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This patient summary on pain is adapted from the summary
written for health professionals by cancer experts. This and other credible
information about cancer treatment, screening, prevention, supportive care,
and ongoing clinical trials is available from the National Cancer Institute.
Pain associated with cancer can be controlled in most patients but is frequently
undertreated. This brief summary describes the management of cancer pain with
the use of medication, physical methods, and psychological intervention.
Cancer pain can be managed effectively in most patients
with cancer or with a history of cancer. Although cancer pain cannot always
be relieved completely, therapy can lessen pain in most patients. Pain management
improves the patient's quality of life throughout all stages of the disease.
Flexibility is important in managing cancer pain.
As patients vary in diagnosis, stage of disease, responses to pain and treatments,
and personal likes and dislikes, management of cancer pain must be individualized.
Patients, their families, and their health care providers must work together
closely to manage a patient's pain effectively.
To treat pain, it must be measured. The patient and
the doctor should measure pain levels at regular intervals after starting cancer
treatment, at each new report of pain, and after starting any type of treatment
for pain. The cause of the pain must be identified and treated promptly.
To help the health care provider determine the type
and extent of the pain, cancer patients can describe the location and intensity
of their pain, any aggravating or relieving factors, and their goals for pain
control. The family/caregiver may be asked to report for a patient who has
a communication problem involving speech, language, or a thinking impairment.
- Pain: The patient describes the pain, when it started, how long
it lasts, and whether it is worse during certain times of the day or night.
- Location: The patient shows exactly where the pain is on his or
her body or on a drawing of a body and where the pain goes if it travels.
- Intensity or severity: The patient keeps a diary of the degree
or severity of pain.
- Aggravating and relieving factors: The patient identifies factors
that increase or decrease the pain.
- Behavioral response to pain: The health care provider and/or caregivers
note behaviors that may suggest pain in patients who have communication
- Goals for pain control: With the health care provider, the patient
decides how much pain he or she can tolerate and how much improvement he
or she may achieve. The patient uses a daily pain diary to increase awareness
of pain, gain a sense of control of the pain, and receive guidance from
health care providers on ways to manage the pain.
The results of pain management should be measured
by monitoring for a decrease in the severity of pain and improvement in thinking
ability, emotional well-being, and social functioning. The results of taking
pain medication should also be monitored. Drug addiction is rare in cancer
patients. Developing a higher tolerance for a drug and becoming physically
dependent on the drug for pain relief does not mean that the patient is addicted.
Patients should take pain medication as prescribed by the doctor. Patients
who have a history of drug abuse may tolerate higher doses of medication to
The World Health Organization developed a 3-step
approach for pain management based on the severity of the pain:
- For mild to moderate pain, the doctor may prescribe a Step 1 pain medication
such as aspirin, acetaminophen, or a nonsteroidal anti-inflammatory drug
(NSAID). Patients should be monitored for side effects, especially those
caused by NSAIDs, such as kidney or stomach and intestinal problems.
- When pain lasts or increases, the doctor may change the prescription to
a Step 2 or Step 3 pain medication. Most patients with cancer-related pain
will need a Step 2 or Step 3 medication. The doctor may skip Step 1 medications
if the patient initially has moderate to severe pain.
- At each step the doctor may prescribe additional drugs or treatments (for
example, radiation therapy).
- The patient should take doses regularly, "by mouth, by the clock" (at
scheduled times), to maintain a constant level of the drug in the body;
this will help prevent recurrence of pain. If the patient is unable to swallow,
the drugs are given by other routes (for example, by infusion or injection).
- The doctor may prescribe additional doses of drug that can be taken as
needed for pain that occurs between scheduled doses of drug.
- The doctor will adjust the pain medication regimen for each patient's
individual circumstances and physical condition.
NSAIDs are effective for relief of mild pain. They
may be given with opioids for the relief of moderate to severe pain. Acetaminophen
also relieves pain, although it does not have the anti-inflammatory effect
that aspirin and NSAIDs do. Patients, especially older patients, who are taking
acetaminophen or NSAIDs should be closely monitored for side effects.
Opioids are very effective for the relief of moderate
to severe pain. Undertreatment results when concerns about addiction (psychological
dependence) to these drugs is confused with tolerance and physical dependence.
Many patients with cancer pain become tolerant to opioids during long-term
therapy. Therefore, increasing doses are necessary to continue to relieve pain,
even at the risk of side effects.
There are several types of opioids. Morphine is
the most commonly used opioid in cancer pain management. Other commonly used
opioids include hydromorphone, oxycodone, methadone, and fentanyl. The availability
of several different opioids allows the doctor flexibility in prescribing a
medication regimen that will meet individual patient needs.
Most patients with cancer pain will need to receive
pain medication on a fixed schedule to manage the pain and prevent it from
getting worse. The doctor will prescribe a dose of the opioid medication that
can be taken as needed along with the regular fixed-schedule opioid to control
pain that occurs between the scheduled doses. The amount of time between doses
depends on which opioid the doctor prescribes. The correct dose is the amount
of opioid that controls pain with the fewest side effects. The goal is to achieve
a good balance between pain relief and side effects by gradually adjusting
the dose. If opioid tolerance does occur, it can be overcome by increasing
the dose or changing to another opioid, especially if higher doses are needed.
Occasionally, doses may need to be decreased or
stopped. This may occur when patients become pain free because of cancer treatments
such as nerve blocks or radiation therapy. The doctor may also decrease the
dose when the patient experiences opioid-related sedation along with good pain
Medications for pain may be given in several ways.
The preferred method is by mouth, since medications given orally are convenient
and usually inexpensive. When patients cannot take medications by mouth, other
less invasive methods may be used, such as rectally or through medication patches
placed on the skin. Intravenous methods are used only when simpler, less demanding,
and less costly methods are inappropriate, ineffective, or unacceptable to
the patient. Patient-controlled analgesia (PCA) pumps may be used to determine
the opioid dose when starting opioid therapy. Once the pain is controlled,
the doctor may prescribe regular opioid doses based on the amount the patient
required when using the PCA pump. Intraspinal administration of opioids combined
with a local anesthetic may be helpful for some patients who have uncontrollable
Patients should be watched closely for side effects
of opioids. The most common side effects of opioids include nausea, sleepiness,
and constipation. The doctor should discuss the side effects with patients
before starting opioid treatment. Sleepiness and nausea are usually experienced
when opioid treatment is started and tends to improve within a few days. Other
side effects of opioid treatment include vomiting, difficulty in thinking clearly,
problems with breathing, gradual overdose, and problems with sexual function.
Opioids slow down the muscle contractions and movement
in the stomach and intestines resulting in hard stools. The key to effective
prevention of constipation is to be sure the patient receives plenty of fluids
to keep the stool soft. The doctor should prescribe a regular stool softener
at the beginning of opioid treatment. If the patient does not respond to the
stool softener, the doctor may prescribe additional laxatives.
Patients should talk to their doctor about side
effects that become too bothersome or severe. Because there are differences
between individual patients in the degree to which opioids may cause side effects,
severe or continuing problems should be reported to the doctor. The doctor
may decrease the dose of the opioid, switch to a different opioid, or switch
the way the opioid is given (for example intravenous or injection rather than
by mouth) to attempt to decrease the side effects.
Other drugs may be given at the same time as the
pain medication. This is done to increase the effectiveness of the pain medication,
treat symptoms, and relieve specific types of pain. These drugs include antidepressants,
anticonvulsants, local anesthetics, corticosteroids, and stimulants. There
are great differences in how patients respond to these drugs. Side effects
are common and should be reported to the doctor.
Noninvasive physical and psychological methods can
be used along with drugs and other treatments to manage pain during all phases
of cancer treatment. The effectiveness of the pain interventions depends on
the patient's participation in treatment and his or her ability to tell the
health care provider which methods work best to relieve pain.
Weakness, muscle wasting, and muscle/bone pain may
be treated with heat (a hot pack or heating pad); cold (flexible ice packs);
massage, pressure, and vibration (to improve relaxation); exercise (to strengthen
weak muscles, loosen stiff joints, help restore coordination and balance, and
strengthen the heart); changing the position of the patient; restricting the
movement of painful areas or broken bones; stimulation; controlled low-voltage
electrical stimulation; or acupuncture.
Thinking and behavior interventions are also important
in treating pain. These interventions help give patients a sense of control
and help them develop coping skills to deal with the disease and its symptoms.
Beginning these interventions early in the course of the disease is useful
so that patients can learn and practice the skills while they have enough strength
and energy. Several methods should be tried, and one or more should be used
- Relaxation and imagery: Simple relaxation techniques may be used
for episodes of brief pain (for example, during cancer treatment procedures).
Brief, simple techniques are suitable for periods when the patient's ability
to concentrate is limited by severe pain, high anxiety, or fatigue. (See
Relaxation exercises below.)
- Hypnosis: Hypnotic techniques may be used to encourage relaxation
and may be combined with other thinking/behavior methods. Hypnosis is effective
in relieving pain in people who are able to concentrate and use imagery
and who are willing to practice the technique.
- Redirecting thinking: Focusing attention on triggers other than
pain or negative emotions that come with pain may involve distractions that
are 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). Patients can also learn
to monitor and evaluate negative thoughts and replace them with more positive
thoughts and images.
- Patient education: Health care providers can give patients information
and instructions about pain and pain management and assure them that most
pain can be controlled effectively. Health care providers should also discuss
the major barriers that interfere with effective pain management.
- Psychological support: Short-term psychological therapy helps some
patients. Patients who develop clinical depression or adjustment disorder
may see a psychiatrist for diagnosis.
- Support groups and religious counseling: Support groups help many
patients. Religious counseling may also help by providing spiritual care
and social support.
The following relaxation exercises may be helpful
in relieving pain.
Exercise 1. Slow rhythmic breathing for relaxation
- Breathe in slowly and deeply, keeping your stomach and shoulders relaxed.
- As you breathe out slowly, feel yourself beginning to relax; feel the
tension leaving your body.
- Breathe in and out slowly and regularly at a comfortable rate. Let the
breath come all the way down to your stomach, as it completely relaxes.
- 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.
- End with a slow deep breath. As you breathe out say to yourself, "I feel
alert and relaxed."
Exercise 2. Simple touch, massage, or warmth for relaxation
- Touch and massage are traditional methods of helping others relax. Some
- Brief touch or massage, such as hand holding or briefly touching or
rubbing a person's shoulders.
- Soaking feet in a basin of warm water or wrapping the feet in a warm,
- 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, consider massage of the hands and feet.
- Use a warm lubricant. A small bowl of hand lotion may be warmed in
the 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 several degrees of pressure along with different types of massage,
such as kneading and stroking, to determine which is preferred.
Especially for the elderly person, a back rub that
effectively produces relaxation may consist of 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. Continuous hand contact is maintained
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 anticipate.
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 draw on 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.
Additional points: Some
of the things that may comfort you, such as your favorite music or a prayer,
can probably be recorded for you. Then you can listen to the tape whenever
you wish. Or, if your memory is strong, you may simply close your eyes and
recall the events or words.
Exercise 4. Active listening to recorded music
- Obtain the following:
- A cassette player or tape recorder. (Small, battery-operated ones
are more convenient.)
- Earphones or a headset. (Helps focus the attention better than a speaker
a few feet away, and avoids disturbing others.)
- A cassette of music you like. (Most people prefer fast, lively music,
but some select relaxing music. Other options are comedy routines, sporting
events, old radio shows, or stories.)
- Mark time to the music; for example, tap out the rhythm with your finger
or nod your head. This helps you concentrate on the music rather than on
- Keep your eyes open and focus on a fixed spot or object. If you wish to
close your eyes, picture something about the music.
- Listen to the music at a comfortable volume. If the discomfort increases,
try increasing the volume; decrease the volume when the discomfort decreases.
- If this is not effective enough, try adding or changing one or more of
the following: massage your body in rhythm to the music; try other music;
or mark time to the music in more than one manner, such as tapping your
foot and finger at the same time.
Additional points: Many
patients have found this technique to be helpful. It tends to be very popular,
probably because the equipment is usually readily available and is a part of
daily life. Other advantages are that it is easy to learn and not physically
or mentally demanding. If you are very tired, you may simply listen to the
music and omit marking time or focusing on a spot.
Less invasive methods should be used for relieving
pain before trying invasive treatment. Some patients, however, may need invasive
A nerve block is the injection of either a local
anesthetic or a drug that inactivates nerves to control otherwise uncontrollable
pain. Nerve blocks can be used to determine the source of pain, to treat painful
conditions that respond to nerve blocks, to predict how the pain will respond
to long-term treatments, and to prevent pain following procedures.
Surgery can be performed to implant devices that
deliver drugs or electrically stimulate the nerves. In rare cases, surgery
may be done to destroy a nerve or nerves that are part of the pain pathway.
Many diagnostic and treatment procedures are painful.
Pain related to procedures may be treated before it occurs. Local anesthetics
and short-acting opioids can be used to manage procedure-related pain, if enough
time is allowed for the drug to work. Anti-anxiety drugs and sedatives may
be used to reduce anxiety or to sedate the patient. Treatments such as imagery
or relaxation are useful in managing procedure-related pain and anxiety.
Patients usually tolerate procedures better when
they know what to expect. Having a relative or friend stay with the patient
during the procedure may help reduce anxiety.
Patients and family members should receive written
instructions for managing the pain at home. They should receive information
regarding who to contact for questions related to pain management.
Older patients are at risk for under-treatment of
pain because their sensitivity to pain may be underestimated, they may be expected
to tolerate pain well, and misconceptions may exist about their ability to
benefit from opioids. Issues in assessing and treating cancer pain in older
patients include the following:
- Multiple chronic diseases and sources of pain: Age and complicated medication
regimens put older patients at increased risk for interactions between drugs
and between drugs and the chronic diseases.
- Visual, hearing, movement, and thinking impairments may require simpler
tests and more frequent monitoring to determine the extent of pain in the
- Nonsteroidal anti-inflammatory drug (NSAID) side effects, such as stomach
and kidney toxicity, thinking problems, constipation, and headaches, are
more likely to occur in older patients.
- Opioid effectiveness: Older patients may be more sensitive to the pain-relieving
and central nervous system effects of opioids resulting in longer periods
of pain relief.
- Patient-controlled analgesia must be used cautiously in older patients,
since drugs are slower to leave the body and older patients are more sensitive
to the side effects.
- Other methods of administration, such as rectal administration, may not
be useful in older patients since they may be physically unable to insert
- Pain control after surgery requires frequent direct contact with health
care providers to monitor pain management.
- Reassessment of pain management and required changes should be made whenever
the older patient moves (for example, from hospital to home or nursing home).