Pain is one of the most common symptoms in cancer patients. Pain can be caused by cancer, cancer treatment, or a combination of factors. Tumors, surgery, intravenous chemotherapy, radiation therapy, targeted therapy, therapies such as bisphosphonates, and diagnostic procedures may cause you pain.
Younger patients are more likely to have cancer pain and pain flares than older patients. Patients with advanced cancer have more severe pain, and many cancer survivors have pain that continues after cancer treatment ends.
This summary is about ways to control cancer pain in adults.
Some tests and procedures are painful. It helps to start pain control before a procedure begins. Some drugs may be used to help you feel calm or fall asleep. Therapies such as imagery or relaxation can also help control pain and anxiety related to treatment. To help lower your anxiety, ask about the test before it begins so you know what to expect. Have a family member or friend stay with you during the procedure.
Patients may have different types of pain from the treatments they receive, including:
Peripheral neuropathy is a nerve problem that can cause pain, numbness, and tingling in the hands and feet. Patients on chemotherapy may have chemotherapy-induced peripheral neuropathy (CIPN). In some patients, CIPN may continue after chemotherapy has ended.
Studies of drugs and natural products used to treat CIPN have shown mixed results. Duloxetine is a drug that has been studied to treat CIPN.
Studies of acupuncture for CIPN have been reported. For more information about these studies, see the Chemotherapy-induced peripheral neuropathy section in Acupuncture.
Pain that is severe or continues after cancer treatment ends increases the risk of anxiety and depression. If you feel depressed or have anxiety, your pain may feel worse and make it harder to control. Some patients are unable to work because of the pain.
Pain can be controlled in most patients who have cancer. Although cancer pain cannot always be relieved completely, there are ways to lessen pain in most patients. Pain control can improve your quality of life during cancer treatment and after it ends.
Each person's diagnosis, cancer stage, response to pain, and personal likes and dislikes are different. For this reason, each patient needs a personal plan to control cancer pain. You, your family, and your health care team can work together to manage your pain. As part of your pain control plan, your health care provider can give you and your family members written instructions to manage your pain at home. Ask your health care provider who you should call if you have questions about your pain.
It's important that the cause of your pain is found early and treated quickly. Your health care team will help you measure pain levels often, including at the following times:
To learn about your pain, the health care team will ask you the following questions:
Your health care team will also review your health history, including the following information:
The information you give your health care team will be used to decide how to help relieve your pain. Treatment may include drugs or non-drug therapies. In some cases, patients are referred to pain or palliative care specialists. Your health care team will work with you to decide whether the benefits of treatment outweigh any risks. They will also let you know how much relief to expect from your pain treatment. Your doctor will continue to ask you how well your treatment is working and make changes if needed.
A family member or caregiver may be asked to give answers for a patient who has problems with speech, language, or understanding.
The following exams will be done:
Your health care team will also assess your psychological, social, and spiritual needs.
Your doctor will prescribe drugs to help relieve your pain. These drugs need to be taken at scheduled times to keep a constant level of the drug in the body to help keep the pain from coming back. Drugs may be taken by mouth or given in other ways, such as by infusion or injection.
Your doctor may prescribe extra doses of a drug for pain that occurs between scheduled doses of the drug. The doctor will adjust the drug dose for your needs.
A scale from 0 to 10 is used to measure how severe the pain is and decide which pain medicine to use. On this scale:
Other pain scales that use happy or sad faces may be used for those who have trouble giving their pain a number. These scales are useful for adults who have trouble with memory or thinking, and with young children.
Acetaminophen and NSAIDs help relieve mild pain. They may be given with opioids for moderate to severe pain.
Pain relievers of this type include:
Side effects of NSAIDs include stomach, kidney, heart, and blood problems. Patients, especially older patients, who take acetaminophen or NSAIDs need to be closely watched for side effects. For more information, see Treating Cancer Pain in Older Patients.
Opioids work well to relieve moderate to severe pain. Some patients with cancer stop getting pain relief from opioids if they take them for a long time. This is called tolerance. Larger doses or a different opioid may be needed if your body stops responding to the same dose. Tolerance of an opioid is a physical dependence on it. This is not the same as addiction (psychological dependence).
Since 1999, the number of prescriptions written for opioids and the number of deaths caused by drug overdose in the United States have increased. Although most patients who are prescribed opioids for cancer pain use them safely, some patients may become addicted to opioids. Your doctor will monitor your opioid doses so that you are treated for pain safely.
There are several types of opioids:
The doctor will prescribe drugs and the times they should be taken to best control your pain. It is important that patients and family caregivers know how to safely use, store, and dispose of opioids.
Opioids are given on a regular schedule to help relieve the pain and keep it from getting worse. The amount of time between doses depends on which opioid you take. The best dose is the amount of opioid that controls your pain with the fewest side effects. If opioid tolerance does occur (the opioid no longer works at the dose you are given), the dose may need to be increased or a different opioid may be prescribed.
There is evidence that patients who are prescribed long-acting opioids (for example, medications that work for 8,12, or 24 hours), are more likely to take them as directed.
Opioids may be given by the following ways:
Your doctor will discuss the side effects with you before opioid treatment begins and will watch you for side effects. The following are the most common side effects:
Nausea and drowsiness most often occur when opioid treatment is first started and usually get better within a few days.
Opioids slow down the muscle contractions and movement in the stomach and intestines, which can cause hard stools. To keep the stool soft and prevent constipation, it's important to drink plenty of fluids, increase fiber in the diet, and get regular exercise. Unless there are problems such as a blocked bowel or diarrhea, you will be given a treatment plan to prevent constipation and other digestive problems while taking opioids.
Other side effects of opioid treatment include the following:
Opioids are more likely to cause damage to the nervous system in patients with the following risk factors:
Talk to your doctor about side effects that bother you or become severe. Your doctor may decrease the dose of the opioid, change to a different opioid, or change the way the opioid is given to help decrease the side effects. For more information about coping with these side effects, see the following:
Other drugs may be given while you take opioids for pain relief. These are drugs that help the opioids work better, treat symptoms, and relieve certain types of pain. The following types of drugs may be used:
Patients will not always respond in the same way to these drugs. Side effects are common and should be reported to your doctor.
Bisphosphonates (pamidronate, zoledronic acid, and ibandronate) are drugs that may be given when cancer has spread to the bones. They are given as an intravenous infusion and combined with other treatments to decrease pain and reduce risk of broken bones. However, bisphosphonates sometimes cause severe side effects. Talk to your doctor if you have severe muscle or bone pain. Bisphosphonate therapy may need to be stopped.
The use of bisphosphonates is also linked to the risk of bisphosphonate-associated osteonecrosis (BON). For more information, see Oral Complications of Cancer Therapies.
Denosumab is another drug that may be used when cancer has spread to the bones. It is given as a subcutaneous injection and may help prevent and relieve pain.
Most cancer pain can be controlled with drugs, but some patients have too many side effects from drugs or have pain in a certain part of the body that needs to be treated in a different way. Talk to your doctor to help decide which methods work best to relieve your pain. Other treatments include nerve blocks, surgery, radiation therapy and palliative care.
A nerve block is the injection of either a local anesthetic or other drug into or around a nerve to block pain. Nerve blocks help control pain that can't be controlled in other ways. Nerve blocks may also be used to find where the pain is coming from, to predict how the pain will respond to long-term treatments, and to prevent pain after certain procedures.
Surgery can be done to insert a device that delivers drugs or stimulates the nerves with mild electric current.
Cordotomy is a less common surgery that is used to relieve pain by cutting certain nerves in the spinal cord. This blocks pain and hot/cold feelings. This procedure may be chosen for patients who are near the end of life and have severe pain that cannot be relieved in other ways.
Certain patients are helped by palliative care services. Palliative care providers may also be called supportive care providers. They work in teams that include doctors, nurses, mental health specialists, social workers, chaplains, pharmacists, and dietitians. Some of the goals of palliative care are to:
For more information, see Planning the Transition to End-of-Life Care in Advanced Cancer.
Radiation therapy is used to relieve pain in patients with skin lesions, tumors, or cancer that has spread to the bone. This is called palliative radiation therapy. It may be given as local therapy directly to the tumor or to larger areas of the body. Radiation therapy helps drugs and other treatments work better by shrinking tumors that cause pain. Radiation therapy may help patients with bone pain move more freely and with less pain.
The following types of radiation therapy may be used:
External radiation therapy uses a machine outside the body to send high-energy x-rays or other types of radiation toward the area of the body with cancer. External radiation therapy relieves pain from cancer that has spread to the bone. Radiation therapy may be given in a single dose or divided into several smaller doses given over time. The decision to have a single or divided dose may depend on how easy it is to get the treatments and how much they cost. Some patients who find little or no pain relief from first-time radiation therapy may benefit from repeated radiation therapy.
Patients may have a pain flare after receiving palliative radiation therapy for cancer that has spread to the bone, but this side effect is only temporary.
Radiopharmaceuticals are drugs that have a radioactive substance that may be used to diagnose or treat disease, including cancer. Radiopharmaceuticals may also be used to relieve pain from cancer that has spread to the bone. A single dose of a radioactive agent injected into a vein may relieve pain when cancer has spread to several areas of bone and/or when there are too many areas to treat with external radiation therapy.
Patients with cancer and pain may lose their strength, freedom of movement, and ability to manage their daily activities. Physical therapy or occupational therapy may help these patients.
Physical medicine uses physical methods, such as exercise and machines, to prevent and treat disease or injury.
Some patients may be referred to a physiatrist (a doctor who specializes in physical medicine) who can develop a personal plan for them. Some physiatrists are also trained in procedures to treat and manage pain.
Complementary and alternative therapies combined with standard treatment may be used to treat pain. They are also called integrative therapies. Acupuncture, support groups, and hypnosis are a few integrative therapies that have been used to relieve pain.
Some problems are more likely in patients 65 years and older. For caregivers of these patients, the following should be kept in mind:
Older patients may have more than one chronic disease and take several drugs for different conditions. This can increase the risk of drug interactions. Drugs taken together can change how they work in the body and can affect the patient's chronic diseases.
Pain medicine is started at lower doses in older patients and adjusted slowly to allow for differences in their pain threshold, pain expression, and effects on physical and mental function. Lower doses given to older patients may provide better pain relief that lasts longer than in younger patients.
Older patients should be watched closely for side effects from opioids and NSAIDs. See common side effects caused by opioids for more information. Other drugs may be given to avoid side effects from certain NSAIDs:
Undertreatment in older patients may occur for the following reasons:
Poor pain control may cause other problems in older patients, including the following:
Treating depression in patients can also help with pain treatment.
For more information from the National Cancer Institute about cancer pain, see the following:
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