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How is cancer pain diagnosed?
What are the myths about pain medicines?
What causes cancer pain?
How is cancer pain treated?
What kinds of medicines are used?
What kinds of non-drug treatments are there?
Are there any other types of pain relief?
Where can I go for help?
Having cancer doesn't mean you always have pain. But if you do, there's no reason to suffer. There are different kinds of medications, and different types of non-drug methods of controlling pain.
Cancer pain is very individual. No one feels pain in the same way. It's important for patients to tell the doctor and nurse about their pain. Not only is pain easier to treat when a patient first has it, but pain can also be an early warning sign of the side effects of the cancer or the cancer treatment.
How is cancer pain diagnosed?
Doctors need to hear what works and what doesn't work for a patient's pain. They may consult with a pain specialist or refer you to one. Pain specialists may be oncologists, anesthesiologists, neurologists, neurosurgeons, other doctors, nurses, or pharmacists. Psychologists and social workers may also be a part of a pain control team.
In recommending pain control, doctors follow guidelines set by the World Health Organization, which includes standard treatments for mild, moderate, and severe pain. Doctors use a pain ladder, on a scale of 0 to 10, to help assess the source, quality, and intensity of pain and determine the right method of relief. Patients should try to assign a number of 0 to 10 for the pain level. No pain equals "0." As the numbers get higher, they stand for pain that is getting worse. A "10" means the pain is the worst pain imaginable.
Use the rating scale to describe:
- How bad the pain is at its worst
- How bad the pain is most of the time
- How bad the pain is at its least
- How the pain changes with treatment
What are the myths about pain medicines?
- Patients don't have to "tough it out" if they have cancer pain. In fact, it's better and easier to control pain when it just starts rather than waiting until after it becomes severe.
- People who take cancer pain medication rarely become addicted to it as long as they take it as prescribed by their doctor. Fear of addiction prevents many people from taking pain medicine. Opioids (also known as narcotics), which originally were derived from the poppy plant, are the strongest pain relievers available.
Morphine is the best-known member of this class, although there are other opioids (codeine, oxycodone, fentanyl, hydrocodone) that produce effects similar to morphine.
Opioids can create a physical dependence if taken over a long period of time. However, most cancer patients do not become addicted to opioids. When a patient is ready to stop taking them, the doctor gradually lowers the amount taken to avoid withdrawal symptoms.
- Most people do not get "high" or lose control when they take pain medicines as prescribed by the doctor. A patient may feel drowsy or sleepy when he or she first takes them, and may need to catch up on sleep missed from the pain. Doctors should be told if dizziness or confusion occur when taking pain medication.
- The body doesn't become immune to pain medicine. Pain should be treated early and with whatever medicine is needed at the time. Stronger medicines don't have to be "saved" for later. If medicine stops being as effective as it was when first taken, then the amount can be changed or other medicines added.
What causes cancer pain?
Pain can be caused by cancer itself. It may depend on the type and extent of the cancer and the patient's pain threshold (tolerance for pain). The pain can be caused by other factors, too, such as pain by treatment or procedures for diagnosing cancer, or pain caused when a tumor spreads to the spine (spinal cord compression), or "phantom pain"; if an arm or leg has been removed by surgery. Phantom pain is not imaginary. It's very real even though doctors aren't sure why it occurs.
How is cancer pain treated?
Cancer pain is usually treated with medicine, called analgesics, and with non-drug treatments, which can be used alone or along with medicine. Some people find they can take a lower dose of medicine with non-drug treatments, such as relaxation, biofeedback, imagery, distraction, hypnosis, skin stimulation, acupuncture, exercise, or physical therapy.
What kinds of medicines are used?
The following medications are recommended for different levels of pain:
Mild-to-moderate pain: Non-narcotics (non-opioids), such as acetaminophen (Tylenol®), aspirin, and other aspirin-like drugs known as non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, many of which can be purchased without a prescription. Check with a doctor before using these medications.
Possible side effects: NSAIDs can slow blood clotting, particularly for patients on chemotherapy. The most common side effect from NSAIDs is stomach upset or indigestion. Occasional gastrointestinal bleeding occurs, causing anemia. Liver damage can occur if the patient drinks moderate amounts of alcohol and takes acetaminophen.
Moderate pain: A combination of NSAIDs and weak narcotics, such as codeine, hydrocodone (Vicodin® or Lortab®), oxycodone (Percocet®, Percodan®), or propyxphene (Darvon®).
Possible side effects: drowsiness, constipation, nausea, and vomiting. Sometimes, dizziness, mental effects (nightmares, confusion, hallucinations), a moderate decrease in rate and depth of breathing, difficulty in urinating, or itching occurs. A patient ingesting alcohol or taking tranquilizers, sleeping aids, antidepressants, antihistamines, or any other medicines causing sleepiness, should tell the doctor. Combinations of opioids, alcohol, and tranquilizers can be dangerous. Even small doses may cause problems.
Severe pain: Strong opioids such as morphine, meperidine (Demerol®), hydromorphone (Dilaudid®), topical fentanyl (Duragesic® patches) or methadone in combination with an NSAID.
Breakthrough pain (moderate-to-severe pain that "breaks through" or is felt for a short time): Immediate-release oral morphine. A short-acting opioid, which relieves breakthrough pain quickly, needs to be used with a long-acting opioid for persistent pain.
Other: For pain not responsive to opioids, doctors have found that adding medications such as steroids, anticonvulsant and antidepressant medications, antihistamines, and sedatives have been successful, even though they are not usually labeled for pain relief:
- Anticonvulsants can help control tingling or burning from nerve injury caused by cancer or cancer therapy. Possible side effects: liver problems, lowered number of red and white blood cells.
- Antidepressants can be used to treat tingling or burning pain from nerve damage. Possible side effects: dry mouth, sleepiness, constipation, drop in blood pressure with dizziness or fainting when standing, blurred vision, or urinary retention. Patients with heart disease may have an irregular heartbeat. Anyone on antidepressants should be watched closely for suicidal thinking or behavior. This is especially important in the beginning of treatment or when changing the dose. If you are concerned, talk to your doctor immediately.
- Anti-anxiety drugs can be used to lesson anxiety, as well as treat muscle spasms that often go along with severe pain. Possible side effects: drowsiness, urinary incontinence.
- Antihistamines can help control nausea and help people sleep. They also help control itching. Possible side effect: drowsiness.
- Antiemetics help control nausea and vomiting.
- Steroids can help relieve bone pain, pain caused by spinal cord and brain tumors, and pain caused by inflammation; they can also counteract the loss of appetite and decrease nausea that often accompanies chemotherapy. Possible side effects: fluid buildup in the body, increased blood sugar, anxiety, and stomach irritation; rarely, confusion, altered behavior, and sleeplessness.
What kinds of non-drug treatments are there?
Non-drug treatments are widely used to help manage cancer pain. These methods include:
Relaxation. (Includes visual concentration, rhythmic breathing, rhythmic massage, listening to music or relaxation tapes). Relaxation relieves pain, reduces tension in the muscles to promote sleep, reduces anxiety, and helps other pain relief methods work better.
Biofeedback. A licensed biofeedback technician uses special machines to teach patients how to control certain body functions such as heart rate, blood pressure, and muscle tension. Biofeedback techniques help patients relax and cope with pain.
Imagery. This technique is like a daydream that uses all of your senses - sight, touch, hearing, smell, and taste - to create mental pictures or situations. Some people believe that imagery is a form of self-hypnosis.
Hypnosis. In this trance-like state of high concentration between sleeping and waking, a person becomes more receptive or open to suggestion. Hypnosis can be used to block the awareness of pain, and to change the sensation to one that is not painful. Self-hypnosis is also possible. Patients should choose a person trained in hypnosis, usually a psychologist or psychiatrist, or someone licensed in the healing arts.
Skin stimulation. This technique involves the use of pressure, warmth, or cold to stimulate the skin, but lessen or block the feeling of pain. Massage, pressure, vibration, heat, cold and menthol preparations can be used.
Transcutaneous electric nerve stimulation (TENS). Mild electric currents are applied to some areas of the skin by a small power pack connected to two electrodes. You may experience a buzzing, tingling, or tapping feeling. These small electric impulses seem to interfere with pain sensations.
Acupuncture. Acupuncture is an ancient Chinese healing technique that involves stimulating specific points in the body by inserting fine needles. Each point controls the pain sensation of a different part of the body. Acupuncture is a widely accepted and proven method of pain relief that should be performed by a licensed acupuncturist.
Emotional support and counseling. Depression, worrying, hopelessness, and helplessness can make a patient's pain seem worse. These normal feelings can be relieved by encouraging patients to talk to their doctors, nurses, social workers, family or friends, mental health professions, the clergy, or other people with cancer.
Are there any other types of pain relief?
Consult a pain specialist or an anesthesiologist specializing in pain control. If pain cannot be relieved adequately through medication and/or non-drug treatments, there are other options:
Radiation therapy. Treatment with high-energy rays can reduce pain by shrinking a tumor. Often, only a single dose or a few doses of radiation is needed to relieve pain.
Surgery. A neurosurgeon may cut nerves, which are usually near the spinal cord, to block the nerve pathways that relay pain impulses to the brain.
Nerve blocks. In this procedure, a local anesthetic (Novocaine® or Xylocain®), which may be combined with a steroid, is injected into, or around a nerve, or into the spine to temporarily block pain. For longer-lasting pain relief, phenol or alcohol can be injected. A nerve block may cause muscle paralysis or loss of all feeling in the affected area.
Where to go for help
A list of pain management facilities can be obtained by contacting the National Cancer Institute's Cancer Information Service at its toll-free number: 1-800-4-CANCER (1-800-422-6237).
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External Sources
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The National Cancer Institute.
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The American Cancer Society.
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The American Pain Foundation.
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Rosenbaum, EH, Rosenbaum, I, Everyone's Guide to Supportive Cancer Care: The Complete Guide for Patients and Their Families, Fourth Edition, Kansas City, Missouri: Andrews McMeel Publishing, 2005.
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Dollinger M, Rosenbaum, EH, Tempero M., et al. Everyone's Guide to Cancer Therapy, Fourth Edition, Kansas City, Missouri: Andrews McMeel Publishing, 2002.
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This article was reviewed and updated June 2007.
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