Aside from the proper use of the least effective amounts of opioid pain medications described in previous entries, different specialized types of pain problems require targeted approaches. Pain along a nerve, nerve-ending pain or bone pain are optimally treated with a variety of different types of medications. Beyond the use of medications of any type, relief from pain due to cancer or its treatment can be greatly enhanced through properly administered massage, acupuncture or exercise. The helpful use of those modalities is addressed here. No matter what type of pain or treatment, make sure to thoroughly address pain management with your cancer treatment team. Our expectations and the prevalence of cancer pain have led us to best describe pain in the most descriptive terms possible and rating its intensity so the proper treatments can be recommended. Even experienced providers are not clairvoyant, and should be as aggressive in relieving symptoms as they control cancer growth.
Nerve Ending or Nerve Tract Pain Requires a Different Approach
Certain types of pain, especially connected to nerve-ending damage or impairment are not relieved with acetaminophen, opiate analgesics or NSAIDs. This type of pain that is transmitted along a nerve tract is most often most helped using one of two groups of medications discovered for other purposes. That those purposes are associated with social stigma makes them unappealing without proper information. This type of pain called neuropathic, is best treated with either anti-seizure medications (anticonvulsants) or antidepressants even though neither seizures nor mood changes are what is being treated. Bone pain that affects close-by nerves that shoots down the nerve tract (like sciatic pain) can likewise be helped by either of these two categories, with good evidence basis from clinical trials to do so. Duloxetine (Cymbalta ® and others), gabapentin (Neurontin ® and others, pregabalin (Lyrica ® and others) or amitriptyline (Elavil ® and others) are all used, carefully staring with small doses and generally using smaller doses than treat depression or seizures. Tapering off these medications is essential as well rather than abruptly stopping them and risking serious withdrawal effects can also be life-threatening. Bone pain and strength may also be helped by bone-strengthening drugs also used to treat osteoporosis (zolendronate or Zometa ® and others). Aching pain in bones may also be alleviated with corticosteroids, which are a different type of steroids that muscle builders use.
Pain Management in Cancer Involves More than Medications
Beyond moving between the many medication types and forms used to treat cancer pain, certain non-drug techniques can be effective for certain types of pain. Acupuncture, various massage techniques, physical therapy (with heat/cold), portable electric nerve stimulators, injections directly into the painful area of anesthetics or pain medicines with anti-inflammatory steroids can all be of tremendous help, and should be considered wisely to minimize the doses of medications used. Cancer that has weakened bone if it is growing there deserves special care for these modalities, but possible when administered by experienced clinicians. Certain bone metastases may even be best corrected with surgeries that stabilize the bone with hardware or medical-grade glues. Diversionary techniques likewise help focus attention off pain, and those coupled with flexibility training (such as yoga) provide solace that transcends any spiritual spheres for those with any religious affiliation. Evaluation by a physical medicine specialist experienced with cancer, and the incorporation of tailored exercise that focuses on retaining flexibility and lean body mass is an essential part of any treatment regimen.
Optimally, pain management with all of these modalities includes a hefty dose of counseling. Situations can make pain worse, as can strong emotions that come with having cancer. Keeping diaries, knowledge about side effects, knowing when to use extra medications or ask to be cut back, and using time-tested diversionary techniques are essential. Some pain management practices offer such targeted counseling. For those patients who find that their practice does not, agencies like CancerCare (www.cancercare.org or 1-800-813-4673) have informative telephone services that include one-on-one counseling, webcasts of CancerCare Connect educational programs and on-line interactive services, all at no cost. Patients and families need not feel as if they are going through cancer treatment alone, whether in a big city or rural setting. Oncology-specialized social workers, and specialist psychologists and psychiatrists are invaluable for tailored education and understanding. The American Psychosocial Oncology Society (www.apos-society.org or 1-866-276-7443) can help with referrals close to home.
Make Your Needs Known to Providers Who Can Help
The biggest obstacles to proper pain management in cancer are in communication, misinformation and the availability of services.
Acknowledging pain with cancer is not a moral failure or character flaw. Cancer pain when severe is beyond the "grit your teeth and toughen up" approach. It needs a coordinated approach and can be effectively treated. The reluctance that most people have to be frank about the degree of pain and how they are suffering has been taken into account by the various sub-specialties and disciplines in oncology. Pain scores are now considered a vital sign with blood pressure, temperature, pulse and respiratory rate. Routinely, patients will now be asked to indicate their level of distress, a more global parameter than pain, though pain is included as one of the factors measured. Many of us without thinking by reflex will answer, "Fine," when asked at follow-up appointments. It is perhaps socially acceptable but unhelpful. Cancer specialists are now asking that you be candid, and the field has responded so that once your needs are known they can be better met.
Experienced Treatment Teams Make a Difference
In cancer centers that are accredited by the American College of Surgeons Commission on Cancer, where more than 70% of Americans are treated, the availability of pain management and rehabilitation services, counseling and case management is available on site or by referral in the community. These are mandatory features to becoming an accredited cancer center. Although early and specialist level intervention is key, attention to these matters often get low priority during after cancer surgery or during chemotherapy and radiation, but are now recognized to ease and speed recovery when applied early and consistently.
By 2022, it is projected that 22 million Americans will be cancer survivors. With the current changes in medical care, patients' needs are once again central to the way that care is delivered. Active management of pain and the other symptoms of cancer is an ever more important part of the present and future health care delivery system.