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Information from PDQ for Patients
Pain
208/04470
** INTRODUCTION **
This patient summary on pain is adapted from the summary written for health
professionals by cancer experts. This and other credible information about
cancer treatment, screening, prevention, supportive care, and ongoing clinical
trials is available from the National Cancer Institute. Pain associated with
cancer can be controlled in most patients but is frequently undertreated. This
brief summary describes the management of cancer pain with the use of
medication, physical methods, and psychological intervention.
** OVERVIEW **
Cancer pain can be managed effectively in most patients with cancer or with a
history of cancer. Although cancer pain cannot always be relieved completely,
therapy can lessen pain in most patients. Pain management improves the
patient's quality of life throughout all stages of the disease.
Flexibility is important in managing cancer pain. As patients vary in
diagnosis, stage of disease, responses to pain and treatments, and personal
likes and dislikes, management of cancer pain must be individualized.
Patients, their families, and their health care providers must work together
closely to manage a patient's pain effectively.
** ASSESSMENT **
To treat pain, it must be measured. The patient and the doctor should measure
pain levels at regular intervals after starting cancer treatment, at each new
report of pain, and after starting any type of treatment for pain. The cause
of the pain must be identified and treated promptly.
-- Patient Self-Report --
To help the health care provider determine the type and extent of the pain,
cancer patients can describe the location and intensity of their pain, any
aggravating or relieving factors, and their goals for pain control, as follows:
- Pain: The patient can describe the pain, when it started, how long it
lasts, and whether it is worse during certain times of the day or night.
- Location: The patient can show exactly where the pain is on his or her
body or on a drawing of a body and where the pain goes if it travels.
- Intensity or severity: The patient can keep a diary of the degree or
severity of pain.
- Aggravating and relieving factors: The patient can identify factors that
increase or decrease the pain.
- Goals for pain control: With the health care provider, the patient can
decide how much pain he or she can tolerate and how much improvement he or
she may achieve.
-- Assessment of the Outcomes of Pain Management --
The results of pain management should be measured by monitoring for a decrease
in the severity of pain and improvement in thinking ability, emotional
well-being, and social functioning. The results of taking pain medication
should also be monitored. Drug addiction is rare in cancer patients.
Developing a higher tolerance for a drug and becoming physically dependent on
the drug for pain relief does not mean that the patient is addicted. Patients
should take pain medication as prescribed by the doctor. Patients who have a
history of drug abuse may tolerate higher doses of medication to control pain.
** MANAGEMENT WITH DRUGS **
-- Basic Principles of Cancer Pain Management --
The World Health Organization (WHO) developed a 3-step approach for pain
management based on the severity of the pain:
- For mild to moderate pain, the doctor may prescribe a Step 1 pain
medication such as aspirin, acetaminophen, or a nonsteroidal
anti-inflammatory drug (NSAID). Patients should be monitored for side
effects, especially those caused by NSAIDs such as kidney or stomach and
intestinal problems.
- When pain lasts or increases, the doctor may change the prescription to a
Step 2 or Step 3 pain medication. Most patients with cancer-related pain
will need a Step 2 or Step 3 medication. The doctor may skip Step 1
medications if the patient initially has moderate to severe pain.
- At each step the doctor may prescribe additional drugs or treatments (for
example, radiation therapy).
- The patient should take doses regularly, "by mouth, by the clock" (at
scheduled times), to maintain a constant level of the drug in the body;
this will help prevent recurrence of pain. If the patient is unable to
swallow, the drugs are given by other routes (for example, by infusion or
injection).
- The doctor may prescribe additional doses of drug that can be taken as
needed for pain that occurs between scheduled doses of drug.
- The doctor will adjust the pain medication regimen for each patient's
individual circumstances and physical condition.
-- Acetaminophen and NSAIDs --
NSAIDs are effective for relief of mild pain. They may be given with opioids
for the relief of moderate to severe pain. Acetaminophen also relieves pain,
although it does not have the anti-inflammatory effect that aspirin and NSAIDs
do. Patients, especially older patients, who are taking acetaminophen or
NSAIDs should be closely monitored for side effects.
-- Opioids --
Opioids are very effective for the relief of moderate to severe pain.
Undertreatment results when concerns about addiction (psychological dependence)
to these drugs is confused with tolerance and physical dependence. Many
patients with cancer pain become tolerant to opioids during long-term therapy.
Therefore, increasing doses are necessary to continue to relieve pain, even at
the risk of side effects.
-- Types of Opioids --
There are several types of opioids. Morphine is the most commonly used opioid
in cancer pain management. Other commonly used opioids include hydromorphone,
oxycodone, methadone, and fentanyl. The availability of several different
opioids allows the doctor flexibility in prescribing a medication regimen that
will meet individual patient needs.
-- Guidelines for Giving Opioids --
Most patients with cancer pain will need to receive pain medication on a fixed
schedule to manage the pain and prevent it from getting worse. The doctor will
prescribe a dose of the opioid medication that can be taken as-needed along
with the regular fixed-schedule opioid to control pain that occurs between the
scheduled doses. The amount of time between doses depends on which opioid the
doctor prescribes. The correct dose is the amount of opioid that controls pain
with the fewest side effects. The goal is to achieve a good balance between
pain relief and side effects by gradually adjusting the dose. If opioid
tolerance does occur, it can be overcome by increasing the dose or changing to
another opioid, especially if higher doses are needed.
Occasionally, doses may need to be decreased or stopped. This may occur when
patients become pain free because of cancer treatments such as nerve blocks or
radiation therapy. The doctor may also decrease the dose when the patient
experiences opioid-related sedation along with good pain control.
Medications for pain may be given in several ways. The preferred method is by
mouth, since medications given orally are convenient and usually inexpensive.
When patients cannot take medications by mouth, other less invasive methods may
be used, such as rectally or through medication patches placed on the skin.
Intravenous methods are used only when simpler, less demanding, and less costly
methods are inappropriate, ineffective, or unacceptable to the patient.
Patient-controlled analgesia (PCA) pumps may be used to determine the opioid
dose when starting opioid therapy. Once the pain is controlled, the doctor may
prescribe regular opioid doses based on the amount the patient required when
using the PCA pump. Intraspinal administration of opioids combined with a
local anesthetic may be helpful for some patients who have uncontrollable pain.
-- Side Effects of Opioids --
Patients should be watched closely for side effects of opioids. The most
common side effects of opioids include nausea, sleepiness, and constipation.
The doctor should discuss the side effects with patients before starting opioid
treatment. Sleepiness and nausea are usually experienced when opioid treatment
is started and tends to improve within a few days. Other side effects of
opioid treatment include vomiting, difficulty in thinking clearly, problems
with breathing, gradual overdose, and problems with sexual function.
Opioids slow down the muscle contractions and movement in the stomach and
intestines resulting in hard stools. The key to effective prevention of
constipation is to be sure the patient receives plenty of fluids to keep the
stool soft. The doctor should prescribe a regular stool softener at the
beginning of opioid treatment. If the patient does not respond to the stool
softener, the doctor may prescribe additional laxatives.
Patients should talk to their doctor about side effects that become too
bothersome or severe. Because there are differences between individual
patients in the degree to which opioids may cause side effects, severe or
continuing problems should be reported to the doctor. The doctor may decrease
the dose of the opioid, switch to a different opioid, or switch the way the
opioid is given (for example intravenous or injection rather than by mouth) to
attempt to decrease the side effects. (Refer to the PDQ summaries on
Constipation, Impaction, and Bowel Obstruction, Nausea and Vomiting, Nutrition,
and Sexuality and Reproductive Issues for more information about coping with
these side effects.)
-- Drugs Used With Pain Medications --
Other drugs may be given at the same time as the pain medication. This is done
to increase the effectiveness of the pain medication, treat symptoms, and
relieve specific types of pain. These drugs include antidepressants,
anticonvulsants, local anesthetics, corticosteroids, and stimulants. There are
great differences in how patients respond to these drugs. Side effects are
common and should be reported to the doctor.
** PHYSICAL AND PSYCHOSOCIAL INTERVENTIONS **
Noninvasive physical and psychological methods can be used along with drugs and
other treatments to manage pain during all phases of cancer treatment. The
effectiveness of the pain interventions depends on the patient's participation
in treatment and his or her ability to tell the health care provider which
methods work best to relieve pain.
-- Physical Interventions --
Weakness, muscle wasting, and muscle/bone pain may be treated with heat (hot
pack or heating pad); cold (flexible ice packs); massage, pressure, and
vibration (to improve relaxation); exercise (to strengthen weak muscles, loosen
stiff joints, help restore coordination and balance, and strengthen the heart);
changing the position of the patient; restricting the movement of painful areas
or broken bones; stimulation; controlled low-voltage electrical stimulation; or
acupuncture.
-- Thinking and Behavioral Interventions --
Thinking and behavior interventions are also important in treating pain. These
interventions help give patients a sense of control and help them develop
coping skills to deal with the disease and its symptoms. Beginning these
interventions early in the course of the disease is useful so that patients can
learn and practice the skills while they have enough strength and energy.
Several methods should be tried, and one or more should be used regularly.
- Relaxation and imagery: Simple relaxation techniques may be used for
episodes of brief pain (for example, during cancer treatment procedures).
Brief, simple techniques are suitable for periods when the patient's
ability to concentrate is limited by severe pain, high anxiety, or
fatigue. (See Relaxation exercises below)
- Hypnosis: Hypnotic techniques may be used to encourage relaxation and may
be combined with other thinking/behavior methods. Hypnosis is effective
in relieving pain in people who are able to concentrate and use imagery
and who are willing to practice the technique.
- Redirecting thinking: Focusing attention on triggers other than pain or
negative emotions that come with pain may involve distractions that are
internal (for example, counting, praying, or saying things like "I can
cope") or external (for example, music, television, talking, listening to
someone read, or looking at something specific). Patients can also learn
to monitor and evaluate negative thoughts and replace them with more
positive thoughts and images.
- Patient education: Health care providers can give patients information and
instructions about pain and pain management and assure them that most pain
can be controlled effectively. Health care providers should also discuss
the major barriers that interfere with effective pain management.
- Psychological support: Short-term psychological therapy helps some
patients. Patients who develop clinical depression or adjustment disorder
may see a psychiatrist for diagnosis.
- Support groups and religious counseling: Support groups help many
patients. Religious counseling may also help by providing spiritual care
and social support.
The following relaxation exercises may be helpful in relieving pain.
Exercise 1. Slow rhythmic breathing for relaxation *
1. Breathe in slowly and deeply, keeping your stomach and shoulders relaxed.
2. As you breathe out slowly, feel yourself beginning to relax; feel the
tension leaving your body.
3. Breathe in and out slowly and regularly at a comfortable rate. Let the
breath come all the way down to your stomach, as it completely relaxes.
4. To help you focus on your breathing and to breathe slowly and rhythmically:
Breathe in as you say silently to yourself,"in, two, three." OR Each time you
breathe out, say silently to yourself a word such as "peace" or "relax."
5. Do steps 1 through 4 only once or repeat steps 3 and 4 for up to 20
minutes.
6. End with a slow deep breath. As you breathe out say to yourself, "I feel
alert and relaxed."
Exercise 2. Simple touch, massage, or warmth for relaxation *
Touch and massage are traditional methods of helping others relax. Some
examples are:
- Brief touch or massage, such as hand holding or briefly touching or
rubbing a person's shoulders.
- Soaking feet in a basin of warm water or wrapping the feet in a warm, wet
towel.
- Massage (3 to 10 minutes) of the whole body or just the back, feet, or
hands. If the patient is modest or cannot move or turn easily in bed,
consider massage of the hands and feet.
- Use a warm lubricant. A small bowl of hand lotion may be warmed in the
microwave oven or a bottle of lotion may be warmed in a sink of hot water
for about 10 minutes.
- Massage for relaxation is usually done with smooth, long, slow strokes.
However, try several degrees of pressure along with different types of
massage, such as kneading and stroking, to determine which is preferred.
Especially for the elderly person, a back rub that effectively produces
relaxation may consist of no more than 3 minutes of slow, rhythmic stroking
(about 60 strokes per minute) on both sides of the spine, from the crown of the
head to the lower back. Continuous hand contact is maintained by starting one
hand down the back as the other hand stops at the lower back and is raised.
Set aside a regular time for the massage. This gives the patient something
pleasant to anticipate.
Exercise 3. Peaceful past experiences *
Something may have happened to you a while ago that brought you peace or
comfort. You may be able to draw on that experience to bring you peace or
comfort now. Think about these questions:
- Can you remember any situation, even when you were a child, when you felt
calm, peaceful, secure, hopeful, or comfortable?
- Have you ever daydreamed about something peaceful? What were you
thinking?
- Do you get a dreamy feeling when you listen to music? Do you have any
favorite music?
- Do you have any favorite poetry that you find uplifting or reassuring?
- Have you ever been active religiously? Do you have favorite readings,
hymns, or prayers? Even if you haven't heard or thought of them for many
years, childhood religious experiences may still be very soothing.
Additional points: Some of the things that may comfort you, such as your
favorite music or a prayer, can probably be recorded for you. Then you can
listen to the tape whenever you wish. Or, if your memory is strong, you may
simply close your eyes and recall the events or words.
Exercise 4. Active listening to recorded music *
1. Obtain the following:
- A cassette player or tape recorder. (Small, battery-operated ones are
more convenient.)
- Earphones or a headset. (Helps focus the attention better than a
speaker a few feet away, and avoids disturbing others.)
- A cassette of music you like. (Most people prefer fast, lively music,
but some select relaxing music. Other options are comedy routines,
sporting events, old radio shows, or stories.)
2. Mark time to the music; for example, tap out the rhythm with your finger or
nod your head. This helps you concentrate on the music rather than on your
discomfort.
3. Keep your eyes open and focus on a fixed spot or object. If you wish to
close your eyes, picture something about the music.
4. Listen to the music at a comfortable volume. If the discomfort increases,
try increasing the volume; decrease the volume when the discomfort decreases.
5. If this is not effective enough, try adding or changing one or more of the
following: massage your body in rhythm to the music; try other music; or mark
time to the music in more than one manner, such as tapping your foot and finger
at the same time.
Additional points: Many patients have found this technique to be helpful. It
tends to be very popular, probably because the equipment is usually readily
available and is a part of daily life. Other advantages are that it is easy to
learn and not physically or mentally demanding. If you are very tired, you may
simply listen to the music and omit marking time or focusing on a spot.
* Adapted and reprinted with permission from McCaffery M, Beebe A: Pain:
Clinical Manual for Nursing Practice. St. Louis, Mo: CV Mosby: 1989.
** ANTICANCER INTERVENTIONS **
-- Radiation Therapy --
Local or whole-body radiation therapy may increase the effectiveness of pain
medication and other noninvasive therapies by directly affecting the cause of
the pain (for example, by reducing tumor size). A single injection of a
radioactive agent may relieve pain when cancer spreads extensively to the
bones.
-- Surgery --
Surgery may be used to remove part or all of a tumor to reduce pain directly,
relieve symptoms of obstruction or compression, and improve outcome, even
increasing long-term survival.
** INVASIVE INTERVENTIONS **
Less invasive methods should be used for relieving pain before trying invasive
treatment, however, some patients may need this type of therapy.
-- Nerve Blocks --
A nerve block is the injection of either a local anesthetic or a drug that
inactivates nerves to control otherwise uncontrollable pain. Nerve blocks can
be used to determine the source of pain, to treat painful conditions that
respond to nerve blocks, to predict how the pain will respond to long-term
treatments, and to prevent pain following procedures.
-- Neurologic Interventions --
Surgery can be performed to implant devices that deliver drugs or electrically
stimulate the nerves. In rare cases, surgery may be done to destroy a nerve or
nerves that are part of the pain pathway.
-- Management of Procedural Pain --
Many diagnostic and treatment procedures are painful. Pain related to
procedures may be treated before it occurs. Local anesthetics and short-acting
opioids can be used to manage procedure-related pain, if enough time is allowed
for the drug to work. Anti-anxiety drugs and sedatives may be used to reduce
anxiety or to sedate the patient. Treatments such as imagery or relaxation are
useful in managing procedure-related pain and anxiety.
Patients usually tolerate procedures better when they know what to expect.
Having a relative or friend stay with the patient during the procedure may help
reduce anxiety.
Patients and family members should receive written instructions for managing
the pain at home. They should receive information regarding who to contact for
questions related to pain management.
** TREATING ELDERLY PATIENTS **
Older patients are at risk for under-treatment of pain because their
sensitivity to pain may be underestimated, they may be expected to tolerate
pain well, and misconceptions may exist about their ability to benefit from
opioids. Issues in assessing and treating cancer pain in older patients
include the following:
- Multiple chronic diseases and sources of pain: Age and complicated
medication regimens put older patients at increased risk for interactions
between drugs and between drugs and the chronic diseases.
- Visual, hearing, movement, and thinking impairments may require simpler
tests and more frequent monitoring to determine the extent of pain in the
older patient.
- Nonsteroidal anti-inflammatory drug (NSAID) side effects, such as stomach
and kidney toxicity, thinking problems, constipation, and headaches, are
more likely to occur in older patients.
- Opioid effectiveness: Older patients may be more sensitive to the
pain-relieving and central nervous system effects of opioids resulting in
longer periods of pain relief.
- Patient-controlled analgesia must be used cautiously in older patients,
since drugs are slower to leave the body and older patients are more
sensitive to the side effects.
- Other methods of administration, such as rectal administration, may not be
useful in older patients since they may be physically unable to insert
the medication.
- Pain control after surgery requires frequent direct contact with health
care providers to monitor pain management.
- Reassessment of pain management and required changes should be made
whenever the older patient moves (for example, from hospital to home or
nursing home).
** TO LEARN MORE **
Call
For more information, U.S. residents may call the National Cancer Institute's
(NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237)
Monday through Friday from 9:00 a.m. to 4:30 p.m. Deaf and hard-of-hearing
callers with TTY equipment may call 1-800-332-8615. The call is free and a
trained Cancer Information Specialist is available to answer your questions.
Web sites and Organizations
The NCI's Cancer.gov Web site (http://cancer.gov) provides online access to
information on cancer, clinical trials, and other Web sites and organizations
that offer support and resources for cancer patients and their families. There
are also many other places where people can get materials and information about
cancer treatment and services. Local hospitals may have information on local
and regional agencies that offer information about finances, getting to and
from treatment, receiving care at home, and dealing with problems associated
with cancer treatment.
Publications
The NCI has booklets and other materials for patients, health professionals,
and the public. These publications discuss types of cancer, methods of cancer
treatment, coping with cancer, and clinical trials. Some publications provide
information on tests for cancer, cancer causes and prevention, cancer
statistics, and NCI research activities. NCI materials on these and other
topics may be ordered online or printed directly from the NCI Publications
Locator (http://cissecure.nci.nih.gov/ncipubs). These materials can also be
ordered by telephone from the Cancer Information Service toll-free at
1-800-4-CANCER (1-800-422-6237), TTY at 1-800-332-8615.
LiveHelp
The NCI's LiveHelp service, a program available on several of the Institute's
Web sites, provides Internet users with the ability to chat online with an
Information Specialist. The service is available from 9:00 a.m. to 7:30 p.m.
Eastern time, Monday through Friday. Information Specialists can help Internet
users find information on NCI Web sites and answer questions about cancer.
Write
For more information from the NCI, please write to this address:
National Cancer Institute
Office of Communications
31 Center Drive, MSC 2580
Bethesda, MD 20892-2580
** ABOUT PDQ **
PDQ is a comprehensive cancer database available on Cancer.gov.
PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information
database. Most of the information contained in PDQ is available online at
Cancer.gov (http://cancer.gov), the NCI's Web site. PDQ is provided as a
service of the NCI. The NCI is part of the National Institutes of Health, the
federal government's focal point for biomedical research.
PDQ contains cancer information summaries.
The PDQ database contains summaries of the latest published information on
cancer prevention, detection, genetics, treatment, supportive care, and
complementary and alternative medicine. Most summaries are available in two
versions. The health professional versions provide detailed information
written in technical language. The patient versions are written in
easy-to-understand, non-technical language. Both versions provide current and
accurate cancer information.
The PDQ cancer information summaries are developed by cancer experts and
reviewed regularly.
Editorial Boards made up of experts in oncology and related specialties are
responsible for writing and maintaining the cancer information summaries. The
summaries are reviewed regularly and changes are made as new information
becomes available. The date on each summary ("Date Last Modified") indicates
the time of the most recent change.
PDQ also contains information on clinical trials.
Some patients have symptoms caused by cancer treatment or by the cancer itself.
Patients who have symptoms related to cancer treatment may want to take part in
a clinical trial. A clinical trial is a study to answer a scientific question,
such as whether one method of treating symptoms is better than another. Trials
are based on past studies and what has been learned in the laboratory. Each
trial answers certain scientific questions in order to find new and better ways
to help cancer patients. During supportive care clinical trials, information
is collected about new treatment methods, the risks involved, and how well they
do or do not work. If a clinical trial shows that a new treatment is better
than one currently being used, the new treatment may become "standard."
Listings of clinical trials are included in PDQ and are available online at
Cancer.gov (http://cancer.gov/clinical_trials). Descriptions of the trials are
available in health professional and patient versions. Many cancer doctors who
take part in clinical trials are also listed in PDQ. For more information,
call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237); TTY at
1-800-332-8615.
Date Last Modified: 07/2002
******************************************************************************
* If you want to know more about cancer and how it is treated, or if you *
* if you wish to know about clinical trials for your type of cancer, you *
* can call the NCI's Cancer Information Service at 1-800-422-6237, toll *
* free. A trained information specialist can talk with you and answer *
* your questions. *
******************************************************************************
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