pain

MANAGEMENT

Debilitating pain is often associated with advanced cancer, leading to fears that a miserable life lies ahead. You can be reassured that this need not be the case and there are many sources of help and drugs to keep you comfortable, pain-free and able to enjoy a good quality of life.
It does, therefore, seem perverse that many people with advanced cancer delay reporting their symptoms, or are unwilling to take their analgesics. The reasons for this include not wishing to become addicted to strong pain-killers; using pain as a gauge to the cancer progressing or side effects such as drowsiness interfering with day to day life. With a proper assessment of your pain and how it affects you individually, a step-wise approach starting with mild analgesics through to the stronger morphine-based drugs can achieve good pain control which in turn can lead to improved sleep, energy levels and appetite. 

WHAT CAUSES PAIN?

Pain is caused by cancerous growths pressing on bones, nerves or organs in the body and may differ in type and severity. Individuals may variously describe pain as aching, throbbing, burning, shooting, sharp or tingling. It may be acute, coming on quickly and lasting only for a short time – post-operative pain for example. More often with advanced cancer, the pain becomes chronic, due to nerve changes and may be persistent. Chronic pain can be more difficult to treat so it is important that your Oncology team and GP are able to build up a picture about the type and cause of your pain, as drugs and other treatments work in different ways.

TYPES OF PAIN

  • Nerve pain also known as neuropathic pain, is caused by pressure on nerves or the spinal cord, and is often described as shooting or tingling.
  • Bone pain also known as somatic pain, is caused by damage to bone tissue. Bone pain is often described as aching or throbbing.
  • Soft tissue pain also known as visceral pain, may be described as sharp, aching or throbbing and is caused by pressure on or damage to an organ.
  • Referred pain arises from pain in one part of the body being felt elsewhere, for example pain may be felt in the right shoulder due to a swollen liver pressing on nerves that supply the shoulder.

N.B. Spinal cord compression, though uncommon, is a medical emergency and requires immediate attention. Symptoms are: severe pain in your back that doesn’t go away; numbness or difficulty using your arms or legs; pins and needles or electric shock sensations; problems controlling your bladder or bowels.

New or increased pain does not necessarily mean your cancer is getting worse, but you should always report it to your medical team as you may require an adjustment of your pain medication along with further investigations. Keeping a pain diary noting where the pain is, what it feels like, how often it occurs and how it is interfering with your sleep and daily life can be useful to work with a doctor or specialist nurse to find the best analgesia for you. Remember that not all pain is caused by your cancer as other health issues for example arthritis, may also cause pain and discomfort.

Macmillan Cancer Support have developed a useful pain diary – download it here.

WHO CAN HELP YOU?

Your Oncology team and Specialist Nurse can advise you on drugs for pain control, but often this can be better managed in the community by your GP, Macmillan Nurse or Hospice Doctor. They can also assess you in your home environment and refer you to Occupational Therapists who may suggest some aids to make life easier (e.g. handrails, bath seats) and to Physiotherapists who can advise on safe exercise. If pain becomes difficult to manage then there are Pain Specialists, usually specialist anaesthetists, and Palliative Care teams who may offer more advanced management such as nerve blocks, epidural and intrathecal analgesia, and patient controlled infusions (syringe drivers).

Treatments for pain include medication, radiotherapy, chemotherapy and non-invasive measures:

Painkillers (Analgesics)

There are many drugs to help control pain caused by cancer, ranging from mild anti-inflammatories to strong opioids. Drugs are available in different strengths and forms – tablets, liquids, patches, injections and infusions. The aim is to gain maximum pain control using the minimum dosage required, in order to reduce unwanted side effects. Building up the correct components for optimum pain control takes time and effort, trial and error and remembering that pain is not a constant thing but will vary day-to-day itself.

Opiates, opioids and narcotics are terms often used interchangeably, although there are some differences. Opiates are naturally derived from the opium poppy plant and include morphine and codeine. Opioids refer to synthetic drugs (examples include fentanyl, methadone and tramadol) or semi-synthetically produced drugs (for example heroin, oxycodone and hydrocodone). Narcotic describes a pain-relieving, sleep inducing drug. The most commonly used term which covers both natural and synthetic drugs is opioid. All are Class A drugs/ Controlled Drugs with laws to prevent their illegal and non-medicinal use.

Analgesics may be “layered” in order to gain good control:

  • Step one: non-opioid drugs including Paracetamol and anti-inflammatory drugs such as Ibuprofen and Diclofenac
  • Step two: weak opioids including Tramadol, Codeine often combined with Paracetamol (Co codamol; Co-Dydramol), and Dihydrocodeine
  • Step three: strong opioid drugs including Morphine (Oramorph), Fentanyl and Oxycodone (Oxynorm; Oxycontin)

Opioids are tolerated differently by people and individuals find a huge variation in each type of opioid, so some specialists will use opioid rotation in order to keep the daily dose to a minimum in an attempt to reduce unwanted side-effects. Tolerance can be a problem with opioids leading to a steep increase in dosage and this is when it may be necessary to look to other agents to manage the pain. Pain can also be affected by emotional, social ,environmental and deeply personal factors in addition to the physical and mechanical nature of the problem.

A word about addiction

There is a popular misconception that people who take opioids regularly to manage their pain will become addicted and for that reason, may be undertreated and needlessly suffer.

Addiction is associated with a psychological desire to get “high” or euphoric. The stigma attached to legal and medically prescribed narcotics comes from their association with illegal recreational drugs such as heroin and cocaine. Experts report that it is rare for people to become addicted to opioids when taken for pain caused by cancer.

Addiction is different from physical dependence on a drug. Your body can get used to a drug and you may require a higher dosage to get the same effect. This does not happen to everyone but may mean that you will need to adjust the dose of your medication under the guidance of your doctors or specialist nurse. Withdrawal symptoms may occur if you suddenly stop your drugs.

Other drugs used to control pain (Non-opioids)

  • Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen; DiclofenacParacetamol and non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen; Diclofenac
  • Steroids to reduce swelling – e.g. Dexamethasone; Prednisolone
  • Anti-depressants can help to relieve nerve pain – e.g. Amytriptyline
  • Anti-epileptics may also relieve nerve pain e.g Gabapentin; Pregabalin
  • Bisphosphonates can slow down bone damage e.g Zoledronic acid/Zometa; Ibandronic acid
  • Denosumab a targeted biological therapy, stops bone cells being broken down and strengthens the bone, thus reducing pain
  • Muscle relaxants such as a benzodiazepine may be added to prevent spasm and alleviate muscle tension in the painful area
Common side effects

Side effects vary between individuals and some people may be more affected than others. Very often, your body will adjust to a new drug after a few doses. Do discuss any side effects with your doctor or specialist nurse as most side effects can be effectively controlled. Listed below are the more common side effects:

  • Opioid drugs may cause – drowsiness, constipation, nausea, dry mouth. Less common side effects include extreme drowsiness, hallucinations, agitation, confusion, these should be reported immediately to your doctor as your dose may need reducing
  • Anti-inflammatory drugs may cause irritation of the bowel and stomach or severe bleeding if you do not take a Proton Pump Inhibitor (PPI) such as Omeprazole to protect your stomach lining. Always take them with food. Blood clotting can sometimes be impaired or your kidney function affected
  • Steroids are often given for short periods and under close medical supervision. They can be associated with many side effects and interactions with other drugs. Always remind medical and nursing staff you are taking steroids and do not stop them suddenly unless advised to do so by your doctor
  • Anti-epileptic drugs may cause fatigue, sleep disturbance and nausea
  • Anti-depressants may cause drowsiness, sleep disturbance, changes to your appetite
  • Bisphosphonates may cause nausea or diarrhoea, a skin rash, muscle aches or fatigue. Osteonecrosis of the jaw (ONJ) is a rare but serious side effect. Regular dental check-ups are advised if on a bisphosphonate, and careful consideration given prior to any invasive dental work
  • Denosumab may cause diarrhoea, bone, joint or muscle pain or breathlessness. Low calcium levels, and osteonecrosis of the jaw are less common but more serious side effects and need prompt medical attention
Other treatments for pain
  • Radiotherapy destroys cancer cells and shrinks tumours, so often used for bone pain or areas at risk of fracture, and can be very successful
  • Chemotherapy can shrink tumours thus reducing pain
  • Hormone treatments may also shrink tumours
  • Intrathecal/epidural/spinal anaesthetic – not a first line choice for pain control but helpful for people whose pain is not controlled by other methods. Requires a specialist anaesthetist to administer this and close supervision thereafter
  • Nerve blocks – again, a highly specialised treatment for problem areas
Controlling pain without drugs
  • Complementary therapies – including acupuncture; acupressure; counselling; relaxation; meditation; hypnotherapy; heat and cold massage; visualisation. Many of these treatments are available at special cancer support centres or via your local hospice. See Complementary Therapies for more details
  • Transcutaneous electrical nerve stimulation (TENS) – this machine blocks nerves that carry pain messages and can be useful for some people. Available through your GP or specialist nurse

You may like to consider your home and environment and what effects these may have on your pain control. Comfortable seating, pillows, mattresses, bathing aids and no undue reaching or pulling can all relieve pressure on your body. An Occupational Therapist can carry out a full assessment in your home, and can often supply the equipment free of charge. Sensible exercise combined with intervals of rest can make a big difference to your pain management.

Constant pain can be isolating and debilitating, so classes such as art therapy or other activities may help distract you and keep you engaged with the outside world. A duvet day or a good film may be necessary occasionally, but days filled slumped on the sofa with daytime TV is probably not so helpful.

Dos and don’ts of pain control

  • Do report uncontrolled, increased or new pain to your healthcare team
  • Do take your drugs regularly, rather than wait for pain to start
  • Do keep well hydrated with water
  • Do take a PPI (Omeprazole, Lansoprazole) to protect your stomach lining if taking NSAIDs
  • Do report any gastro-intestinal upset, pain or irritation
  • Don’t suddenly stop your analgesics especially morphine-based ones as they can cause withdrawal effects
  • Remember that alcohol can enhance the actions of some drugs, particularly opioids – most advise no alcohol to be taken with these drugs You may want to discuss this with your Oncologist or specialist nurse
  • Do not drive your car if your drugs make you drowsy (new laws have made this an offence)

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