Cancer pain management

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Dr. Pankaj N Surange

Posted By : Dr. Pankaj N Surange - mbbs,md

Posted On : Apr 24, 2009 (Views : 3479)

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Understanding cancer pain


Interventional pain and spine specialist


Introduction


When you or a loved one receives a diagnosis of cancer, it isn't long before you begin to think of the pain many people associate with cancer. It can be a frightening time. What will the pain be like? What will it do to our lives? Many people with cancer eventually experience pain due to their condition. Approximately twenty percent of patients with newly diagnosed malignancies complain of pain. Thirty percent of patients undergoing cancer treatment complain of pain, and up to ninety percent of those with advanced cancer experience pain (Grossman 1994).

Pain associated with cancer can take many forms and is experienced differently by each patient. Pain can be sharp and severe, or it can be a dull constant ache. Regardless of the type of pain, a diagnosis of cancer does not mean you have to suffer with debilitating pain.

Today, most concerns about cancer-related pain can be relieved by understanding the facts about cancer pain, and learning about the help that is available for pain relief.


How pain happens?


Pain is transmitted through the body by the nervous system when our nerve endings detect damage to a part of the body. The nerves transmit the warning through defined nerve pathways to the brain, where the signals are interpreted as pain. Sometimes pain results when the nerve pathways themselves are injured. You feel pain when your brain receives the signal from your nerves that damage is occurring. All types of pain are transmitted this way, including cancer pain.


Pain can be acute or chronic: Acute pain usually starts suddenly, may be sharp, and often triggers visible bodily reactions such as sweating, an elevated blood pressure, and more. Acute pain is generally a signal of rapid-onset injury to the body, and it resolves when pain relief is given and/or the injury is treated. 


Chronic pain lasts, and pain is considered chronic when it lasts beyond the normal time expected for an injury to heal or an illness to resolve. Chronic pain, sometimes called persistent pain, can be very stressful for both the body and the soul, and requires careful, ongoing attention to be appropriately treated.

Along with chronic cancer pain, sometimes people have acute flares of pain when not all pain is controlled by the medication or therapy. This pain, usually called breakthrough pain, can also be controlled by medications.


Cancer pain can be caused by many different sources. Pain can be experienced when a tumor presses on nerves or expands inside a hollow organ. Pain also commonly originates from bone destructive lytic lesions. Bone marrow infiltration commonly cause bone pain that can be severe. Unfortunately, the radiation and chemotherapeutic treatments that are frequently used to treat cancer can also cause pain.




Assessment of your pain


The first step in getting your pain under control is talking honestly about it.

This means telling them:


• Where you have pain

• What it feels like (sharp, dull, throbbing, constant, burning, or shooting)

• How strong your pain is

• How long it lasts

• What lessens your pain or makes it worse

• When it happens (what time of day, what you're doing, and what's going on)

• If it gets in the way of daily activities


Your pain physician may ask you to describe your pain in a number of ways. A pain scale is the most common way. The scale uses the numbers 0 to 10, where 0 is no pain, and 10 is the worst. You can also use words to describe pain, like pinching, stinging, or aching. Some doctors show their patients a series of faces and ask them to point to the face that best describes how they feel.


Your Pain Control Plan


Only you know how much pain you have. Telling your doctor and nurse when you have pain is important. Not only is pain easier to treat when you first have it, but pain can be an early warning sign of the side effects of the cancer or the cancer treatment. You have a right to pain relief, and you should insist on it.


Cancer pain can almost always be relieved.

There are many different medicines and interventions available to control cancer pain. You should expect your doctor to seek all the information and resources necessary to make you as comfortable as possible. However, no one doctor can know everything about all medical problems. If you are in pain and your oncologist suggests no other options, ask to see a pain specialist or have your doctor consult with a pain specialist.


Controlling your cancer pain is part of the overall treatment for cancer.

Your pain physician wants and needs to hear about what works and what doesn’t work for your pain. Knowing about the pain will help your doctor better understand how the cancer and the treatment are affecting your body.


Preventing pain from starting or getting worse is the best way to control it.

Pain is best relieved when treated early. You may hear some people refer to this as “staying on top” of the pain. Do not try to hold off as long as possible between doses. Pain may get worse if you wait, and it may take longer, or require larger doses, for your medicine to give you relief.


You have a right to ask for pain relief.

Not everyone feels pain in the same way. There is no need to be “stoic” or “brave” if you have more pain than others with the same kind of cancer. In fact, as soon as you have any pain you should speak up.


People who take cancer pain medicines, as prescribed by the doctor, rarely become addicted to them.

Addiction is a common fear of people taking pain medicine. Such fear may prevent people from taking the medicine. Or it may cause family members to encourage you to “hold off” as long as possible between doses. Addiction is defined by many medical societies as uncontrollable drug craving, seeking, and use. When opioids (also known as narcotics) — the strongest pain relievers available — are taken for pain, they rarely cause addiction as defined here. When you are ready to stop taking opioids, your pain physician gradually lowers the amount of medicine you are taking. By the time you stop using it completely, the body has had time to adjust.


Treatment options


There is more than one way to treat pain. A simple, well-validated and effective method for assuring the rational titration of therapy for cancer pain has been devised by WHO. It has been shown to be effective in relieving pain for approximately 90 percent of patients with cancer and over 75 percent of cancer patients who are terminally ill. The World Health Organization (WHO) in 1986 established a stepladder approach for treatment of patients with cancer pain (fig.). The goal for this ladder was to provide treatment guidelines that healthcare practitioners could easily follow. The five essential concepts in the WHO approach to drug therapy of cancer pain are:



i) By the mouth. ii) By the clock. iii) By the ladder. iv) For the individual.

v) With attention to detail. 



Medicines

Non opioids

Opioids

Adjuvants


Medicines are prescribed based on the kind of pain you have and how severe it is. In studies, these medicines have been shown to help control cancer pain. Doctors use three main groups of drugs for pain: nonopioids, opioids, and other types


1. Nonopioids - for mild to moderate pain

Nonopioids are drugs used to treat mild to moderate pain, fever, and swelling. On a scale of 0 to 10, a nonopioid may be used if you rate your pain from 1 to 4. These medicines are stronger than most people realize. In many cases, they are all you'll need to relieve your pain. You just need to be sure to take them regularly.


You can buy most nonopioids without a prescription. But you still need to talk with your doctor before taking them. Some of them may have things added to them that you need to know about. And they do have side effects. Common ones, such as nausea, itching, or drowsiness, usually go away after a few days.


2. Opioids - for moderate to severe pain

If you're having moderate to severe pain, your doctor may recommend that you take stronger drugs called opioids. Opioids are also known as narcotics. You must have a doctor's prescription to take them. They are often taken with aspirin, ibuprofen, and acetaminophen.


Getting relief with opioids

Over time, people who take opioids for pain sometimes find that they need to take larger doses to get relief. This is caused by more pain, the cancer getting worse, or medicine tolerance (see Medicine Tolerance and Addiction). When a medicine doesn't give you enough pain relief, your doctor may increase the dose and how often you take it. He or she can also prescribe a stronger drug. Both methods are safe and effective under your doctor's care. Do not increase the dose of medicine on your own. 


3.Adjuvants

They can be used along with nonopioids and opioids. Some include:

Antidepressants. Some drugs can be used for more than one purpose. For example, antidepressants are used to treat depression, but they may also help relieve tingling and burning pain. Nerve damage from radiation, surgery, or chemotherapy can cause this type of pain.


Antiseizure medicines (anticonvulsants). Like antidepressants, anticonvulsants or antiseizure drugs can also be used to help control tingling or burning from nerve injury.

Steroids . Steroids are mainly used to treat pain caused by inflammation (swelling.)


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