Continuum Cancer Centers of New York

Our Special Services > Symptom Specific Services > Pain

Will I experience pain?
Many people with cancer fear pain and, at the same time, believe it to be an unavoidable part of the disease. However, only 30 percent to 40 percent of patients treated for cancer report pain.

Not everyone with cancer has pain, and those who do can control it with medication and other state-of-the-art treatments.

Pain left untreated can cause fatigue, depression, anger and stress. It can keep you from sleeping well, enjoying family and friends, and eating properly. If you have cancer and are feeling pain, you need to tell your doctor or nurse. Getting help for your pain early on can make treatment more effective.

What causes pain?
Pain has many causes in people with cancer, including:

• Pressure from a tumor on bone, nerves, or other sensitive organs

• Cancer treatments such as chemotherapy, surgery, or radiation

• Other conditions, such as arthritis

Pain caused by the actual cancer can be divided into two categories, nociceptive pain and neuropathic pain.

Nociceptive pain is caused by damage to tissue. It is usually described as a sharp, aching, or throbbing pain. Nociceptive pain may be due to:

• Cancer that is growing

• Cancer that has spread to the bones, muscles or joints

• A blockage of an organ such as the colon, or parts of the digestive system

• A tumor in the esophagus or throat

• Swelling from blood vessels blocked by a tumor

Neuropathic pain occurs when there is actual nerve damage. It is usually described as a burning or heavy sensation, or numbness. Neuropathic pain may be due to:

• A tumor pressing on or intruding on a nerve or a group of nerves

• A tumor pressing on the spinal cord

Cancer treatments can also cause pain.

Surgery is sometimes necessary for cancer treatments, to remove a tumor or reduce the size of a tumor to relieve pressure. Pain from surgery can be treated and may go away quickly, after the surgical incision heals. Doctors may prescribe medicines like Advil (ibuprofen), Tylenol (acetaminophen), or patient-controlled analgesia (PCA), a mechanism that allows patients to manage their own intravenous pain medication.

Chronic (long-term) pain can result from surgery if there has been nerve damage or other changes in the body due to surgery. This type of pain may be more difficult to control, and treatment must be tailored to each patient.

Chemotherapy can cause pain in a variety of ways:

• Some chemotherapy drugs, called vesicants, can harm surrounding tissue if they leak out of the vein. Staff members who administer chemotherapy now use special IV catheters that help reduce the chance of this occurring. They will alert your doctor or nurse if you feel any burning or pain while chemotherapy is being administered to you.

• Repeated needle sticks bother some people when they receive several cycles of chemotherapy. You should ask your doctor if you are a candidate to receive a port, which is an access device placed just under the skin through a minor outpatient procedure. A port allows you to receive chemotherapy and have blood drawn from the exact same spot without repeated needle sticks.

• Chemotherapy can cause sores in the mouth (stomatitis), which can be painful during eating or drinking, and sores in the lining of the intestines (mucositis), which can cause cramping and diarrhea. Inform your doctor or nurse if these problems occur. Your doctor can prescribe medications to numb your throat and treat your intestinal discomfort.

• Peripheral neuropathy, a tingling, numbness or pain in the extremities, (hands, fingers, toes, and feet) can be one effect of chemotherapy. Certain chemotherapy drugs (Vincristine, Cisplatin, Taxol, and Vinblastine) are more likely to cause this type of problem when given long-term in high doses. While this may not be preventable, alerting your health care provider to these symptoms will allow them to modify your therapy.

• Nausea and vomiting are common side effects of chemotherapy. Your doctor can prescribe effective treatments to reduce or even halt these side effects. For quick, practical tips on coping with nausea, click here.

Radiation treatment can damage normal cells and tissues as it destroys cancer cells, sometimes causing pain and discomfort. Skin dryness, difficulty swallowing, or skin sores may occur. Your radiation oncology nurse can recommend a skin care program to alleviate these reactions.

Fatigue can also be a disabling side effect of cancer and treatment, restricting a person's ability to manage their usual activities. For more information on how to deal with fatigue, click here.

What are the goals at Continuum Cancer Centers of New York for treating pain?
At Continuum Cancer Centers of New York our goal is to relieve pain safely and effectively. We strive to:

• Assess and treat each person's pain individually

• Provide access to an interdisciplinary group of professionals who can implement an array of state-of-the-art approaches, psychological treatments, and pain management approaches

• Encourage patients to be active participants in their treatment, drawing on non-medical interventions in addition to, not instead of, medical treatment

• Educate patients and their families about pain and its treatment, as it relates to cancer

• Reassess the treatment plan regularly, responding promptly to changes in pain or the development of new pain

Physicians, nurses, social workers and other health professionals are trained to ask about your pain and provide you with the means to relieve it. Your physician or nurse will also ask what makes the pain feel better or worse.

Your answers should include a description of the body positions and activities that increase or decrease pain. Also consider how well your pain medication is working, and the degree to which you feel relief and for how long. All of this information will help your doctor manage your pain as effectively as possible.

How can I get pain relief?
Your pain is unique and it will be treated individually and uniquely. What works for one person may not work for the next. Pain is treated through the use of drug therapies or medications.

Different treatments exist for different types of pain. Before we describe this further, it's important to remember:

• You may be taking several medications at the same time. Be sure you understand when and how to take them, and report any side effects.

• If one medication isn't helping, changes in the dosage can be made. Or you and your doctor can explore other medications in place of one that isn't helping.

• No medication, not even aspirin, should be taken without your doctor or nurse knowing.

• The pain control plan created by you and your doctor should be one that you can easily follow. If you are having trouble getting or taking the medication, talk with your doctor. If there is any reason you cannot follow your plan, your medications and the schedules for taking them can be adjusted to fit your lifestyle.

Types of Pain Medicine
For mild or low-level pain, acetaminophen and other nonsteroidal anti-inflammatory (NSAIDS) medications are recommended. These medications include aspirin and ibuprofen; most are available without a prescription. NSAIDS, used alone, have a limit to their pain-relieving effect, which is known as a ceiling; taking a higher dose than specified will not bring about greater pain relief and is not recommended.

Although aspirin is an excellent pain reliever, it is not usually given to people receiving radiation or chemotherapy. Even though these medications are sold over the counter, you still need to be monitored by your medical team for any side effects that could occur with long-term use.

For moderate to severe pain, you may need an opioid, also called a narcotic, which requires a prescription. Morphine, Fentanyl, Hydromorphone, Oxycodone and codeine are all opioids. They can be taken by mouth (pill or liquid), through a patch on the body (similar to nicotine patches), in suppository form, or by injection.

Unlike NSAIDS, opioids do not have a ceiling. Your doctor can increase the dose of these medications as much as it takes to relieve your pain. The dosage can always be increased, which means there is never a time when medication cannot treat your pain.

One of the main obstacles to opioid use is constipation. The effect of opiates on bowel function is so consistent that most experts recommend administering Senokot-S (senna and docusate sodium) on a scheduled basis rather than when necessary. For information about how to minimize and treat constipation, please see diarrhea and constipation.

Sometimes your doctor will prescribe non-opioids along with opioids. Many people have the misconception that medications such as morphine lead to addiction. Studies have shown that this is not the case.

Pain caused by swelling or inflammation is often treated with steroids. Examples of steroids are Prednisone and Dexamethasone. Prescriptions are necessary for these medications and it is important to carefully follow the directions for taking them. Do not stop taking these medications without letting your doctor know, as the dosage must be decreased on a schedule over time before you can stop taking them.

Anti-depressants may be prescribed to relieve symptoms such as the burning and tingling that occurs from nerve pain. Amitriptyline and Imipramine are examples of antidepressants. These medications are commonly prescribed to relieve these symptoms. Taking anti-depressants does not mean that you are depressed or unable to cope.

How is pain medication given?
There are several ways, or “routes of administration” that medication can be given. If one does not work well, another route may be used. According to experts in cancer pain, 85 percent to 95 percent of cancer pain can be effectively relieved using oral medications. The other 5 percent to 15 percent of patients may need to use a different route of administration, and/or see a specialist to relieve pain. Your doctor will work with you to decide the route that may work best, and the schedule that will meet your needs.

Taking medication by mouth is generally the most convenient and inexpensive method. Oral medications come in tablet, capsule and liquid forms. Most people can be treated with oral medications. If you have problems swallowing, or problems with nausea and vomiting, your doctor may prescribe your medications to be taken through either the rectal or transdermal (under the skin) route.

Medications administered rectally are in the form of a suppository, which dissolves from the heat of your body and releases medication. This route is not useful if you have diarrhea or rectal pain, or if you have difficulty placing the suppository.

Only two pain medications are currently available using the transdermal route. One is Duragesic, a fentanyl patch that attaches to the skin and allows medicine to flow into the skin over time. The other is Lidocaine, a local anesthetic that can be placed over the involved skin or nerve tract close to the area of pain.

Medications can also be delivered into a muscle or a vein, which is called the parenteral route. Medicine can be delivered into:

1) A muscle (intramuscular or IM injections)

2) Under the skin (subcutaneously or Sub-Q)

3) A vein (intravenously or IV)

4) The spinal fluid (intraspinal)

5) Chambers in the brain, called ventricles (intraventricular). This is a relatively new route, but it is becoming more common.

You may also use a parenteral system called Patient-Controlled Analgesia (PCA). This system allows you to control how much pain medicine you receive. PCA may be dispensed through oral, intravenous, subcutaneous and intraspinal routes. When dispensed through a parenteral route, a special pump is used, and a predetermined dose is given in a steady infusion. You may give yourself an extra dose (bolus) if you are experiencing breakthrough pain (see below), or adjust the medication if it would help you engage more comfortably in a physical activity or treatment. Your doctor will evaluate whether you are a good candidate to use this method at home.

Medications are generally prescribed around the clock to help keep your pain from building up. You may take medications every three, four, eight, 12 or 24 hours. You should discuss a plan with your doctor and decide what schedule of medications works best for you.

There are many options from which you and your doctor can to choose when trying to control pain. If one is not working, speak with your doctor about alternative treatment methods.

What is breakthrough pain?
People with cancer have two types of pain, persistent pain and breakthrough pain.

Persistent pain is continuous and present most of the time. You may be on medication around the clock for this type of pain. Pain is an unstable phenomenon, meaning that it may vary due to numerous factors, including disease progression, activity level, specific movements or stress level. Most patients experience many peaks and valleys of pain daily.

Breakthrough pain is a temporary, moderate to severe flare in pain that occurs even though you may be taking medications regularly. It is called breakthrough pain because it "breaks through" your regular pain medication schedule. This does not mean that your around-the-clock medication has failed, or that your pain is uncontrolled. If you have breakthrough pain, your doctor may want to consider adding other medications that work quickly and for shorter periods of time.

There are several types of breakthrough pain:

• Incident pain -- an increase in pain with movement or activity, such as walking, sitting up, going to the bathroom or coughing.

• Idiopathic or spontaneous pain – Pain that has no particular pattern or reason that it increases.

• End-of-dose failure -- Your pain may increase just before you are scheduled to take a dose of your regular pain medicine. This is called end-of-dose failure, and it may not be an actual breakthrough of pain. This type of pain may be best managed by an adjustment to the dose of your around-the-clock pain medication.

Pain is best controlled when both persistent and breakthrough pain are treated. This means that you may be taking a long-acting medication around the clock to prevent your persistent pain, as well as a short-acting medication that is taken only when you experience episodes of breakthrough pain.

Things to remember:

• You should take your short-acting medication as soon as you feel the breakthrough pain. If you let the pain build up and become too severe, it is harder to relieve.

• Adding short-acting medication will not cause more side effects; in fact, it will lessen them. These medications stay in your body for a shorter period of time. Side effects are similar to long-acting medications, such as drowsiness, occasional nausea, or constipation.

• The short-acting medications should relieve most of your breakthrough pain without causing unacceptable side effects such as constant nausea. Your doctor or nurse may adjust the dose of your breakthrough medication to give you the best relief with the least amount of side effects. Contact them if you are not getting relief from your pain, or if breakthrough pain is occurring more than four times a day.

• If your pain is not being relieved and your doctor has exhausted all of his or her options, ask to see a doctor who specializes in pain management. They may be anesthesiologists, oncologists, neurosurgeons or a team of specialists that can evaluate your situation and let you know your options.

Reducing pain without drugs
Contrary to what some people believe, there are many ways to relieve pain without drugs. It is important to continually diagnose treatable, reversible causes of pain. Treating the cancer with surgery, radiation, and/or chemotherapy can reduce or eliminate pain related to the cancer.

Non-drug approaches may be helpful alone, or as an added boost to the pain medication you are taking. The Karpas Cancer Library and the health section of most libraries have more information on the following techniques to help you help yourself.

Relaxation and Meditation
Relaxation and meditation can help reduce tension by relaxing your muscles or inducing a deeply relaxed state. These techniques include simple breathing exercises, progressive muscle relaxation, and visualization that reduces tension and anxiety.

All of these methods may help you feel more energized and focused and, in turn, relieve pain. Distraction or focusing your attention on something other than your pain is one approach that can be helpful. Listening to music, watching television, reading, cooking, or talking to family and friends can all work to take your mind off the pain. Relaxation and meditation are often useful during procedures that may be brief but painful.

Imagery
Imagery for pain control is a method of allowing your mind and powers of concentration to focus on soothing images. It is a way for you to further extend the benefits of relaxation and distraction for your own benefit. For example, visualize that your pain is like hot coals and your relaxation techniques are like water pouring over the coals and putting them out the fire.

Another way to use imagery is to imagine you are in your favorite place relaxing. You could imagine yourself walking along a beautiful beach, noticing all the details, such as how the sounds and smells and the warmth of the sun. There are many good audiotapes available to guide you through imagery, which have been effective in relieving stress and discomfort for many people.

Skin stimulation
Skin stimulation refers to methods you use to alleviate pain, such as massage, heating pads, or ice packs. Skin stimulation can be used alone or in combination with other methods for relieving pain. Your doctor or nurse will be able to tell you which forms are likely to be more effective in relieving your type of pain. For example, some pain responds better to heat than to cold. Be especially careful with extreme temperatures, especially heat, which can cause burns or affect your blood circulation.

Exercise
Exercise can help relieve tension, depression and fatigue. Exercises like swimming or walking can be comforting and can increase your energy level. An exercise program should only be started after your doctor gives you a thorough examination, and after he or she gives you approval to begin such a program.

Support groups, either facilitated by a trained professional or with a peer group, may also be beneficial. In a group setting, you can receive emotional support and talk to others who are experiencing the same problems. Together you can share information about coping.

For more information on alternative and complementary therapies to treat pain, click here.

Can Radiation Oncology help with pain?
Radiation Oncology treatments are often used to relieve pain from cancer that has spread to the bones. A consultation with a radiation oncologist as well as a pain specialist can be an important step in the management of bone pain and cancer.

What are common concerns for patients who experience cancer pain?
• Concern: If I complain too much, I am not being a good patient.
Controlling your pain is important to your doctor. If you feel pain, tell your doctor or nurse, so they can help you.

• Concern: I will become addicted to the pain medication.
Addiction to pain medication is extremely rare. A person with cancer only desires relief from pain and rarely continues to use the medication once the pain is gone.

• Concern: If I take too much medication, it will stop working.
Your medication will not stop working. Tolerance is rare but may develop. If this happens, your doctor can increase your dose or prescribe a different medication.

• Concern: I am worried about the side effects of pain medication.
Your health care team or pain specialist can effectively deal with any medication side effects.

How can I benefit from the specialized services of the Department of Pain Medicine?
Continuum Cancer Centers of New York are committed to offering its patients the most advanced pain management options available. We believe that providing relief from pain is an integral part of providing care.

The Department of Pain Medicine and Palliative Care is composed of a team of multidisciplinary specialists who work with you to assess and treat cancer pain. The multidisciplinary team that staff this program includes neurologists, board-certified pain anesthesiologists, rehabilitation medicine physicians, psychologists, advance practice nurses, and physical therapists.

Based on a careful assessment, the team offers a treatment approach tailored to your diagnosis and specific physical and psychosocial condition. The goals are to reduce pain, improve function, enhance quality of life and reduce dependence on the health care system.

Treatment approaches include:

• Expertise in drug therapy for pain, including non-opioid and opioid drugs.

• Psychological therapy, including cognitive approaches such as biofeedback and hypnosis, and formal psychotherapy.

• Access to rehabilitative therapies, including physical therapy and occupational therapy. Treatment with analgesic modalities such as transcutaneous electrical nerve stimulation (TENS) and ultrasound are other possible rehabilitative therapies.

• Minimally invasive pain-relieving treatments, including myofascial trigger point injections, nerve blocks, spinal infusions using implanted pumps, and spinal stimulators.

• Access to complementary approaches, including acupuncture and massage.

How to evaluate and describe your own pain
Remember that the most important thing you can do to relieve your pain is to tell your doctor or nurse about it right away. It is a good idea for you or a family member to record on a daily basis all information about your pain. On the day you go to the doctor, you may not be having pain and may not remember the specific details. Writing down answers to the following questions about your pain daily will help your doctor understand how you are feeling and the best way to treat you.

Keep a record of answers to the following questions:

1)Where is your pain located? Be sure to note all the places where you feel pain.

2) How would you describe your pain? Words like "discomfort" or "hurt" don't really give your doctor the necessary information. It is important to be more precise. Is it sharp? Shooting? Burning? Do you experience numbness? Does it feel different at different times? Here are some other words that may be helpful for you to describe your pain:

Aching
Pounding
Prickly
Tight
Deep
Shock-like
Stabbing
Pinching
Dull
Tender
Throbbing
Tingling
Heaviness
Radiating
Fullness

3) When does it hurt? Is your pain predictable? When does it start? When is it better or worse? Does it wake you up at night? Does it hurt when you move, when you eat, or when you are in a certain position?

4) How severe is your pain? On a scale from zero to 10, where zero is no pain and 10 is the worst pain you can imagine, how would you rate your pain? Keep a record of these measures.

5) What are you doing to control the pain, and is it helping? You may have found some ways to relieve your pain, such as taking medication or using a heating pad or cold pack. Using the same 10-point scale as above, compare your pain score from before you do what helps with about an hour afterwards.

6) How does your pain affect your everyday life? Have you stopped doing certain activities like walking, climbing stairs or working? Does your pain make it difficult for you to concentrate? Do you isolate yourself from others because you are in pain? Helping your doctor or nurse understand how pain limits your activities and affects the quality of your life will help in setting goals for dealing with your pain.

Other useful tips
Bring your daily journal with you to each appointment, or use it when you are speaking to your doctor on the phone.

• If you don't have the ability to keep daily information on pain, ask someone close to you for help. They can ask you the questions and write down your answers. Bring this person to your appointment with you, so he or she can help you describe your pain.

• Your doctor or nurse should evaluate your pain and any changes at every visit. Don't be afraid to add your own information if they haven't asked enough questions. Ask to see another doctor or nurse if you are not confident your pain is being treated or your concerns addressed.

• Severe pain should be reported to your doctor right away, not at your next appointment.

• All pain should be reported, not just pain that is disabling.

• Remember: YOU are the expert in your pain and what relieves it.

For more information on controlling cancer pain, go to www.stoppain.org.

© 2003 Continuum Cancer Centers of New York.