Cancer Doctors: Negligent Over-Reliance on Narcotics.  

Opioid promoting cancer doctors have done absolutely no research to support their irrational dependence on highly addictive drugs, i.e., there is not a single study ever done in the history of the world showing opioids better than non-addictive pain medications for moderate to severe cancer pain.  In fact, after diligent searching and finding well over 220 studies comparing non-narcotic pain relievers to narcotics, I have been able to find only 12 studies comparing them in cancer victims.  In seven studies, the opiate (codeine, Demerol, morphine, Percocet, pentazocine (Talwin), tramadol (Ultram)) proved inferior as a pain reliever to a non-narcotic (diclofenac, flupirtine, hydroxyzine, ketamine, naproxen, pirprofen), while in three more the non-narcotic (dipyrone, ketorolac, nefopam) did as well as the opiate with fewer side-effects.  For pain in cancer victims, the track record for opiates is 0 wins, 10 losses, and 2 ties.  Where's the evidence for the massive drugging by American doctors of cancer victims.  Shouldn't there be some?  Cancer doctors are not practicing evidence-based medicine.

I can find absolutely no scientific evidence that narcotics have any place in the treatment of cancer pain.  Not one single study shows them to be superior to the many non-addictive pain strategies available.  If you know of one, please send it to me.  Despite the blatant untruths repeatedly claimed by some narcotic cancer doctors that cancer patients don't become addicts, large numbers of their patients become seriously addicted to the narcotics and are greatly dependent on their doctors for an ungoing supply.  Often, they don't dare move or even travel for fear of losing access to their narcotics.  Yet, they go on suffering because of inadequate pain relief along with the repeated daily discomfort of narcotic withdrawal in between doses of narcotics.  Many are on doses of narcotics which would cost several hundred dollars a day on the street, higher doses than many street junkies are hooked on.  While a significant percentage of cancer patients do doctor shop so as to have more opiates than any one doctor would be willing to give them, and a significant percentage do buy off the street to supplement what they get at the office, over 50% will be good patients for the rest of the lives, carefully keeping every appointment to be assured of the opiates on which they have become heavily dependent.  

Several studies show that opiate withdrawal causes a state of hypersensitivity to pain with severe back and body pains.  Might this be the real cause of "breakthrough pain?"  While a number of studies do show that cancer victims suffer less pain with opiates than if they received no pain treatment at all, there is not one study showing that non-narcotics would not be better.  

There are numerous studies showing that adding a non-narcotic pain medication to an opiate pain medication considerably reduces the pain that the cancer patients are suffering.  Despite this, most cancer patients are deprived of this easily obtained benefit.  Cancer doctors have been strongly conditioned into promoting and defending opiates.  Unfortunately, the opiates which they use in vast quantities (e.g. Vicodin, Oxycontin, Percocet) have been repeatedly shown to have the pain relieving strength of Tylenol, and are clearly inferior to even ibuprofen for moderate to severe pain in patients without cancer.  Every study which I have ever seen where a non-narcotic pain medication is added to an opiate which a patient is taking shows a major improvement in pain and reduction in narcotic usage.  And yet, only 20% of cancer victims in their last week of life are on any pain medication other than opiates.  Why is this?  Is the humane practice of medicine?  Many dying patients are kept so doped up from their inferior opiate pain treatment that they are deprived of being able to say goodbye.

Giving opiates to cancer patients is almost a sacred religious belief among cancer specialists.  While there are many, many studies comparing narcotics to placebos in the treatment of moderate to severe pain from many other causes and while such studies are routinely approved by the FDA, it is considered unethical by cancer doctors to deprive their cancer patients of narcotics for even a single day once the pain intensity reaches a moderate to severe level.  However, over 200 studies show that non-narcotics are better for moderate to severe pain.  Obviously, from the patient's point of view, moderate pain is moderate pain, whatever the cause.  Large percentages of patients would like to avoid highly addictive narcotics if an option were made available to them.  Unfortunately, even some ethics boards now refuse to allow pain patients be given a try of non-addictive medications instead of narcotics! (Kern Singh, Rush University Medical Center, private communication 1/7/06 who recently proposed such a study).  These "ethics" boards are negligently and unethically ignorant of the massive body of research evidence showing that non-narcotic pain medicines are superior.

Children: Ketamine Much Better than Meperidine (Demerol) for Bone Marrow Aspiration Pain: In a DB crossover study of 21 children with cancer having bone marrow aspiration or lumbar punctures, ketamine (1.5 mg/kg)/atropine/midazolam resulted in much less distress than meperidine (2 mg/kg)/midazolam (1.37 vs. 7.04 OSBD-R units; P < .05). Both operators and nurses rated KM more effective than MM. KM use was associated with earlier readiness for the procedure (19 vs. 24 minutes) and much more rapid recovery (39 vs. 74 minutes for removal of monitoring devices and 58 vs. 87 minutes for discharge). Procedures undertaken after ketamine sedation were associated with fewer side effects (hypoxia, 18% vs. 82%; hypotension, 17% vs. 56%; reduced respiratory rate, 0% vs. 39%). Parents and children expressed a preference for KM over MM in 12 of 18 cases (P < .05). Ketamine-midazolam versus meperidine-midazolam for painful procedures in pediatric oncology patients. Marx CM, et al. Case Western Reserve University. J Clin Oncol 1997 Jan;15(1):94-102.

Diclofenac (NSAID) Alone as Good as With Codeine or With Imipramine for Even Severe Cancer Pain: In a 4-day DB random assignment study of 184 cancer patients with moderate to severe chronic pain, diclofenac alone (50 mg q.i.d.) did as well as for pain relief as the combination of diclofenac and codeine 40 mg q.i.d., or the combination of diclofenac and imipramine, 10 or 25 mg t.i.d.. Withdrawal rates were similar in all groups. Double-blind evaluation of short-term analgesic efficacy of orally administered diclofenac, diclofenac plus codeine, and diclofenac plus imipramine in chronic cancer pain. Minotti V, et al. Divisione Oncologia Medica, Policlinico Monteluce, Perugia, Italy. Pain. 1998 Feb;74(2-3):133-7.

Dipyrone (NSAID) as Good as Morphine with fewer Side-Effects for Cancer Pain: In a 7-day DB PC study of 121 cancer pain patients without gastric involvement, dipyrone 2 g every 8 hours did as well as 10 mg of oral morphine given every 4 h for the relief of chronic cancer pain. Both did better than dipyrone 1 g. Dipyrone tended to be better tolerated than morphine. Efficacy and tolerance of oral dipyrone versus oral morphine for cancer pain. Rodriguez M, et al. Malaga, Spain. Eur J Cancer 1994;30A(5):584-7

Flupirtine (NSAID) Better than Pentazocine with Fewer Troublesome Side-Effects in Short, Small Study: In a 1-week DB study of 52 adults with "severe" to "very severe" cancer pain, NSAID flupirtine 100 mg (a centrally-acting analgesic) did better than pentazocine 50 mg with a daily dose of up to 6 capsules of each drug. Flupirtine produced more "good" or "very good" results than pentazocine (68% vs. 50%). Flupirtine fulfilled the requirements of both patients and doctors for effective cancer pain relief e.g. maintenance of the quality of life by complete or nearly complete pain remission in association with lack of abuse potential, oral dosage form and lack of disturbance of vital functions. Analgesic efficacy and safety of oral flupirtine in the treatment of cancer pain. Scheef W. Robert-Janker-Klinik, Bonn, Federal Republic of Germany. Postgrad Med J 1987;63 Suppl 3:67-70. Final evaluation demonstrated that flupirtine was significantly more effective than pentazocine in reducing pain. The incidence of side-effects was similar in both treatment groups, flupirtine, however, caused less intensive and less clinically relevant adverse reactions. Arzneimittelforschung 1985;35(1):75-7.

Flupirtine (NSAID) Superior to Tramadol for Pain with Fewer Side-Effects: In a 4-week DB study of 71 cancer patients with moderate to severe pain, flupirtine 400 mg/day was superior to tramadol 200 mg/day in relieving cancer pain. The final general assessment by the attending doctors of the results achieved was "good" to "very good" in 63% of the patients on flupirtine, and in 46% of those on tramadol. Undesired effects were observed in 6% of the flupirtine patients and in 19% of those taking tramadol. Treatment of tumor pain with flupirtine. Results of a double-blind study versus tramadol. Luben V, et al. Universitat Giessen, Germany. Fortschrit Med 1994 Jul 10;112(19):282-6. (loss)

Hydroxyzine Better than Meperidine (Demerol); Demerol Called "Not Justified" for Metastatic Pain: In a DB crossover study of 30 patients with chronic moderate to severe metastatic cancer pain, meperidine (50 mg IM) provided pain relief for only up to two hours while hydroxyzine (100 mg IM) provided relief for six hours. The combination of meperidine (50 mg IM) plus hydroxyzine (100 mg IM) provided additive pain relief only during the first two hours. The authors conclude, "(T)he limited additive analgesia observed with the addition of meperidine to hydroxyzine does not justify the added toxicity of the narcotic. Analgesic efficacy and pharmacokinetic evaluation of meperidine and hydroxyzine, alone and in combination. Stambaugh JE Jr et al. Cancer Invest 1983;1(2):111-7.

Ibuprofen (NSAID) Caused Major Decrease in Oxycodone/APC (Percodan) Usage and Improved Pain Control: In a DB PD 7-day study of 30 patients with chronic moderate to severe cancer pain who were already on oxy/APAP, ibuprofen 600 mg led to a marked decrease in oxy/APAP use (p less than 0.01) vs. a slight increase in use in the placebo group. Reduction in oxy/APAP usage occurred within 24 hours and maximized at 5 days. Daily pain intensity (p less than 0.05) and pain relief scores (p less than 0.05) also improved with the addition of ibuprofen. The combination of ibuprofen and oxycodone/acetaminophen in the management of chronic cancer pain. Stambaugh JE Jr, et al. Jefferson Medical College, Philadelphia, Pa. Clin Pharma Ther 1987 Aug;42(2):210-9. Ed: While this study doesn't address the issue of whether the narcotic has any value, it does document, as have numerous other studies, that the negligent and irrational reliance by cancer doctors on narcotics is causing huge numbers of patients to suffer needlessly in pain.  The majority of cancer victims are forced to suffer intense pain while doped up on narcotics, which are well documented to be poor pain relievers.  During the last week of life, only 20% of cancer patients are receiving an NSAID pain reliever!

Indoprofen IV (NSAID) as Effective as Morphine IM for Severe Cancer Pain: PRL response to thyrotropin-releasing hormone nor serum GH levels. Indoprofen may be a safer alternative to opiates for relief of moderate to severe pain in women with breast tumors suspected of being prolactin-dependent. Effect of i.v. indoprofen on cancer pain and serum prolactin and growth hormone levels--a controlled pharmacologic study vs i. m. morphine and placebo. Pellegrini A, et al. Int J Clin Pharmacol Ther Toxicol 1983 Sep;21(9):483-6

Ketorolac as Good as Pentazocine (Talwin)  with Fewer Side-Effects: In a DB study of 40 patients with moderate to severe cancer pain, 10 mg ketorolac (Toradol) orally every 6 h reduced pain as well as 50 mg pentazocine for up to 7 days. Withdrawals due to adverse reactions were much less with ketorolac (p< 0.005). Ketorolac, a new non-opioid analgesic: a double-blind trial versus pentazocine in cancer pain. Estape, et al. Clinic and Provincial Hospital, Barcelona, Spain. J Int Med Res 1990 Jul-Aug;18(4):298-304. Ed: This is a surprisingly small dose of ketorolac.

Naproxen Better Than Morphine SR for Malignant Nerve Pain: In a DB 1-week/phase crossover study of 20 patients with malignant nerve pain, naproxen 1500 mg provided better pain relief than slow-release morphine 60 mg/day. At day 7, significant pain relief of 32% (P < 0.05) was observed in the naproxen group, but not in the morphine group (21%, P = 0.14). Patients using morphine needed approximately twice as much paracetamol rescue than patients using naproxen. Medical therapy of malignant nerve pain. A randomised double-blind explanatory trial with naproxen versus slow-release morphine. Dellemijn PL, et al. University Hospital Rotterdam, The Netherlands. Eur J Cancer 1994;30A(9):1244-50.

Nefopam (NSAID) At Least as Good with Fewer Side-Effects Than Pentazocine: In a 10-day DB study of 40 cancer patients with chronic pain, NSAID nefopam relieved pain at least as well as the narcotic pentazocine. Side efftects after nefopam were different in nature and less frequent than after pentazocine. Analgesia with mild side effects. Schietzel M. Fortschr Med 1977 Dec 1;95(45):2743-6.

Pirprofen (NSAID) Better Than Pentazocine: In a DB study of 168 hospitalized cancer patients, NSAID pirprofen (200 and 400 mg) was clearly better at pain relief than pentazocin (100 mg) which did no better than placebo (p< 0.05). Pirprofen 400 mg was more effective than 200 mg (p<0.05). The analgesic effect of pirprofen appeared after 30 minutes and was maximum at one or two hours. Analgesic effects of pirprofen in cancer painBuckert D. Nouv Presse Med 1982 Aug 28;11(33):2511-3.

Zomepirac (NSAID) as Good as Oxycodone/APC (Percocet), Even for Severe Cancer Pain: In a single-dose, DB crossover study of 40 patients with moderate to severe chronic pain due to advanced cancer, zomepirac 100 mg (Zomax), did as well as oxycodone with APC (Percodan) on all assessments of pain intensity and pain relief. The authors state, "Zomepirac sodium, 100 mg, appears to be an acceptable alternative to narcotic combinations such as oxycodone with APC in the management of moderate to severe cancer pain."  Analgesic efficacy of zomepirac sodium in patients with pain due to cancer. Stambaugh JE Jr, et al. J Clin Pharmacol. 1981 Nov-Dec;21(11-12 Pt 1):501-7.

Opiate Cancer Pain Studies Without Non-narcotic Pain Relievers:

Many hundreds of studies, primarily funded by drug companies wishing to introduce expensive, patented narcotics, compare a traditional opiate to the new opiate and always include a placebo, usually finding little or no difference with the old narcotic and significantly better than the placebo.  If a study doesn't do better than placebo, it simply doesn't get published.  These companies intentionally avoid comparing their highly addictive narcotics to non-narcotic pain medications.  They don't want their cherished money makers to look bad.  Many patients in these studies are already on opiates for an extended period of time before the study.  

In my opinion, such studies are highly unethical.  They mislead doctors and patients into thinking that the narcotics are good medications, indeed, the best medications for those disorders.  They deprive the public of the knowledge of how their narcotics compare against non-narcotic pain meds.  In real life, a doctor never gives a patient in pain a placebo.  Doctors have to decide between various non-addictive and addictive medications available.  Maybe, cancer doctors don't tell their patients the truth, because they don't know the truth.

Hydrocodone No Better than Codeine or Non-Narcotic Tramadol: In a DB study of 177 patients with cancer pain, codeine, hydrocodone, and tramadol, 60% of the patients described their pain intensity as moderate (4-6/10), and 40% severe (7-10/10). The symptoms most associated with pain were weakness, insomnia. and anorexia. No significant statistical difference in the analgesic efficacy of the three opioids was found (p: 0.69; chi(2): 0.73). Use of tramadol produced slightly higher rate of adverse events than codeine and hydrocodone: vomiting, dizziness, loss of appetite, and weakness (p < 0.05). Incidence of weak opioids adverse events in the management of cancer pain: a double-blind comparative trial. Rodriguez RF, et al. Universidad Libre, Cali , Colombia . [email protected]. J Palliative Med 2007 Feb;10(1):56-60. Ed: Non-opiates have done better opiates for cancer pain in 8 of 10 double-blind studies. Opiates have never done better.

Non-narcotic Studies for Cancer Pain

Despite my being told by one opiate "expert" on cancer pain that it is unethical to do double-blind research using only non-narcotics for moderate to severe cancer pain, many such studies already exist.  That so-called expert was recently featured in the British Medical Journal giving truly bogus advice.

Ketorolac and Voltaren Both Effective for Severe Pain in Advanced Cancer: In a DB PC crossover study of 138 advanced cancer patients with moderate to severe pain, there was no significant difference in pain relief either afte a single dose or after one week between oral ketorolac (Toradol) 10 mg t.i.d. and diclofenac (Voltaren) 50 mg t.i.d. Satisfactory pain relief was reported for multiple 7-day treatments, with no significant differences between the two therapies: according to the physician's evaluation, in 73% on ketorolac vs. 71% on diclofenac; according to the patient's evaluation, 65% for ketorolac vs. 57% for diclofenac. Adverse symptoms were acceptable with both drugs. A double-blind evaluation of the analgesic efficacy and toxicity of oral ketorolac and diclofenac in cancer pain. The TD/10 recordati Protocol Study Group. Pannuti F, et al. ANT Laboratory,  University of Bologna, Italy. Tumori 1999 Mar-Apr;85(2):96-100

IM Ketorolac 10 mg as Good as 30 mg or IM Diclofenac for Severe Cancer Pain: In a single dose DB study patients suffering acute, moderate, or severe cancer pain, IM ketorolac 10 vs. 30 mg vs. diclofenac 75 mg. resulted in sustained and prompt pain relief in approximately 70% of patients throughout the 6-hour observation period with no significant differences in any efficacy measure. A double-blind study comparing two single-dose regimens of ketorolac with diclofenac in pain due to cancer. Minotti V, et al. Perugia Hospital, Italy. Pharmacother 1998 May-Jun;18(3):504-8.

Piroxicam as Effective as Aspirin with Fewer Side-Effects for Severe Head and Neck Cancer Pain: In a 4-day DB study of 50 head and neck cancer patients with moderate to severe pain, piroxicam did as well as acetylsalicylic acid (ASA) with fewer GI side-effects. There was a significant reduction in a pain and an increase in the hours of sleep in both groups. Comparison of piroxicam and acetylsalicylic acid for pain in head and neck cancers: a double-blind study. Saxena A, et al. All India Institute of Medical Sciences, New-Delhi. Palliat Med 1994;8(3):223-9.

NSAIDs Called First Choice for Cancer Pain: In a DB crossover study of 65 cancer pain patients receiving one week of each medication: acetylsalicylic acid, paracetamol, diclofenac, ibuprofen, indomethacin, pirprofen, sulindac, naproxen and suprofen were compared in the treatment of cancer pain. Naproxen, diclofenac and indomethacin were highly effective in pain relief  and were relatively well tolerated. It is concluded that these non-steroidal anti-inflammatory drugs can be considered as first choice in the treatment of cancer pain. Non-steroidal anti-inflammatory drugs as the first step in cancer pain therapy: double-blind, within-patient study comparing nine drugs. Ventafridda V, et al. National Cancer Institute, Milan, Italy. J Int Med Res 1990 Jan-Feb;18(1):21-9.

Naproxen Helped Severe Metastatic Bone Cancer Pain: In a 3-day DB study of 100 metastatic cancer patients with moderate to severe bone pain, patients receiving the high-dosage regimen received naproxen sodium (NS) 550 mg every 8 h for 3 days vs. the low-dosage regimen of an initial dose of NS 550 mg followed by NS 275 mg capsules every 8 h through day 3. Patients evaluated pain intensity 8 times/day. Pain intensity scores decreased by approximately one-third in each treatment group. Differences between regimens in adverse events during treatment were non-significant; complaints were mainly gastrointestinal and mild. Naproxen sodium in treatment of bone pain due to metastatic cancer. Levick S, et al. AlbertEinstein Medical Center, Philadelphia, PA 19141. Pain 1988 Dec;35(3):253-8.

Additional Studies

85% of French Terminal Cancer Patients on Opiates: Despite a significant body of research showing opiates inferior to other options, opiates are the norm, not the exception. Palliative Support Care 2003 Dec;1(4):345-52.

Opiates Kill Many European Cancer Patients: Questionnaires sent to physicians who signed a representative sample of death certificates in each country found that alleviation of pain opiates were thought to possibly have had a life-shortening effect in from 19% of all deaths in Italy to 26% in Denmark. Physicians usually administered opioids (from 76% of APS cases in Italy to 96% in The Netherlands), but the type of opioids and administration practice differed markedly between countries. The doses of opioids given in the last 24 hours also varied significantly and were usually lower than 300 mg oral morphine equivalent (from 83% of cases in Belgium to 93% in Sweden). Drugs used to alleviate symptoms with life shortening as a possible side effect: end-of-life care in six European countries. Bilsen J, et al. EURELD Consortium. End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium. . J Pain Symptom Management 2006 Feb;31(2):111-21. Ed: Oddly, the group of opiate activists doing this study somehow looks at the results of this study and still favors further increasing the use of opiates for the terminally ill. In view of the total lack of research showing that opiates are as good at relieving cancer pain as other alternatives, one wonders whether patients are being adequately informed before being started on opiates that there is a good chance that the opiates will hasten their deaths.