Pain (PDQ®): Supportive care - Patient Information [NCI]
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General Information About Pain
Cancer or treatment for cancer may cause you to feel pain.
Tumors, surgery, chemotherapy, or radiation therapy may cause you pain. Patients with advanced cancer have more severe pain, and many cancer survivors have pain that continues after cancer treatment ends.
Pain control can improve your quality of life.
Pain can be controlled in most patients with cancer. Although cancer pain cannot always be relieved completely, there are ways to lessen pain in most patients. Pain control can improve your quality of life all through your cancer treatment and after it ends.
Pain can be managed before, during, and after diagnostic and treatment procedures.
Many diagnostic and treatment procedures are painful. It helps to start pain control before the procedure begins. Some drugs may be used to help you feel calm or fall asleep. Treatments such as imagery or relaxation can also help control pain and anxiety related to treatment. Knowing what will happen during the procedure and having a relative or friend stay with you may also help lower anxiety.
Each patient needs a personal plan to control cancer pain.
Each person's diagnosis, cancer stage, response to pain, and personal likes and dislikes are different. For this reason, each patient needs a personal plan to control cancer pain. You, your family, and your healthcare team can work together to manage your pain. As part of your pain control plan, your healthcare provider can give you and your family members written instructions to control your pain at home. Find out who you should call if you have questions.
This summary is about ways to control cancer pain in adults, including the following:
- Physical therapies.
- Psychological support.
Assessment of Pain
You and your healthcare team work together to assess cancer pain.
It's important that the cause of the pain is found and treated quickly. The first step in controlling pain is to assess and measure it. Your healthcare team will help you measure pain levels often, including at the following times:
- After starting cancer treatment.
- When there is any new pain.
- After starting any type of pain treatment.
- During pain treatment.
To learn about your pain, the healthcare team will ask you to describe the pain with the following questions:
- When did the pain start?
- How long does the pain last?
- Where is the pain? You will be asked to show exactly where the pain is on your body or on a drawing of a body.
- How strong is the pain?
- Have there been changes in where or when the pain occurs?
- What makes the pain better or worse?
- Is the pain worse during certain times of the day or night?
This information will be used to decide how to help relieve your pain. This may include drugs or other treatments. Your healthcare team will work with you to decide how much pain you can stand and how much improvement you should expect. After pain control is begun, the doctor will continue to assess how well it is working for you and make changes if needed.
The family or caregiver may be asked to give answers for a patient who has a problem with speech, language, or understanding.
A physical exam and tests will be done to help plan pain control.
The assessment will include the following:
- Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of your health habits and past illnesses and treatments will also be taken.
- Neurological exam: A series of questions and tests to check the brain, spinal cord, and nerve function. The exam checks your mental status, coordination, and ability to walk normally, and how well the muscles, senses, and reflexes work. This may also be called a neuro exam or a neurologic exam.
Your healthcare team will also assess your mental and spiritual needs.
Using Drugs to Control Pain
The doctor will prescribe drugs based on whether the pain is mild, moderate, or severe.
Your doctor will prescribe drugs to help relieve your pain. These drugs need to be taken at scheduled times to keep a constant level of the drug in the body to help keep the pain from coming back. Drugs may be taken by mouth or in other ways, such as by infusion or injection.
Your doctor may prescribe extra doses of a drug that can be taken as needed for pain that occurs between scheduled doses of drug. The doctor will adjust the drug dose for your needs.
Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to relieve mild pain.
NSAIDs help relieve mild pain. They may be given with opioids for moderate to severe pain. Acetaminophen also relieves pain, although it does not have the anti-inflammatory effect that aspirin and other NSAIDs do.
Patients, especially older patients, who are taking acetaminophen or NSAIDs need to be closely watched for side effects. See Treating Pain in Older Patients for more information. Most NSAIDs affect the blood platelets so that it takes longer for blood to clot and stop any bleeding. Aspirin should not be given to children to treat pain.
Opioids may be used to relieve moderate to severe pain.
Opioids work very well for the relief of moderate to severe pain. Some patients with cancer pain stop getting pain relief from opioids during long-term therapy. This is called tolerance. Larger doses or a different opioid may be needed if your body stops responding to the same dose. Tolerance of an opioid is a physical dependence on it. This is not the same as addiction (psychological dependence). Opioid doses can be safely increased by your doctor as needed for your pain, without causing addiction.
There are several types of opioids:
- Morphine (the most commonly used opioid for cancer pain).
The doctor will prescribe drugs and the times they should be taken in order to best control your pain.
Most patients with cancer pain will need to receive opioids on a regular schedule.
Receiving opioids on a regular schedule helps manage the pain and keeps it from getting worse. The amount of time between doses depends on which opioid is being used. The correct dose is the amount of opioid that controls your pain with the fewest side effects. The dose will be slowly adjusted until there is a good balance between pain relief and side effects. If opioid tolerance does occur, it can be overcome by increasing the dose or changing to another opioid.
Sometimes, the opioid dose needs to be decreased or the opioid is stopped. This may be done when you no longer have pain because of treatments such as nerve blocks or radiation therapy. The doctor may also decrease the dose if it makes you too sleepy or if your kidney function decreases.
Opioids may be given in different ways.
Opioids may be given by the following ways:
- Mouth: If your stomach and intestines work normally, medicine is usually given by mouth. Opioids given orally are easy to use and usually low-cost. Oral opioids are sometimes placed under the tongue or on the inside of the cheek to be absorbed.
- Rectum: If you cannot take opioids by mouth, they may be given as rectal suppositories.
- Skin patches: Opioid patches are placed on the skin.
- Nose spray: Opioids may be given in the form of a nasal spray.
- Intravenous (IV) line: Opioids are given into a vein only when simpler and less costly methods cannot be used, don't work, or are not wanted by the patient. Patient-controlled analgesia (PCA) pumps are one way to control pain through your IV line. A PCA pump allows the patient to control the amount of drug that is used. With a PCA pump, you can receive a preset opioid dose by pressing a button on a computerized pump that is connected to a small tube. Once the pain is controlled, the doctor may prescribe regular opioid doses based on the amount you used with the PCA pump.
- Subcutaneous injection: Opioids are given by injection into the fatty layer of tissue just under the skin. The small needle used for the injection may be left in place for up to one week.
- Intraspinal injection: Intraspinal opioids are injected into the fluid around the spinal cord. These may be combined with a local anesthetic to help some patients who have pain that is very hard to control.
Common side effects are nausea, sleepiness, and constipation.
Your doctor will discuss the side effects with you before opioid treatment begins and will watch you for side effects. The following are the most common side effects:
Sleepiness and nausea most often occur when opioid treatment is first started and usually get better within a few days.
Opioids slow down the muscle contractions and movement in the stomach and intestines, which can cause hard stools. To keep the stool soft and prevent constipation, it's important to drink plenty of fluids. Unless there are problems such as a blocked bowel or diarrhea, you will be given a treatment plan to follow to prevent constipation and information on how to avoid problems with your intestines while taking opioids.
Other side effects of opioid treatment include the following:
- Trouble thinking clearly.
- Problems with breathing.
- Problems with sexual function.
Talk with your doctor about side effects that bother you or become severe. The doctor may decrease the dose of the opioid, change to a different opioid, or change the way the opioid is given to help decrease the side effects. See the following PDQ summaries for more information about coping with these side effects:
- Gastrointestinal Complications
- Nausea and Vomiting
- Nutrition in Cancer Care
- Sexuality and Reproductive Issues
Other drugs may be added to help treat your pain.
Other drugs may be given while you are taking opioids for pain relief. These are drugs that help the opioids work better, treat symptoms, and relieve certain types of pain. The following types of drugs may be used:
- Local anesthetics.
There are big differences in how patients respond to these drugs. Side effects are common and should be reported to your doctor.
Bisphosphonates are drugs that are sometimes used when cancer has spread to the bones. They are used to decrease pain and reduce risk of broken bones. However, bisphosphonates sometime cause severe side effects. Talk to your doctor if you have severe muscle or bone pain. Bisphosphonate therapy may need to be stopped.
The use of bisphosphonates is also linked to the risk of bisphosphonate-associated osteonecrosis (BON). See the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information.
The use of cannabinoids given with pain medicine is being studied for cancer-related pain.
Radiation Therapy for Pain
Radiation therapy may be used to relieve bone pain.
Radiation therapy is used to relieve pain in patients with cancer that has spread to the bone. This is called palliative radiation therapy. It may be given as local therapy directly to the tumor or to larger areas of the body. Radiation therapy helps drugs and other treatments work better by shrinking tumors that are causing pain. Radiation therapy may help patients with bone pain move more freely and with less pain.
The following types of radiation therapy may be used:
External radiation therapy
External radiation therapy uses a machine outside the body to send high-energy x-rays or other types of radiation toward the cancer. External radiation therapy relieves pain from cancer that has spread to the bone. Radiation therapy may be given in a single dose or divided into several smaller doses given over a period of time. The decision whether to have single or divided dose radiation therapy may depend on how convenient the treatments are and how much they cost.
Stereotactic body radiation therapy
Stereotactic body radiation therapy (SBRT) is a type of external radiation therapy that uses special equipment to position a patient and give a single large dose of radiation to a tumor. This type of radiation therapy causes less damage to nearby normal tissue. SBRT may be used to treat tumors that have spread to the bone, especially spinal tumors. SBRT may also be used to treat areas that have already received radiation.
Radiopharmaceuticals are drugs that contain a radioactive substance that may be used to diagnose or treat disease, including cancer. Radiopharmaceuticals may also be used to relieve pain from cancer that has spread to the bone. A single dose of radioactive agent injected into a vein may relieve pain when cancer has spread to several areas of bone and/or when there are too many areas to treat with external radiation therapy.
Radiofrequency ablation uses a special probe with tiny electrodes to kill cancer cells. Sometimes the probe is inserted directly through the skin and only local anesthesia is needed. In other cases, the probe is inserted through an incision in the abdomen. This is done in the hospital with general anesthesia. This procedure may relieve pain in patients who have cancer that has spread to the bone. More studies are needed to learn about possible risks and benefits.
Radiation therapy with bisphosphonates
The use of radiation therapy given together with bisphosphonates is being studied in patients with cancer that has spread to the bone. More studies are needed to find out if this relieves pain better than radiation therapy alone.
Other Treatments for Pain
When radiation therapy does not relieve pain, other treatments may be used.
Other therapies can be used along with drugs and radiation therapy to manage pain. You can help decide which methods work best to relieve your pain.
A nerve block is the injection of either a local anesthetic or a drug into or around a nerve to block pain. Nerve blocks help control pain that can't be controlled in other ways. Nerve blocks may also be used to find where the pain is coming from, to predict how the pain will respond to long-term treatments, and to prevent pain after certain procedures.
Surgery can be done to implant a device that delivers drugs or stimulates the nerves with mild electric current. In rare cases, surgery may be done to destroy a nerve or nerves that are part of the pain pathway.
Physical treatments, such as heat, cold, and exercise, can help relieve pain.
Physical methods to treat weakness, muscle wasting, and muscle and bone pain include the following:
- Applying heat (a hot pack or heating pad).
- Applying cold (ice packs).
- Exercise to strengthen weak muscles, loosen stiff joints, help coordination and balance, and strengthen the heart.
- Changing position (for patients who are not able to move on their own).
- Limiting the movement of painful areas or broken bones.
- Transcutaneous electrical nerve stimulation (TENS), a procedure in which mild electric currents are applied to some areas of the skin to control pain.
Integrative treatments include massage therapy, acupuncture, and music.
Integrative therapy combines conventional (standard) medical treatment with complementary and alternative (CAM) therapies that have been shown to be safe and to work. CAM therapies treat the mind, body, and spirit.
Massage therapy has been studied as supportive care in managing pain related to cancer. Massage may help you relax and improve your mood. Studies show that massage therapy may do the following:
- Cause the body to release endorphins, which relieve pain and give a feeling of well-being.
- Increase the flow of blood and lymph fluid.
- Increase the effects of drugs used for pain.
- Decrease inflammation and swelling.
- Decrease pain caused by muscle spasms and tension.
Massage has a direct effect on body tissues and should be used with care in patients with cancer. Studies show that massage therapy may be safe in patients with cancer. However, when massage is used in cancer patients, the following precautions should be taken:
- Avoid massaging any open wounds, bruises, or areas where the skin has broken down.
- Avoid massaging directly over the area where the tumor is.
- Avoid massaging areas with deep vein thrombosis (blood clot in a vein). Symptoms may include pain, swelling, warmth, and redness in the affected area.
- Avoid massaging soft tissue when the skin is sensitive following radiation therapy.
(For more information on massage, see Exercise 2 in the following section.)
Acupuncture is an integrative therapy that applies needles, heat, pressure, and other treatments to one or more places on the skin called acupuncture points. Acupuncture may be used to manage pain, including pain related to cancer. See the PDQ summary on Acupuncture for more information.
Music has been used to relieve pain and anxiety caused by cancer and cancer treatments. Studies have reported that music may work on areas of the brain that increase pleasant feelings and decrease unpleasant responses. Your favorite music may help you the most. Music is more helpful if you begin listening before a procedure than it is during or after a procedure. Music may be used along with pain medicine.
There are two main types of music treatments—music therapy and music medicine:
- Music therapy is given by a trained specialist called a music therapist. The music used may be live or recorded. Therapy may include music improvisation (making up music), song writing and singing, and relaxing to music. The music therapist bases treatment on your needs, such as controlling pain, decreasing anxiety, or learning new coping skills.
- Music medicine is listening to music (usually recorded music) to take attention away from the pain. Music medicine is guided by a medical professional who does not have special training in music therapy.
The use of music for pain related to cancer is still being studied.
Music is also used in relaxation exercises.
Some methods help relieve pain by changing how you think about pain and teaching you ways to relax.
Treatments that change how you think about pain and respond to it are also helpful in treating pain. These are called psychological interventions. Psychological interventions give you a sense of control and teach you coping skills to deal with the disease and its symptoms. Staying calm when you feel pain may keep you more comfortable. You may try several methods and choose one or more to use regularly.
- Hypnosis: Hypnosis may help you relax and may be combined with other thinking and behavior methods. Hypnosis to relieve pain works best in people who are able to concentrate and use imagery and who are willing to practice the technique.
- Redirecting thinking: In redirecting thinking, you focus your attention away from pain by thinking about other things. Methods may be internal (for example, counting, praying, or saying things like "I can cope") or external (for example, music, television, talking, listening to someone read, or looking at something specific). You can also learn to replace negative thoughts with positive thoughts and images.
- Talk therapy: Talk therapy may help you focus your attention away from the pain.
- Support groups and religiouscounseling: Support groups help many patients. Religious counseling may also help by offering spiritual care and social support.
- Imagery: Imagery is imagining positive, calming images. This can help you relax, reduce stress, and give you a sense of well-being.
Relaxation exercises: Simple relaxation exercises may be used for short periods of pain (for example, during cancer treatment procedures). Short, simple techniques are helpful when it's hard to concentrate because of severe pain, high anxiety, or fatigue.
The following relaxation exercises may help relieve pain:
Exercise 1. Slow rhythmic breathing for relaxation
- Step 1. Breathe in slowly and deeply, keeping your stomach and shoulders relaxed.
- Step 2. As you breathe out slowly, feel yourself begin to relax; feel the tension leaving your body.
- Step 3. Breathe in and out slowly and regularly at a comfortable rate. Let your breath come all the way down to your stomach, as it completely relaxes.
- Step 4. To help you focus on your breathing and to breathe slowly and rhythmically: Breathe in as you say silently to yourself, "in, two, three." OR Each time you breathe out, say silently to yourself a word such as "peace" or "relax."
- Do Steps 1 through 4 only once or repeat Steps 3 and 4 for up to 20 minutes.
- Step 5. End with a slow deep breath. As you breathe out, say to yourself, "I feel alert and relaxed."
Exercise 2. Receiving touch, massage, or warmth for relaxation
- Touch and massage are traditional methods that caregivers use to help patients relax. Some examples are:
- Brief touch or massage, such as hand holding or briefly touching or rubbing the patient's shoulders.
- Soaking the patient's feet in warm water or wrapping the feet in a warm, wet towel.
- Massage (3 to 10 minutes) of the whole body or just the back, feet, or hands. If the patient is modest or cannot move or turn easily in bed, just the hands and feet can be massaged.
- Use warm lotion. A small bowl of hand lotion may be warmed in a microwave oven or a bottle of lotion may be warmed in a sink of hot water for about 10 minutes.
- Massage for relaxation is usually done with smooth, long, slow strokes. Try different amounts of pressure along with different types of massage, such as kneading and stroking, to find out what the patient likes.
Especially for the elderly person, a relaxing back rub may be no more than 3 minutes of slow, rhythmic stroking (about 60 strokes per minute) on both sides of the spine, from the crown of the head to the lower back. Keep one hand on the body at all times by starting one hand down the back as the other hand stops at the lower back and is raised. Set aside a regular time for the massage. This gives the patient something pleasant to look forward to.
Exercise 3. Peaceful past experiences
- Something may have happened to you a while ago that brought you peace or comfort. You may be able to remember that experience to bring you peace or comfort now. Think about these questions:
- Can you remember any situation, even when you were a child, when you felt calm, peaceful, secure, hopeful, or comfortable?
- Have you ever daydreamed about something peaceful? What were you thinking?
- Do you get a dreamy feeling when you listen to music? Do you have any favorite music?
- Do you have any favorite poetry that you find uplifting or reassuring?
- Have you ever been active religiously? Do you have favorite readings, hymns, or prayers? Even if you haven't heard or thought of them for many years, childhood religious experiences may still be very soothing.
Exercise 4. Active listening to recorded music
Step 1. You will need the following:
- An MP3 player, CD player, or iPod®.
- Earphones or a headset. (This helps focus the attention better than a speaker does, and avoids disturbing others.)
- A recording of music you like. (Most people like fast, lively music, but some select relaxing music. Others like comedy routines, sporting events, old radio shows, or stories.)
Step 2. Mark time to the music; for example, tap out the rhythm with your finger or nod your head. This helps you think about the music instead of your discomfort. Step 3. Keep your eyes open and focus on a fixed spot or object. If you wish to close your eyes, picture something about the music. Step 4. Listen to the music at a comfortable volume. If the discomfort increases, try increasing the volume; decrease the volume when the discomfort decreases. Step 5. If the music is not helping enough, try adding or changing one or more of the following:
- Massage your body in rhythm to the music.
- Try other music.
- Mark time to the music in more than one manner, such as tapping your foot and finger at the same time.
Many patients have found listening to music to be helpful. It tends to be very popular, probably because playing music is a part of daily life and easy to do. If you are very tired, you may simply listen to the music without marking time or focusing on a spot.
These exercises were adapted and reprinted with permission from McCaffery M, Beebe A: Pain: Clinical Manual for Nursing Practice. St. Louis, Mo: CV Mosby: 1989.
Treating Pain in Older Patients
Older patients with cancer pain may have special needs.
Some problems are more likely in older patients. For caregivers of older patients, the following possible problems should be kept in mind:
Having more than one chronic disease and source of pain
Older patients may have more than one chronic disease and take several drugs for different conditions. This can increase the risk of drug interactions. Drugs taken together can change how they work in the body and can affect the patient's chronic diseases.
Problems with vision, hearing, movement, or ability to communicate
Older patients may need simpler and more frequent tests to find out how much pain they are having.
Side effects of nonsteroidal anti-inflammatory drugs (NSAIDs)
Side effects of NSAIDs, such as stomach and kidney damage, memory problems, constipation, and headaches, are more likely in older patients.
Effects of opioids
Older patients may be more sensitive to the effects of opioids. This can give better pain relief that lasts longer. The dose of the opioids may need to be adjusted.
Patient-controlled pain relief
Patient-controlled pain relief must be used carefully in older patients, since drugs are slower to leave the body and older patients are more sensitive to the side effects.
Changes in living arrangements
When older patients move (for example, from hospital to home or nursing home), their needs for pain control may change. These needs should be checked so that pain control methods can be adjusted if needed.
Changes to This Summary (04 / 10 / 2014)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Editorial changes were made to this summary.
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This PDQ cancer information summary has current information about the causes and treatment of pain. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.
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Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Date Last Modified") is the date of the most recent change.
The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.
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