pain meds versus liver damage

Hi, Your brother, unfortunately, has advanced cancer with disseminated disease. He has stage IV lung cancer, with distant metastasis. In such cases, the aim of any treatment is palliation, not cure. As you correctly pointed out, pain management is a very important component of your brother’s treatment plan. The idea is to keep him as comfortable as possible. Principles of palliative care state that he should be given adequate pain relief during end-of-life. Pain clinics in cancer hospitals are well equipped to effectively control pain in a majority of cancer patients. Your brother is on Decadron, which is a corticosteroid. This drug has been prescribed to reduce brain swelling (cerebral edema) as he has metastatic involvement of the brain. Decadron also has a mild benefit in reducing bone pain. The other drug he is getting is Oxycontin, which is an opioid analgesic called oxycodone. This is useful in severe cancer related pain syndromes. Pain-killers in cancer patients are prescribed according to the World Health Organization Three-Step Analgesic Ladder. Your brother is currently on WHO Step 2. Since he is not getting adequate relief, he should be prescribed Step 3 medications. This means that in addition to opioids, he should also receive non-opioid analgesics like ibuprofen, naproxen, or ketorolac. He may also benefit from adjuvant drugs for neuropathic pain (anti-convulsants, antidepressants, etc) and adjuvant drugs for bone pain (bisphosphonates, gallium nitrate, etc). The approach to his bone pain should include palliative radiation and bisphosphonate therapy. In my experience, bisphosphonates like zoledronic acid are well-tolerated by most patients, and result in moderate reduction in bone pain within a few days. Another effective therapy that your treating oncologist or palliative care physician may like to consider is fentanyl trans-dermal patch. This can simply be applied to his skin like a sticker, and changed every 3 days. His wife too is understandably worried about him, and does not want any harm to occur to his liver. She needs to be counseled and gently explained that these interventions are for his overall benefit, and will make him much more comfortable during his last days. She may then be more willing to accept adequate pain-relief therapy for him.

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