May 4, 2009
Pain and Pain Management
Wendye Robbins, MD, Ernest H. Rosenbaum, MD, and Richard Shapiro, MD
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Ask any group of cancer patients to describe their greatest fear, and chances are that they will say, "Pain and suffering - not death." This is not an unreasonable response. Pain is terrifying and debilitating: it can lead to depression, loss of appetite, fitful sleep, irritability, and feelings of isolation which, in turn, can strain relations with family and friends and erode the will to live.
Pain has been rated by some as the most common symptom in cancer survivors, especially when bones are involved. It has been estimated that from 50 - 80% of cancer survivors have some form of chronic pain. The goal is to help decrease suffering and distress, loss of function and improve quality of life.
Pain can be somatic (originating in tissue, skin, extremities, muscles, joints, bones, or organs), neuropathic (resulting from damage to or pressure on nerves), or a combination of the two. Somatic pain is often described as achy, dull, and localized when it results from a broken bone associated with tumor involvement or as crampy and diffuse when it results from an obstruction in the intestine or urinary tract. Bone metastases often are associated with pain, both locally and generally, necessitating an active treatment program.
Neuropathic pain, on the other hand, usually is described as sharp, burning, electrical, shooting, or buzzing. These sensations typically occur in areas served by the injured nerves, which can be either in the peripheral nerves or in the central nervous system. Such an injury can be caused by the direct spread of a tumor, such as that of colon cancer in the pelvis, where the nerves to the legs or pelvic structures reside. It can also be caused by pressure on nerves, as when spinal tumors pinch or press on nerves to the arms or legs. Other types of neuropathic dysfunction include hypersensitivity of the skin or an exaggerated, painful response to nerve stimuli (even a simple touch) and occasional motor changes such as weakness or atrophy of an affected muscle group. Surgery, various chemotherapeutic drugs, and radiation treatment can also produce temporary side effects of somatic or neuropathic pain or discomfort.
There can also be organ pain (caused by tumor expansion of organs such as the liver or spleen), intra-abdominal pressure, or neuropathic (nerve) pain, which can be related to the therapy (some chemotherapy drugs) or the cancer itself. Radicular radiating neuropathic pain from spinal metastases, caused by spinal (bone and spinal cord) nerve root tumor invasion, is common, as is visceral organ (internal) pain, which may also respond to chemotherapy or radiation therapy narcotic treatment. Other associated problems are anxiety, depression, and general suffering, which can be caused by the cancer at the pain site. In some instances, a neurological evaluation can be helpful in assessing neuropathic (nerve) and other types of pain. Sometimes, there is constant pain, requiring special procedures, often neurosurgical, to relieve nerve pain.
Many treatments are used, including narcotics, local radiation, and epidural spinal blocks. An additional mechanism is the use of patient-controlled analgesia (PCA), using infusion pumps or IVs (intravenous) to administer narcotics for severe uncontrollable pain.
Pain can occur at any time in the course of dealing with some forms of cancer - during treatment that leads to remission or cure as well as following treatment. However, according to the Committee on Pain of the World Health Organization (WHO), 90 - 95% of most pain problems can be controlled with appropriate therapy.
Good communication between patients and caregivers is essential to achieving optimal pain relief. Many people feel they should be able to tolerate pain and are therefore ashamed to discuss the extent of their suffering with their physicians. Not wanting to be perceived as weak, they fail to receive adequate pain relief. Talk to your medical team and caregivers!
Progressive Pain Relief Measures
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In recommending palliative measures for pain, physicians use guidelines set forth by the World Health Organization (WHO), which include standard treatments for mild, moderate, and severe pain - sometimes given with adjuvant medications. For those who fail to benefit from these standard procedures, physicians can try one of several means of direct intervention. To augment all of these options, patients can also experiment with any of several methodologies that enlist the mind and emotions in reducing the stress that exacerbates pain.
World Health Organization Guidelines
An expert committee convened by WHO's Cancer Unit developed a pain ladder on a scale of 1 to 10 (least to greatest) to aid physicians in assessing the source, quality, and intensity of pain and determining the most appropriate relief measures. The goal is to keep pain down to a level of less than 4 through continual reassessment of the cause of the problem and the effectiveness of the means of control. Effectiveness requires that a balance be maintained between the administration of any necessary increases in the strength of a medication and the production of toxic side effects, such as delirium, confusion, constipation, nausea or vomiting, allergies, or skin rashes.
Primary Pain Relief Measures
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- The following medications are recommended for different levels of pain, as determined by the pain ladder scale:
- - Nonnarcotic medications such as aspirin, acetaminophen (Tylenol®), or other aspirin-like drugs®known as nonsteroidal anti-inflammatory drugs (NSAIDs)
- Moderate pain:
- - A combination of NSAIDs and weak narcotics, such as codeine, hydrocodone (Vicodin® or Lortab®), Percocet®, Percodan®, or propyxphene (Darvon®)
- Severe pain:
- - Strong opioids such as morphine, Demerol®, Dilaudid®, fentanyl (Duragesic® patches), or methadone in combination with an NSAID
- Reprinted by permission