Aging Begins at 30

Managing Pain: Important Part of Cancer Treatment

About a third of cancer patients have pain at diagnosis. Two thirds have it with advanced disease. Cancer pain is a serious problem greatly interfering with the quality of life and should be controlled.

There is a three step World Health Organization (WHO) antipain "ladder" of drugs. The first step is round-the-clock pain killers in the aspirin-acetaminophen (Tylenol)-non steroidal anti-inflammatory (NSAID) drug families. If this does not work the second step is to continue these drugs and add a weak synthetic opium imitator (opioid) such as codeine or oxycodone. They have a ceiling where increased doses result in increased side-effects without any more pain relief. Demerol is not very useful for cancer pain.

The third pain relief ladder step has no pain killing ceiling and consists of morphine (isolated from opium in 1803), hydromorphine (dilaudid), levorphanol,methadone, and fentanyl (duragesic). Unfortunately nausea, sedation, breathing depression, and especially constipation can occur. Colace and senna are usually effective against the constipation. Addiction is rare and does not interfere with pain control. Effective pain control can be achieved by most doctors in 80% and by pain specialists in 95%. Some patients imagine that if they report pain it will distract their doctors from cancer treatment. Rescue doses should be available consisting of 8% of the previous day's dose every two hours on request and are added to the next day's dose. Morphine is the drug of choice. My father had it for self treatment of stomach cancer pain in 1943. After total dose selection, long acting preparations can be substituted.

Ineffective pain control follows failure to chart pain or misconceptions about the use of morphine. "As needed doses" (p.r.n.) of pain medicine are inappropriate, as a constant blood level is needed. Begin with a low dose and increase until pain relief is obtained or until side effects are unmanageable. Drug dosage is gauged by pain relief. There is no standard dose. It may have to be escalated for advanced disease. Most side-effects are manageable by waiting for tolerance or with symptom-controlling medicines. e.g. anti-nausea pills. Equivalent dose tables are available when switching route or changing drugs.

Tolerance occurs when increased doses are needed to maintain an effect. Physical dependence is return of pain when the opiate is cut back. Neither is addiction. Start with a brief intravenous course of an opioid but the oral course is better. Some patients use self controlled dosage devices. You push a button for an immediate IV dose. Depression, anger, and anxiety can develop and aggravate pain and can be treated. Pleasant diversion and vigorous exercise help as they increase the inborn production of pain killers called endorphins or enkephalins. The keys to good treatment are careful pain charting, early treatment, ongoing assessment, and clear doctor-patient communication. If all else fails, pain nerves can be temporarily or permanently blocked.

Inadequate pain management is a persistent problem. In a recent evaluation in 15,000 nursing home cancer patients 30% reported daily pain. Only a quarter received morphine and another quarter did not receive any pain medication. Pain in cancer patients is often untreated among older and minority patients. Pain is derived from a Latin word poena which means punishment. Nowadays such punishment is unnecessary.

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See related Patient Topics Brain and Nervous System, Cancer--General, Cancer--Living with Cancer, Cancers, Mental Health and Behavior, Pain or Symptoms and Manifestations.

See related Provider Topics Brain and Nervous System, Cancer--General, Cancers, Mental Health and Behavior, Pain or Symptoms and Manifestations.

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