Cancer Pain

People who have cancer don't always have pain. Everyone is different. But if you do have cancer pain, you should know that you don't have to accept it. Cancer pain can almost always be relieved.
The key messages we want you to learn from this booklet are:

Your pain can be managed.

Controlling pain is part of your cancer treatment.

Talking openly with your doctor and health care team will help them manage your pain.

The best way to control pain is to stop it from starting or keep it from getting worse.

There are many different medicines to control pain. Everyone's pain control plan is different.

Keeping a record of your pain will help create the best pain control plan for you.

People who take cancer pain medicines as prescribed rarely become addicted to them.

Your body does not become immune to pain medicine. Stronger medicines should not be saved for "later."

Pain specialists can help

Cancer pain can be reduced so that you can enjoy your normal routines and sleep better. It may help to talk with a pain specialist. These may be oncologists, anesthesiologists, neurologists, surgeons, other doctors, nurses, or pharmacists. If you have a pain control team, it may also include psychologists and social workers.

Pain and palliative care specialists are experts in pain control. Palliative care specialists treat the symptoms, side effects, and emotional problems of both cancer and its treatment. They will work with you to find the best way to manage your pain. Ask your doctor or nurse to suggest someone. Or contact one of the following for help finding a pain specialist in your area:

  • Cancer center
  • Your local hospital or medical center
  • Your primary care provider
  • People who belong to pain support groups in your area
When cancer pain is not treated properly, you may be: When cancer pain is managed properly, you can:
  • Tired
  • Depressed
  • Angry
  • Worried
  • Lonely
  • Stressed
  • Enjoy being active
  • Sleep better
  • Enjoy family and friends
  • Improve your appetite
  • Enjoy sexual intimacy
  • Prevent depression

Types and Causes of Cancer Pain

Cancer pain can range from mild to very severe. Some days it can be worse than others. It can be caused by the cancer itself, the treatment, or both.

You may also have pain that has nothing to do with your cancer. Some people have other health issues or headaches and muscle strains. But always check with your doctor before taking any over-the-counter medicine to relieve everyday aches and pains.

Different types of pain

Here are the common terms used to describe different types of pain:

  • Acute pain ranges from mild to severe. It comes on quickly and lasts a short time.

  • Chronic pain ranges from mild to severe. It either won't go away or comes back often.

  • Breakthrough pain is an intense rise in pain that occurs suddenly or is felt for a short time. It can occur by itself or in relation to a certain activity. It may happen several times a day, even when you're taking the right dose of medicine. For example, it may happen as the current dose of your medicine is wearing off.

What causes cancer pain?

Cancer and its treatment cause most cancer pain. Major causes of pain include:

  • Pain from medical tests. Some methods used to diagnose cancer or see how well treatment is working are painful.

    Examples may be a biopsy, spinal tap, or bone marrow test. If you are told you need the procedure, don't let concerns about pain stop you from having it done. Talk with your doctor ahead of time about what will be done to lessen any pain you may have.

  • Pain from a tumor. If the cancer grows bigger or spreads, it can cause pain by pressing on the tissues around it. For example, a tumor can cause pain if it presses on bones, nerves, the spinal cord, or body organs.

  • Spinal cord compression. When a tumor spreads to the spine, it can press on the spinal cord and cause spinal cord compression. The first sign of this is often back or neck pain, or both. Coughing, sneezing, or other motions may make it worse.

  • Pain from treatment. Chemotherapy, radiation therapy, surgery, and other treatments may cause pain for some people. Some examples of pain from treatment are:
    o Neuropathic pain. This is pain that may occur if treatment damages the nerves. The pain is often burning, sharp, or shooting. The cancer itself can also cause this kind of pain.
    o Phantom pain. You may still feel pain or other discomfort coming from a body part that has been removed by surgery. Doctors aren't sure why this happens, but it's real.

How much pain you feel depends on different things. These include where the cancer is in your body, what kind of damage it is causing, and how you experience the pain in your body. Everyone is different.

Listen to your body

If you notice that everyday actions, such as coughing, sneezing, or moving, cause new pain or your pain to get worse, tell your doctors right away. Also let them know if you have unusual rashes or bowel or bladder changes.

Your Pain Control Plan

Make your pain control plan work for you.

Your pain control plan will be designed for you and your body. Everyone has a different pain control plan. Even if you have the same type of cancer as someone else, your plan may be different.

Take your pain medicine dose on schedule to keep the pain from starting or getting worse. This is one of the best ways to stay on top of your pain. Don't skip doses. Once you feel pain, it's harder to control and may take longer to get better.

Here are some other things you can do:

Bring your list of medicines to each visit.

If you are seeing more than one doctor, make sure each one sees your list of medicines, especially if he or she is going to change or prescribe medicine.

Never take someone else's medicine. What helped a friend or relative may not help you. Do not get medicine from other countries or the Internet without telling your doctor.

Don't wait for the pain to get worse.

Ask your doctor to change your pain control plan if it isn't working.

The best way to control pain is to stop it before it starts or prevent it from getting worse.

Don't wait until the pain gets bad or unbearable before taking your medicine. Pain is easier to control when it's mild. And you need to take pain medicine often enough to stay ahead of your pain. Follow the dose schedule your doctor gives you. Don't try to "hold off" between doses. If you wait:

  • Your pain could get worse.
  • It may take longer for the pain to get better or go away.
  • You may need larger doses to bring the pain under control.

Keep a list of all your medicines.

Make a list of all the medicines you are taking. If you need to, ask a member of your family or health care team to help you. Bring this list of medicines to each visit. You can take most pain medicines with other prescription drugs. But your health care team needs to know what you take and when. Tell them each drug you are taking, no matter how harmless you think it might be. Even over-the-counter medicines, herbs, and supplements can interfere with cancer treatment.

How to tell when you need a new pain control plan

Here are a few things to watch out for and tell your health care team about:

Your pain isn't getting better or going away.

Your pain medicine doesn't work as fast as your doctor said it would.

Your pain medicine doesn't work as long as your doctor said it would.

You have breakthrough pain.

You have side effects that don't go away.

Pain interferes with things like eating, sleeping, or working.

The schedule or the way you take the medicine doesn't work for you.

Medicines To Treat Cancer Pain

There is more than one way to treat pain.

Your doctor prescribes medicine based on the kind of pain you have and how severe it is. In studies, these medicines have been shown to help control cancer pain. Doctors use three main groups of drugs for pain: nonopioids, opioids, and other types. You may also hear the term analgesics used for these pain relievers. Some are stronger than others. It helps to know the different kinds of medicines, why and how they're used, how you take them, and what side effects you might expect.

Nonopioids - for mild to moderate pain

Nonopioids are drugs used to treat mild to moderate pain, fever, and swelling. On a scale of 0 to 10, a nonopioid may be used if you rate your pain from 1 to 4. These medicines are stronger than most people realize. In many cases, they are all you'll need to relieve your pain. You just need to be sure to take them regularly.

You can buy most nonopioids without a prescription. But you still need to talk with your doctor before taking them. Some of them may have things added to them that you need to know about. And they do have side effects. Common ones, such as nausea, itching, or drowsiness, usually go away after a few days. Do not take more than the label says unless your doctor tells you to do so.

Nonopioids include:

  • Acetaminophen, which you may know as Tylenol®
    Acetaminophen reduces pain. It is not helpful with inflammation. Most of the time, people don't have side effects from a normal dose of acetaminophen. But taking large doses of this medicine every day for a long time can damage your liver. Drinking alcohol with the typical dose can also damage the liver.

Make sure you tell the doctor that you're taking acetaminophen. Sometimes it is used in other pain medicines, so you may not realize that you're taking more than you should. Also, your doctor may not want you to take acetaminophen too often if you're getting chemotherapy. The medicine can cover up a fever, hiding the fact that you might have an infection.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (which you may know as Advil® or Motrin®) and aspirin
    NSAIDs help control pain and inflammation. With NSAIDs, the most common side effect is stomach upset or indigestion, especially in older people. Eating food or drinking milk when you take these drugs may stop this from happening.

NSAIDs may also keep blood from clotting the way it should. This means that it's harder to stop bleeding after you've hurt yourself. NSAIDs can also sometimes cause bleeding in the stomach.

  • Your stools become darker than normal
  • You notice bleeding from your rectum
  • You have an upset stomach
  • You have heartburn symptoms
  • You cough up blood
Acetaminophen and NSAIDs at a Glance
Type Other Names Action Side Effects
Acetaminophen Tylenol® Reduces pain and fever Large doses can damage the liver.

May cause liver damage if you drink three or more alcoholic drinks a day.

Lowers fever. Talk to your doctor if your body temperature is above normal (98.6°) and you are taking this medicine.
NSAIDs (asprin, ibuprofen, naproxen) Bayer®
(aspirin)

Ecotrin®
(aspirin)

Advil®
(ibuprofen)

Motrin®
(ibuprofen)

Nuprin®
(ibuprofen)

Aleve®
(naproxen)
Reduces pain, inflammation (swelling), and fever Can upset the stomach.

Can cause bleeding of the stomach lining, especially if you drink alcohol (wine, beer, etc.).

Can cause kidney problems, especially in the elderly or those with existing kidney problems.

Can cause heart problems, especially in those who already have heart disease. However, aspirin does not cause heart problems.

Avoid these medicines if you are on anticancer drugs that may cause bleeding.

Lowers fever. Talk to your doctor if your body temperature is above normal (98.6°) and you are taking this medicine.

What to avoid when taking NSAIDs

Some people have conditions that NSAIDs can make worse. In general, you should avoid these drugs if you:

Are allergic to aspirin

Are getting chemotherapy

Are on steroid medicines

Have stomach ulcers or a history of ulcers, gout, or bleeding disorders

Are taking prescription medicines for arthritis

Have kidney problems

Have heart problems

Are planning surgery within a week

Are taking blood-thinning medicine (such as Coumadin®)

Opioids - for moderate to severe pain

If you're having moderate to severe pain, your doctor may recommend that you take stronger drugs called opioids. Opioids are also known as narcotics. You must have a doctor's prescription to take them. They are often taken with aspirin, ibuprofen, and acetaminophen.

Common opioids include:

Codeine

Fentanyl

Hydromorphone

Levorphanol

Meperidine

Methadone

Morphine

Oxycodone

Oxymorphone

Getting relief with opioids

Over time, people who take opioids for pain sometimes find that they need to take larger doses to get relief. This is caused by more pain, the cancer getting worse, or medicine tolerance (see Medicine Tolerance and Addiction). When a medicine doesn't give you enough pain relief, your doctor may increase the dose and how often you take it. He or she can also prescribe a stronger drug. Both methods are safe and effective under your doctor's care. Do not increase the dose of medicine on your own.

Managing and preventing side effects

Some pain medicines may cause:

Constipation (trouble passing stools)

Drowsiness (feeling sleepy)

Nausea (upset stomach)

Vomiting (throwing up)

Usually these side effects last only a few days. But if they last longer, your doctors can change the medicine or dose you're taking. Or they may also add another medicine to your pain control plan to control the side effects. Keep in mind that constipation will only go away if it's treated. Your health care team can talk with you about other ways to relieve side effects. Don't let side effects stop you from getting your pain under control.

Other less common side effects include:

Dizziness

Confusion

Breathing problems

Itching

Trouble urinating

Constipation

Almost everyone taking opioids has some constipation. This happens because opioids cause the stool to move more slowly through your system, so your body takes more time to absorb water from the stool. The stool then becomes hard.

You can control or prevent constipation by taking these steps:

Ask your doctor about giving you laxatives and stool softeners when you first start taking opioids. Taking these right when you start taking pain medicine may prevent the problem.

Drink plenty of liquids. Drinking 8 to 10 glasses of liquid each day will help keep stools soft.

Eat foods high in fiber, including raw fruits with the skin left on, vegetables, and whole grain breads and cereals.

Add 1 to 2 tablespoons of bran to your food or sprinkle it on your food. Remember to drink a glass of water when you eat bran, or it will make the problem worse.

Exercise as much as you are able. Any movement, such as light walking, will help.

Call your doctor if you have not had a bowel movement in 2 days or more.

Drowsiness

If your pain has kept you from sleeping, you may sleep more at first when you begin taking opioids. The drowsiness usually goes away after a few days.

If you are tired or drowsy:

Don't walk up and down stairs alone.

Don't do anything where you need to be alert - driving, using machines or equipment, or anything else that requires focus.

Call your doctor if the drowsiness is severe or doesn't go away after a week.

You may have to take a smaller dose more often or change medicines.

It may be that the medicine isn't relieving your pain, and the pain is keeping you awake at night.

Your other medicines may be causing the drowsiness.

Your doctor may decide to add a new drug that will help you stay awake.

Nausea and vomiting

Nausea and vomiting usually go away after a few days of taking opioids.

These tips may help:

Stay in bed for an hour or so after taking your medicine if you feel sick when walking around. This kind of nausea is like feeling seasick. Some over-the-counter drugs may help, too. But be sure to check with your doctor before taking any other medicines.

You may want to ask your doctor to prescribe antinausea drugs.

Ask your doctor if something else could be making you feel sick. It might be related to your cancer or another medicine you're taking. Constipation can also add to nausea.

Starting a new pain medicine

Some pain medicines can make you feel sleepy when you first take them. This usually goes away within a few days. Also, some people get dizzy or feel confused. Tell your doctor if any of these symptoms persist. Changing your dose or the type of medicine can usually solve the problem.

What to watch out for when taking pain medicine

All drugs must be taken carefully. Here are a few things to remember when you are taking opioids:

  • Take your medicines as directed. Also, don't split, chew, or crush them, unless suggested by your doctor.

  • Doctors will adjust the pain medicine dose so that you get the right amount for your body. That's why it's important that only one doctor prescribes your opioids. Make sure that you bring your list of medicines to each visit. That way, your health care team is aware of your pain control plan.
  • Combining pain medicine with alcohol or tranquilizers can be dangerous. You could have trouble breathing or feel confused, anxious, or dizzy.

Tell your doctor how much and how often you:

Drink alcohol

Take tranquilizers, sleeping pills, or antidepressants

Take any other medicines that make you sleepy

Other types of pain medicine

Doctors also prescribe other types of medicine to relieve cancer pain. They can be used along with nonopioids and opioids. Some include:

  • Antidepressants. Some drugs can be used for more than one purpose. For example, antidepressants are used to treat depression, but they may also help relieve tingling and burning pain. Nerve damage from radiation, surgery, or chemotherapy can cause this type of pain.

  • Antiseizure medicines (anticonvulsants). Like antidepressants, anticonvulsants or antiseizure drugs can also be used to help control tingling or burning from nerve injury.
  • Steroids. Steroids are mainly used to treat pain caused by swelling.

Other ways to relieve pain

Medicine doesn't always relieve pain in some people. In these cases, doctors use other treatments to reduce pain:

  • Radiation therapy. Different forms of radiation energy are used to shrink the tumor and reduce pain. Often one treatment is enough to help with the pain. But sometimes several treatments are needed.

  • Neurosurgery. A surgeon cuts the nerves that carry pain messages to your brain.

  • Nerve blocks. Anesthesiologists inject pain medicine into or around the nerve or into the spine to relieve pain.

  • Surgery. A surgeon removes all or part of a tumor to relieve pain. This is especially helpful when a tumor presses on nerves or other parts of the body.

  • Chemotherapy. Anticancer drugs are used to reduce the size of a tumor, which may help with the pain.

  • Transcutaneous Electric Nerve Stimulation (TENS). TENS uses a gentle electric current to relieve pain. The current comes from a small power pack that you can hold or attach to yourself.
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