Pain remains among the top five symptoms experienced in cancer. Despite the many effective interventions, many patients do not have accurate or up-to-date information, and get inadequate relief. Likewise, many non-cancer physician providers harbor biases based upon outdated practices they learned in training, sometimes decades ago.
What is pain?
Pain is a subjective and uncomfortable feeling in body tissues. A variety of words is used to describe it: hurt, soreness, stabbing, "on fire", cold, leaden, uncomfortable or "ouch". Pain develops when specialized nerve endings in the body sense pressure or are disrupted in some way, physically or chemically. Pain is particularly bad when there is pressure on a nerve in or near the nerves, bones or the skin and muscles, where there are many pain receptor cells. Cancer exerts pain in a variety of ways: growing tissues that compress nerves or replaces bone. Pain along nerve tracts themselves is often described as "electric" and "shooting". These descriptions are so important, as different types of pain are treated in different ways, with different types of medications and non-medication interventions. Good pain management starts when the pain experience can be translated accurately into words.
Treating Mild Pain
Like a weather forecast, there are different components. Instead of temperature, humidity, and wind speed, think about these parameters:
- Where is the pain?
- When did it start?
- Is it episodic or continuous?
- What makes it worse?
- What relieves it?
- Where does it travel?
- What is closest word descriptor?
- Is it like pain you have had before?
Many of us have had pain from non-cancer illness, from routine life events like childbirth to a burn from hot cookware. Diabetes, for example, is associated with nerve-ending pain similar to that associated with some types of chemotherapy or during the healing process from surgery. Describing the intensity of the pain is also extremely helpful to get relief. This has been standardized so that we all speak a common language: 0 for no pain and 10 for the worst pain imaginable, at intervals of one number. Mild pain is generally rated 1-3, moderate pain 4-6, and severe pain 7-10.
The first line of treatment for most pain is intuitive: medications, cold or warmth, or massage. Since some pain medications are available over-the-counter and marketed widely, a do-it-yourself first pass at pain management is both common and smart. What is available without guidance is often not enough to get through treatment, but a good place to begin. For mild pain, acetaminophen (Tylenol ® or others) can be used, at doses of 325-650 mg - "regular strength", or 500 mg - "extra strength" every four hours or as needed. Certain principles apply which allow most relief from the least amount of medication. Acetaminophen products are usually effective for about four hours, so it is not wise to try to "hold out" for six hours; best to use one tablet every 4 hours instead of 2 tablets every 6-8 hours. You'll use less, and benefit more. There is a known and safe maximal dose to be used in a 24 hour period of about 2000 mg (six regular strength or four extra-strength) as the liver works hard to digest thee products, as it does other medications and food. The labeling may say more, but that really holds for a short course, not for a few weeks or months.
Acetaminophen relieves pain or fever, not inflammation. Much cancer pain is associated with inflammation, so even maximal daily doses only go so far. Aspirin and its cousins, the non-steroidal antiinflammatory drugs (NSAIDs) like ibuprofen or naproxen (many brand names such as Motrin ® or Aleve ® and others) control inflammation, pain and fever. Ibuprofen or aspirin lasts only about 4 hours, whereas naproxen about 12 hours. All can cause indigestion or irritate the stomach lining, so should be taken with food. They can also make platelets, the cells that clot blood 'slippery" so caution must be taken when cancer or treatments also affect platelet count, limiting the use of NSAIDs. Bleeding or easy bruising complicate treatment.NSAIDs or acetaminophen become much more useful again after treatment is completed when the side effect overlap is no longer as important.
Future entries will focus on moderate and severe levels of pain, and the non-drug approaches so that the least amount of medications can be used to control pain.