CANCER PAIN

Relief from Pain: What to Know, What to Do

There are different treatments for different kinds of pain. Before we define this further, it's important to remember:

* You may be taking several medications. Be sure you understand when and how to take them, and report any side effects. Side effects can be helped.

* If one medicine isn't helping, there are many others you and your doctor can explore, or changes in the dosage that may help.

* No medication, not even an aspirin, should be taken without your doctor or nurse knowing.

* The pain control plan created by you and your doctor should be one that you can follow. Are you able to follow the plan? Are you having any trouble getting or taking the medicine? Talk to your doctor and re-evaluate your plan if there is any reason you cannot follow it. Medications and schedules of taking them can be changed.

Types of Pain Medicine

For mild or low level pain, acetaminophen and other nonsteroidal anti-inflammatory (NSAIDS) medication are recommended. These include aspirin and ibuprofen, and most are available without a prescription. NSAIDS, used alone, have a limit (ceiling) to their pain relieving effect, so taking a higher dose than specified is not recommended. Aspirin, although an excellent pain reliever, is not often given to people receiving radiation or chemotherapy. Even though these medications are usually sold over the counter, you still need to be monitored by your medical team for any side effects that could occur with long-term use.

For moderate to severe pain, you may need an opioid, which requires a prescription. Morphine, fentanyl, hydromorphone, oxycodone and codeine are all opioids. They can be taken by mouth (pill or liquid), through a patch on the body, in suppository form, or by injection. Unlike the NSAIDS, your doctor may increase the dose of these medications as much as it takes to relieve your pain. The dose of these medications can always be increased; meaning there is never a time when there is nothing to treat your pain. Sometimes your doctor may prescribe nonopioids along with opioids for this kind of pain. Many people have the misconception that medications such as morphine will lead to addiction. Studies have shown that this is not the case.

Pain caused by swelling is often treated with steroids. Examples of steroids include Prednisone and Dexamethasone. Prescriptions are necessary for these medications. It is important to carefully follow directions for taking these medications. Do not stop taking these medications without letting your doctor know, as they need to be decreased on a schedule over time before you can stop taking them.

Antidepressants may be prescribed for you to relieve symptoms such as the burning and tingling that occurs from nerve pain. This is a common practice. Taking antidepressants does not mean you are depressed, unable to cope or are "crazy". Amitriptyline and Imapramine are examples of antidepressants, but there are many others.

How is Pain Medication Given?

There are several "routes of administration" or ways a medication can be given. If one does not work well another route can be used. According to experts in cancer pain, 85% to 95% of cancer pain can be effectively relieved using oral medications. The other 5% to 15% of patients may need to have a different route of administration, and/or see a specialist to relieve pain. The message is, however, that no one with cancer needs to live with unrelieved pain.* Your doctor should work with you to decide the route that may work best for you, and the schedule that meets your needs.

* Taking medication by mouth, or the oral route, is generally the most convenient and inexpensive method. Oral medications come in tablet, capsule and liquid forms. Most people can be treated using oral medications.

* If you have problems swallowing, or problems with nausea and vomiting, your doctor may prescribe your medications to be taken through the rectal route, or the transdermal route. Medications administered rectally are in the form of a suppository, which dissolves from the heat of your body and releases medication. This route is not useful if you have diarrhea or rectal pain, or if you have difficulty placing the suppository.

* The only pain medication currently available using the transdermal route is fentanyl. Medication given in this way is put into a patch that attaches to the skin. Medicine from the patch flows into the skin over time.

* Medications can also be delivered into a muscle or a vein called the parenteral route. Medicine can be delivered into:
o The muscle (intramuscular or IM injections)
o Under the skin (subcutaneously or Sub-Q)
o The vein (intravenously or IV)
o The spinal fluid (intraspinal)
o Chambers in the brain called ventricles (intraventricular). This is a relatively new route, but it is becoming more common.

* You can also use a system called a patient-controlled analgesia (PCA). This allows the person taking the medication to control how much they receive. PCA can be dispensed through oral, intravenous, subcutaneous and intraspinal routes. When dispensed through a parenteral route, a special pump is used. In this way a predetermined dose is given in a steady infusion. You can give yourself an extra dose (bolus) if you are experiencing breakthrough pain, or adjust the medication if it would help you engage more comfortably in a physical activity, or treatment. It is safe to use this method at home, if your doctor evaluates you as a good candidate.

* Medications are generally prescribed around the clock to help keep your pain from building up. You can take medications every 4, 8, 12 or 24 hours. You should discuss this with your doctor and decide what schedule of medications works best for you.

We hope this helps you to understand that there are many options for you and your doctor to choose from when trying to control your pain. If one is not working, communicate with your doctor, and find about the other choices you have.

*Source: Journal of the National Cancer Institute, Vol. 89, No.17, September 3, 1997.

What is Breakthrough Pain?

People with cancer have two types of pain. Persistent pain means it is continuous and present most of the time. You may be on medication around the clock for this type of pain. Pain is an unstable phenomenon, meaning that it may vary due to numerous factors, including disease progression, activity level, specific movements, or stress level. Most patients experience many peaks and valleys of pain daily. Breakthrough pain is defined as a temporary moderate to severe flare in pain that occurs even though you may be taking medications regularly. It is called this because it "breaks through" your regular pain medication schedule. This does not mean that your around the clock medication has failed, or that your pain is uncontrolled. It means that your doctor may want to consider adding other medications that work quickly and for short periods of time. There are several types of breakthrough pain:

* Incident pain is an increase in pain with movement or activity, such as walking, sitting up, going to the bathroom or coughing.

* Idiopathic or spontaneous pain has no particular pattern or reason that pain increases.

* Another time that your pain may increase is just before you are to take a dose of medication on your regular pain medicine. This is called end of dose failure, and may not be an actual break through of pain. It may be best managed by your doctor adjusting the dose of your around the clock pain medication.

Pain is better controlled when both persistent and breakthrough pain are treated. This means you may be taking a long-acting medication around the clock to prevent your persistent pain, and prescribed a short-acting medication that is taken only when you experience episodes of breakthrough pain. Things to remember:

* The short-acting medicine should be taken as soon as you feel the breakthrough pain. If you let the pain build up and become too severe it is harder to get relief.

* Adding this medication will not give you more side effects; in fact it is done this way to lessen side effects because these medications stay in your body for a shorter period of time. Side effects from these short-acting medications are similar to the long-acting medicines, such as drowsiness, occasional nausea, or constipation.

* The short-acting medications should relieve most of your breakthrough pain without causing unacceptable side effects such as constant nausea. Your doctor or nurse can adjust the dose of your breakthrough medication to give you the best relief with the least amount of side effects. Contact them if you are not getting relief from your pain, or if breakthrough pain is occurring more than 4 times a day.

* If your pain is not relieved and your doctor says there is nothing more that can be done, ask to see a doctor who specializes in pain. They may be anesthesiologists, oncologists, neurosurgeons or a team of specialists that can evaluate your situation and let you know your options. See the section on Resources and Links for more information on where to go.

Reducing Pain Without Drugs

Contrary to what you may believe, there are lots of ways you can help relieve pain without drugs. Non-drug approaches can be helpful alone, or as an added boost to the pain medication you may be taking. The health section of any library or bookstore will have more information on the following techniques to help you help yourself.

Relaxation and Meditation can help reduce tension by relaxing your muscles or inducing a deeply relaxed state. These techniques include simple breathing exercises, progressive muscle relaxation, and visualization that reduces tension and anxiety. All of which can help you feel more energized and focused, and in turn relieve pain. For simple exercises click here.

Distraction or focusing your attention on something other than your pain is one approach that can be helpful. Listening to music, watching television, reading, cooking, or talking to family and friends can all work to take your mind off of the pain. It is often a useful technique during procedures that may be brief but painful.

Imagery for pain control is a method of allowing your mind and powers of concentration to focus on soothing images. It is a way of further extending the benefits of relaxation and distraction for your own benefit. For example, visualizing that your pain is like hot coals being put out as water is poured over them. Another way to use imagery is to imagine you are in your favorite place, relaxing. You could imagine yourself walking along a beautiful beach, imagining all the details such as how it sounds and smells, and how the warmth of the sun feels on you. There are many good audiotapes created to guide you through imagery, which has been very effective in relieving stress and discomfort for many people.

Skin stimulation simply refers to methods you use to alleviate pain such as massage, heating pads or ice packs. They can be used alone or in combination with other methods for relieving pain. Your doctor or nurse may be able to tell you which forms are more likely to be more effective in relieving your type of pain. For example, some pain responds better to heat than to cold. Just make certain you are careful, particularly with heat, which can cause burns or accidentally affect your blood circulation.

Exercise can help relieve tension, depression and fatigue. Exercise such as swimming or walking can be comforting and increase your energy level. An exercise program should only be started after your doctor gives you a thorough examination, and gives you the okay to begin such a program.

Support groups, either facilitated by a trained professional or through a peer led model can also be of benefit. In the group setting you can receive emotional support, you can talk to others who are experiencing the same problems and share information about coping.

CHRONIC OPIOID THERAPY for Chronic Non- Cancer Pain

Why the controversy?

by Jay Ellis, MD

Few topics in pain medicine generate as many disagreements as the use of chronic opioid therapy for chronic pain not due to cancer. Why would experts devoted to the care of chronic pain patients disagree so fervently about the wisdom of giving opioids to a patient with chronic pain? The controversy arises not so much from the accepted facts about opioid therapy, but rather in the interpretation of those facts and the application of the facts to the lives of the patients.

Do opioids work for benign chronic pain? The philosopher says, “First, define your terms.” Whether opioids work depends on the therapeutic endpoint sought by the patient and the physician. Proponents of opioid therapy point out that patients with chronic pain on opioid therapy report lower pain scores, improved quality of life and better sleep when started on opioid therapy.

Evidence based algorithms for neuropathic pain, such as diabetic neuropathy and post-herpetic neuralgia list opioids, especially sustained release oxycodone and tramadol, as second or third line treatment agents. Critics of opioid therapy point out that the studies of pain relief in chronic pain patients are of short duration, weeks to months, and that there is a shortage of good longitudinal studies. Observational studies such as a recent study from Denmark suggest there may be negative long-term health impact from chronic opioid therapy. Critics further argue that opioid therapy seldom results in significant functional improvement, and proponents of opioid therapy agree that functional improvement is modest at best.

Critics of opioid therapy further argue that the effect size, or degree of pain relief, with opioid therapy is often modest and lies in the 30 to 50 percent range for absolute reduction of pain scores. Proponents of opioid therapy counter that the same could be said for nonsteroidal anti-inflammatory medications, antidepressants and antiepileptic medications, which show pain reduction of a similar magnitude.

Critics of opioid therapy argue that many patients with chronic pain would benefit more from physical therapy, exercise, psychological counseling and treatment of psychosocial problems. Proponents of opioid therapy agree that those therapies are an important part of any therapeutic plan, and that if such treatments were uniformly successful there would be no need for opioid therapy. Patients on opioid therapy are individuals who have no other effective treatment.

What are the side effects/risks? Like all treatments, chronic opioid therapy has side effects and risks. The three issues that attract most discussion are tolerance, dependence and addiction. The terms are not interchangeable and space limitations prevent a full discussion of each term.

Tolerance, a physiologic response to the medication resulting in dose escalation can occur in some patients, and seems to be more of a problem in younger patients. It should be treated as a therapeutic failure and the patient should be weaned off opioids or considered for an alternative agent.

Dependence does develop in almost all opioid patients and will result in an abstinence syndrome if the medication is halted abruptly. This is a phenomenon seen in other medications (steroids, clonidine). Addiction, the major concern among many practitioners, does occur in 2 to 13 percent of patients, depending on the definition used and method of detection.

Critics of opioid therapy find this to be an unacceptable complication rate. Proponents of opioid therapy point out that it compares favorably with complication rates for long term NSAID therapy and the rate of addiction is equal to reported rates of illicit drug use in the general population. Proponents argue that the risk is justified when no better alternative is available. Other side effects of opioid therapy include cognitive dysfunction, constipation, suppression of hormonal secretion (especially testosterone) and opioid induced hypersensitivity. These side effects must be balanced against the benefits of therapy.

What should the doctor do? The decision to start a patient on chronic opioid therapy is not unlike a decision to embark on other treatments with significant risk, such as surgery or chemotherapy. The physician and patient must evaluate all of the treatment options available to them. There must be full disclosure of all potential risks and side effects along with a statement of the anticipated benefits. If the patient fails to respond due to lack of therapeutic benefit, intolerable side effects or development of abuse behavior, then therapy should be terminated with a gradual taper of the medication.

Not all patients are good candidates for opioid therapy Patients with a history of substance abuse and patients with significant untreated psychiatric disorders are especially problematic. Older patients do better than younger ones. Some disorders (fibromyalgia, muscle tension headaches) respond poorly to opioid therapy. Despite these misgivings, opioid therapy does provide selected patients with less pain and mild improvements in functional capacity. Denying chronic opioid therapy to all patients is no less a mistake than giving it to all chronic pain patients.

Jay Ellis, MD is a private practice Pain Management Physician/ Anesthesiologist with the River City Division of Tejas Anesthesia. He is also a Clinical Professor of Anesthesiology/Pain Management with the University of Texas Health Science Center at San Antonio and has been treating pain patients for 20 years.