Cancer Pain. What is Pain?

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1 Cancer Pain What is Pain? The International Association for the Study of Pain says that pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage." Pain is very personal and many people will feel it differently (for example some people will feel dull pain and others will have burning or stabbing pain). Unlike a fever, where you can use a thermometer to show if you have a high temperature, there is no easy way to measure how much pain you are feeling. I was just diagnosed with cancer, am I going to experience pain? Pain is one of the most feared symptoms in people with cancer. But having cancer does not mean that you will have pain. Some people will have no pain with their cancer or their treatment. I am very worried about pain, what should I do? Cancer pain does not only cause discomfort but can also affect the way a person feels and thinks. A high amount of pain will have a large impact on a person s quality of life and increase the risk for depression and anxiety. For many people it is difficult to separate the emotional and physical suffering from pain.

2 Some of the feelings that pain can have on the person are: Angry Difficulty focussing and thinking Nervous Depressed or sad Stressed Tired What causes pain in people with cancer? Pain in people with cancer can be caused by a wide number of causes. It may be due to the cancer, medical procedures or even the treatments given to help the cancer. These reasons are discussed in greater detail in table 1.

3 Table 1 Causes of Pain in People with Cancer Cancer itself A tumour from cancer can cause pain by pushing and causing pressure against a nerve, bone or an organ in the body Many times this type of pain can improve when the person starts chemotherapy Medical procedures Some medical tests can cause pain Tests such as biopsies, blood tests, lumbar punctures can cause pain Many people with cancer have surgery to remove a tumour. This surgery could be a cause of pain Cancer treatments Chemotherapy and radiation can cause pain in people with cancer Some chemotherapy has side effects that can cause: o o o o Mouth sores Nerve pain Joint and bone pain Muscle pain Other causes Muscle stiffness and tightness can happen in people with cancer from not being as mobile Bone fracture caused by metastasis or cancer-induced osteopenia Infections or illness in the person with cancer

4 What is the impact of pain on the person with cancer? Cancer pain can have a tremendous impact on the person with cancer. This pain can cause a wide array of emotions in this person and their family. The pain can affect the person s life by: Disturbing their sleep Reducing their appetite Preventing them from working Causing exhaustion Preventing the person from enjoying the simple pleasures of life Feeling isolated Putting strain on friends and caregivers Every person has different aspect of his/her life that is impacted by cancer pain. I am starting to have some pain, what should I do? Many people with cancer are worried if they start to get some pain. The first step is to bring it to the attention of your cancer healthcare team. They will want to know about the pain, its location and how severe it is. Table 2 has a checklist of what to tell your doctor about your pain.

5 Table 2 Information your Doctor needs to know about your pain 1. Where the pain is on your body 2. When it started to hurt 3. What the pain feels like (dull ache, stabbing pain, throbbing) 4. Rate your pain on a scale from 1 to 10: a. When the pain is the worse b. The average pain for the day c. When the pain is the best 5. What makes the pain feel better and what makes it worse 6. They will want to know when the pain starts, how long it lasts and how often you get it 7. The impact of the pain on your life 8. Any medications or other modalities (heat, cold, stretches) that you have tried for your pain: a. How much it helped b. Any side effects c. If you have breakthrough pain with the medication

6 Isn t it a sign of weakness to talk about pain? Most cancer pain is completely treatable with the right strategies. Cancer pain can have a major impact on your quality of life and can impact your sleep and appetite. By not sleeping and eating you will become weaker and may have a harder time with your cancer treatment. Many times the treatment for the pain can make a big difference in the way you feel even on the same day. What kind of pain can people with cancer have? People with cancer can experience acute, chronic or breakthrough pain. Acute Pain All of us have experienced acute pain. Whether it is a stubbed toe, a sore throat, or even surgery, these are pains that have a specific cause and go away once healing has taken place. In people with cancer this type of pain is usually caused by surgery, fractured bone, or a something like a blood test. This pain is temporary, lasting minutes to several weeks. Acute pain goes away when healing occurs and is usually easily treated. Chronic Pain Chronic pain is pain that has lasted for at least three months. Chronic pain may also be any recurrent pain that happens at least three times in the last three months. Chronic pain can be: Persistent: Continuous pain Recurrent: Frequent episodes of pain with a break in between. Chronic pain in people with cancer can range from mild to severe. This type of pain is very hard on the person with cancer both physically and emotionally.

7 Breakthrough Pain When a person with cancer is prescribed medications for pain, it is normally designed to provide 24 hour pain control. Occasionally some people will experience breakthrough pain. This pain happens when the pain reliever s effects wears off temporarily or is not strong enough to control the pain. If a person with cancer has many episodes of breakthrough pain every day, then this could be a sign they need a change in their pain medication. Should I talk to people about my pain? Talking about pain is important for people with cancer. Your family, caregivers, friends and healthcare team want to do everything they can to make your cancer treatment as comfortable as possible. The only way they can do this is with good communication. Talking openly to the people that are there to help you is the only way to get your cancer pain under control. Powered by BestLifeRewarded What is a pain diary? Cancer pain will normally change with time and when you start treatment. People with cancer pain will also have good pain days and bad pain days. The best way for you and your healthcare team to keep track of your pain is using a pain diary. A pain diary is a book (can be a regular notebook or calendar) where you keep track of your pain. By writing down information about your pain, you and your team can look at how well your pain is controlled. This can help everyone make decisions on the type of pain treatment that you need. Table 3 lists some of the information you can consider recording in your pain diary. Check with your healthcare team if they have a diary they want you to use. Many times they have them available so you don t have to create your own.

8 Table 3 - Information you may want to Record in a Pain Diary 1. On a scale from 1 to 10 rate your: a. Worse pain of the day b. Least pain of the day c. Average pain of the day 2. If pain occurred: a. What time did it happen at b. Where it was c. What it felt like (dull, throbbing, stabbing, burning) d. How bad it was at that time 3. Anything that made your pain better or worse 4. Medications that you used that day a. The number of times you took your breakthrough medication is very important 5. Any side effects that you may be having from your medications My pain is getting worse, so that must mean my cancer is getting worse Right? Actually pain can happen at any stage in the treatment of cancer. Patients with fully curable cancer or low grade cancer may have more pain than someone with a higher grade of cancer. Pain is unpredictable, but we know that it should be treated right away if it appears.

9 If my pain is not too bad can I try some non-drug treatments? Managing pain is a very personal choice for cancer patients. Some non-drug treatments have worked to not only help lower pain but also anxiety and stress. Some of the most common treatments are biofeedback, cognitive behaviour therapy and relaxation therapy. Biofeedback Biofeedback is a special training that uses equipment that monitors physical tension. It teaches you how to control the way your body responds to stress. Biofeedback can be used in combination with medications to help control pain. It is not something a person can learn by themselves and is usually taught by a specialized instructor. Cognitive behavioural therapy Cognitive behavioural therapy is a specific type of education that can help for people with different types of painful conditions. Cognitive behavioural therapy is a process where the therapist works with the person to find false beliefs they have about their pain and condition and replaces them with more positive substitutes. Cognitive behavioural therapy has been shown to improve: The pain Make the person more aware of the stress and triggers that cause the pain to worsen The way a person copes with pain

10 Relaxation therapy Relaxation can help you manage both the pain and the consequences of living with pain. It can help with tense muscles, anger, stress, depression, and fatigue. There are many different relaxation programs. The key is to try many or all of them to find the one that suits you best. Once you find your favourite relaxation program, stick with it faithfully. Table 4 shows some of the most common relaxation techniques. Table 4 - Common Relaxation Techniques Deep Abdominal Breathing This simple technique works for many people. It is commonly used as the base for other relaxation techniques Deep abdominal breathing can be used anywhere at any time. For instructions on how to do deep abdominal breathing, see this website from the American Medical Student Association Deep Muscle Relaxation This is a combination of tensing a certain muscle group then relaxing it. This helps the muscle relax and you feel less tension. For instructions on how to do progressive muscle relaxation, see this website from Guide to Psychology. Be sure to use abdominal breathing while doing this technique. Caution: Depending on the nature of your pain, tensing a particular muscle group may cause pain. If this is the case, simply skip that area of your body.

11 Visualization If you have a good imagination, this technique might be a good fit. Start with your abdominal breathing and add to this by visualizing yourself in a favourite place. Choose a relaxing place that involves just you. This could be you on a beach or sitting in a little rowboat with your fishing line in the lake before anyone else is awake. Try to think about all the senses in as much detail as possible. How does your place look, feel, smell, taste, and sound? Mindfulness meditation This is an advanced technique on meditation Most people will need some help learning this way to meditate Consider taking a class or ordering some CDs on this technique from Powered by BestLifeRewarded How much pain relief should I receive with pain medications? In the past, many people with cancer pain did not receive suitable pain relief. This should not be the case today. The World Health Organization (WHO) feels that with the treatments we have today 80-90% of people with cancer pain should have it completely controlled. How does my healthcare team decide on the pain medications to use? The choice of pain medications will be tailored based on your pain and how you respond to the treatment. If your pain is mild you may only need to take the occasional over-the-counter pain medication. If it is more severe your healthcare team will suggest a treatment that offers more pain relief.

12 My doctor says that I should take my pain medication faithfully, is this right? The best way to manage cancer pain is to take medication at regular intervals. This prevents people from waiting for pain to arrive. By taking pain medication regularly many people will be able to control their pain around the clock. For this around the clock control many doctors will prescribe long-acting products that last 12 or more hours. Your doctor may prescribe a breakthrough pain medication. These medications are used if you are having a bad day and your regular pain medications are not controlling your pain. What is the stepped approach to treating cancer pain? The World Health Organization developed a model to help guide the treatment of cancer pain. This model is actually three steps. The steps are shown in figure 1. Figure 1 - The World Health Organization Three-Step Model for Cancer Pain

13 As the pain increases your healthcare team will step up the pain medication. If the pain improves they step back down. The nice thing about this ladder it makes sure you are getting the right amount of medication to control your pain. What are the Step 1 medications for pain relief? The most common step 1 medications are acetaminophen and anti-inflammatory drugs. Acetaminophen Acetaminophen (Tylenol ) is a commonly used medication for pain. It helps to lower the pain from a large number of conditions but does not have any anti-inflammatory properties. What are the common side effects of acetaminophen? Acetaminophen is very well tolerated but if a person takes too high of a dose (more than 8 extra strength tablets per day) or combines it with alcohol there is a risk of liver damage. Most people have very little side effects with this drug. What are some of the important things to know about acetaminophen? It is available over-the-counter without a prescription Acetaminophen is commonly used for mild cancer pain and can be taken on a very flexible schedule Anti-Inflammatory Drugs Anti-inflammatory drugs (also called NSAIDs) are commonly used to treat mild cancer. Antiinflammatory drugs reduce pain, inflammation and swelling.

14 What are the common side effects of anti-inflammatory drugs? Anti-inflammatory are linked to some adverse effects that can be a problem in some people. Taking these medications long-term puts a person at higher risk of stomach problems like nausea, vomiting and even bleeding. They can also have an effect on blood pressure and the kidneys. For this reason these drugs are avoided or used very carefully in people with active stomach ulcers, congestive heart failure, kidney disease and asthma. What are some of the important things to know about anti-inflammatory drugs? Ibuprofen and naproxen are both available over-the-counter without a prescription. There are many other anti-inflammatories that are only available by prescription There is very little evidence that one anti-inflammatory is better than any other There are some anti-inflammatories that have a lower risk of stomach problems (e.g. celecoxib) They are commonly used in people with cancer that have bone pain What are the step 2 and 3 pain medications? Step 2 and 3 on the pain ladder use opioid drugs (also called narcotics). These medications are commonly used for treating cancer pain and include drugs like morphine, oxycodone, codeine, hydromorphone and fentanyl. Opioids can work really well in people with cancer pain that are not getting enough pain relief with other medications. Don t opioids have many side effects? Opioids can commonly cause side effects like constipation, nausea, fatigue and rash. Fortunately most of these side effects will go away with continued use. Constipation is the most common side effect and it will normally not improve with time. If you start an opioid, many doctors will start a laxative at the same time.

15 Won t I become addicted to opioids? Many people confuse addiction with dependence or tolerance. Addiction is someone who will continue to take a medication even when it is causing them harm (to their body, their family relationships or work). People who are addicted will also take the medication when there is no pain. Dependence happens when a person takes an opioid over a longer period of time. When the opioid is stopped suddenly it can cause withdrawal symptoms such as pain, trouble sleeping, rapid heartbeat, tremor, shiver and flu-like symptoms. Almost everyone on opioids will become dependent, but this is not the same thing as addiction. Tolerance means the body gets used to the opioid over a period of time. A person will need higher and higher doses to help give the same pain relief. Tolerance is not the same thing as addiction. When opioids are used for cancer pain, the risk of addiction is small unless there is a history of drug abuse. If you have a personal history of problems with drugs or alcohol, discuss it with your doctor before starting any opioid. What other medications are used for cancer pain? There are many other medications that can be used to help for cancer pain but the three most common types of drugs are steroids, seizure medications and antidepressants. Steroids Corticosteroids are commonly used to help relieve pressure and pain when a tumour is pressing on a nerve. The most common steroids used in people with cancer are dexamethasone and prednisone. What are the common side effects of steroids? The most common side effects with steroids include stomach upset, headache, swelling, restlessness and trouble sleeping

16 What are some of the important things to know about steroids? Steroids are commonly used with other pain medications These steroids are very different from the steroids taken by athletes. These steroids are designed to help for pain and swelling Steroids should never be stopped suddenly if you are on them for some time. Your doctor will normally reduce your dose slowly when it is time to stop them. Steroids may also help to improve appetite Seizure medications How do seizure medications work for pain? Two of the most common seizure medications used for pain are gabapentin and pregabalin. These medications seem to work on the way pain is transmitted to the brain. What are the most common side effects with these drugs? Seizure medications commonly cause drowsiness, unsteadiness on your feet and dizziness when they are first started. These side effects usually go away with continued use What are some of the important things to know about seizure medications? Seizure medications are commonly used for nerve pain. This happens when a tumour is pressing on a nerve or when chemotherapy is causing nerve pain They are not like other pain relievers and can take several weeks until their full effect They can be used with other pain medications

17 Antidepressants How do antidepressants work for pain? Antidepressants are commonly used to treat nerve pain. They seem to affect the way pain is transmitted by the nerves in the body. Older antidepressants such as amitriptyline are used as well as newer antidepressants like duloxetine. What are the most common side effects of these drugs? The older antidepressants (amitriptyline) have many side effects that make them hard for some people to take. The most commonly experienced side effects with these older drugs are weight gain, drowsiness, dry mouth, constipation, confusion. For the newer antidepressants they are better tolerated. They can cause nausea, drowsiness, insomnia and dizziness What are some of the important things to know about antidepressants? These medications are different from standard pain pills and can take several weeks until their full effect They are commonly used for nerve pain. This happens when a tumour is pressing on a nerve or when chemotherapy is causing nerve pain Many people with cancer pain also have depression and these drugs can help for both They can be used with other pain medication