them easier to take. Are there any medications that I shouldn’t do this with?

You should be very cautious about crushing pills. Many pills have a special timed-release coating that allows small doses of the medication to be absorbed over time as the coatings dissolve. Crushing a pill destroys its coating, and releases a much larger dose all at once, which can lead to dangerous side effects or even death.

Talk to your pharmacist about whether your medications are available in a different form. Your doctor might be able to change the prescription to a liquid, or to several smaller pills that are easier to take. If you have to use a large pill, ask your doctor or pharmacist if it is safe to crush it or dissolve it in food. To be safe, it’s important to ask about every medication, and even for refills if the pill changes from one manufacturer to another.

Medication Safety

I have some over-the-counter medications with an expiration date that has passed. Is it safe to still use these medications?

Expired over-the-counter drugs are usually safe, but they might not be effective. The expiration date on the bottle is the last date the manufacturer guarantees the full potency and safety of the drug. Research has showed that expired over-the-counter drugs are not harmful and they may have much of their original strength for up to a decade. However, to be certain that your drug is 100% effective, you should buy a new bottle. If you have concerns, ask a pharmacist or your doctor.

Note that expired prescription drugs are NOT always safe to use. Consult your doctor or pharmacist about whether old prescription medications should be discarded.

You should also ask about the best way to dispose of old medications. Some medications, such as many opioids, must be flushed down the toilet or drain. But others should not be flushed.

In recent years, discarded medications have been showing up in the water supply. To avoid this, mix the medication with coffee grounds or kitty litter and water, then wrap them in plastic and throw them into the trash.


I have been told by pain management specialists that I have a naturally opioid blockers that prevent any and all pain medication from relieving the severe pain that I suffer from. My doctors have said that the only option left for me is methadone and I don’t want to do that. Isn’t that a medication that they give to heroin users or drug abusers in general?

  • Methadone is a medication which has two FDA approved uses:
  • Management of moderate to severe pain
  • Detoxification and management of opioid addictionWhile it is true methadone can be used to help individuals addicted to opiates, including prescription medications (e.g., oxycodone, fentanyl, morphine) and non-prescription (e.g., heroin), it is also a very powerful pain reliever. As a pain reliever, your doctor may have you take it every 6-8 hours (for treatment of dependence it is taken one time every day).Many side effects of methadone are similar to other opioids including constipation, nausea, and respiratory depression (trouble breathing). With prolonged use, you may become tolerant, meaning you may require higher doses to achieve the same analgesic effect. Methadone, especially at higher doses, can cause irregular heartbeats (arrhythmias). Much of the negative press surrounding methadone in recent years is related to the potential to cause arrhythmias. Current research indicates that your risk of developing arrhythmias may be predictable. Your doctor may perform tests (like an ECG) prior to initiating therapy to help determine if you are at risk for developing this complication. In addition, your doctor may perform follow up monitoring of your heart’s response to the medication. While you are taking methadone, it is important to have your prescriptions filled at a pharmacy which is aware you are taking methadone: there are medications that can increase the likelihood of developing arrhythmias which you should avoid while taking methadone. In addition, it is important to let your doctor know what medications you are already taking to determine if methadone is an appropriate medication for you.There are benefits to using methadone as an analgesic. Methadone may offer benefits in the treatment of chronic pain over other opioid medications. While most opioids offer pain relief by acting at “mu” receptors, methadone is also thought to act at “NMDA” receptors. By also working at the NMDA receptor, methadone may offer these benefits:
    • Suppress nerve sensitization which helps to decrease your response to painful stimuli
      Help to prevent tolerance to the pain relieving effects of opioids
    • It is important to take this medication as your doctor prescribes it. The full effects of this medication may not be apparent immediately; do not take additional doses if you do not think it is providing adequate relief. If you miss a dose, do not take an extra dose. Your doctor will adjust your dose slowly to make sure that you tolerate it well. This medication is generally safe to use to treat chronic pain conditions, however, you must:
      • Make sure your health care provider is aware of your entire medical history
      • Make sure your pharmacy is aware of all medications you are taking so they can perform a complete check for potential drug interactions
      • Keep this medication away from children and pets and never give your medication to anybody for whom it was not prescribed
      • Seek medical attention if you believe you are experiencing any side effects


I have been prescribed Tegretol to treat trigeminal neuralgia. The package insert says this is an anticonvulsant medication. Does this mean I have a seizure disorder or I’m at risk of convulsing?

Yes, carbamazepine (Tegretol®) is classified as an anticonvulsant and used to treat seizures, but it is also approved by the FDA to treat neuralgia pain. It does not mean that you are at risk for seizures. This medication works on both seizures and trigeminal neuralgia pain because both of these symptoms are caused by overactive neurons, the cells that conduct electrochemical impulses in your nerves.

The word “neuralgia” means pain caused by a nerve. The trigeminal nerve is one of the main nerves in your face; it has branches that carry sensory information from your forehead, eye, cheek, and jaw. There is one trigeminal nerve on each side of your face. With trigeminal neuralgia, the nerve does not work correctly, and you experience sharp pain instead of regular sensation.

Carbamazepine blocks some of the signals in the nerve, in effect “calming it down.” With trigeminal neuralgia, reducing the nerve’s activity reduces the sensation of pain.

When I was given the original prescription for Tegretol, I was told the dose would likely be increased over time. Why?

Carbamazepine (Tegretol®) has some troubling side effects and it is not well tolerated by everyone. For those reasons, it usually is prescribed in a low dose at first. If you can do not have side effects, the dose can be increased gradually to a level that gives you enough pain relief. Over time, your doctor should adjust the dosage to the lowest possible amount that works for you.

There are many pain management techniques that you can try to help you get relief with lower doses of any medication. These include relaxation, pacing, distraction, and more. You can learn more about them on the ACPA web site or through our materials.

Why aren’t traditional pain medications like Tylenol, Percocet, or Vicodin used for controlling the pain of trigeminal neuralgia?

Traditional pain medications like the ones you listed are not very effective at treating pain from trigeminal neuralgia. Those analgesic (pain-fighting) medications are better for pain that increases gradually and persists for hours, but trigeminal neuralgia pain comes on suddenly and is very intense for a shorter time. Also, traditional pain medications do not block the trigeminal nerve’s signals like carbamazepine does.

Working With Your Doctor

What can I expect from a visit with a Pain Management Doctor?

Coming to your appointment prepared will help the doctor to assess your condition more efficiently and effectively. Some things you can do to prepare yourself for your appointment include:

  • Keep a pain journal. Note when your symptoms seem to be worse, what activities exacerbate your pain, and what alleviates your pain.
  • Bring a record of what medications you have tried to alleviate your pain. Make sure to include over the counter medications as well as medications you have been prescribed by other doctors.
  • Bring any previous x-rays, CT scans, and MRI films with you to the doctor. The doctor may request previous records from other doctors you have seen.
  • Bring a list of your current medications. It is important for the doctor to know all of your medications, even those which are not for your pain condition. Also include any over the counter medications, dietary supplements, vitamins, or minerals.
  • Think about how your pain affects your life; does it prevent you from participating in your regular activities? Is there anything you would like to be able to do that your pain currently prevents you from doing?
  • Bring a list of questions you may have for the doctor.

The doctor will complete a history and physical exam. The doctor will need to know what other medical conditions you have (for example; diabetes, hypertension, thyroid problems, etc.). It is also important to note when the pain started. Your healthcare provider will ask about the location of the pain, the severity of the pain, activities which influence your pain, whether the pain is accompanied by weakness, and the type of pain (aching, burning, stabbing, etc.)

Other symptoms the doctor may ask you about which seem related or unrelated to pain but may be a result of your condition may include sleep patterns and emotional status, recent infections, and stomach or bowel symptoms.

After completing the history and physical exam, the healthcare provider may order additional tests such as radiographic images (including x-rays, MRIs, etc.) or blood tests. Chronic pain is a complex process that requires a combination of treatments in order to achieve the best results. A multimodal treatment plan tailored to the patient will be developed that may include medications, possible procedures, assistance with emotional aspect of pain, and physical therapy. Developing a treatment plan which is likely to provide the most benefit given your treatment options and preferences requires a joint effort between you and your healthcare provider. The treatment of chronic pain requires a continuing and active effort from both the individual suffering from the chronic pain and the healthcare team.