Dealing With Pain

By Roger C. Bone, MD, reprinted with permission

PLEASE NOTE: This article is a chapter in Reflections: A Guide to End of Life Issues for You and Your Family, distributed by the National Kidney Cancer Association. While it refers to the problem of pain for cancer patients, almost everyone who faces death is concerned about undermedicated pain. In fact, many patients say that they are more afraid of pain than of death itself. However, something CAN be done about pain and we recommend you read this and Myths About Cancer Pain (in the Chronic and Serious Illness section) in order to begin dealing constructively with whatever pain you might experience.

Approximately 50-80% of patients in the advanced stages of cancer experience major pain; however, recent findings indicate that more than 40% of such patients receive inadequate relief. Pain affects people differently depending on such factors as age, gender, and personality type. The most common causes of pain are metastatic bone disease, nerve compression or infiltration, and hollow viscus involvement resulting in obstruction. All of the major treatment modalities may also contribute to your pain as well as any pre-existing conditions that are not directly associated with cancer. Through simple pharmacological prescriptions or nonpharmacological procedures, this pain can be managed 90% of the time for the eight million Americans who have cancer or a history of cancer.

However, the pain associated with cancer is often undertreated, and the majority of severely ill patients fear they will die in great agony. This undertreatment is largely the result of society's perception of addiction. Clinicians and patients often link drug use to drug abuse and erroneously believe cancer patients may turn into addicts. While drug use in our country is a serious and important issue, regulation of prescription medication has had an unfortunate impact on patients who are in severe pain.

When pain medication is prescribed and taken the right way, cancer patients do not become addicted. There is an impressive amount of data that confirm proper pain management as effective and non-addictive. Any patient who needs pain medications for a short time can easily discontinue them once the source of the pain is removed. Physicians can gradually reduce the dosage until the body has time to adjust to the change. Pain medication taken regularly for chronic pain can also be administered without fear of addiction.

If you are experiencing major pain, you should ask your physician for relief. By taking an active role in procuring the best cancer treatment available, it is possible for you to prevent and manage pain effectively. The National Cancer Institute and National Institutes of Health recommend that you ask the following questions when speaking with your physician about pain management:

What medications can you prescribe to relieve my pain?

How long should I take the medicine(s) and when?

Are there side effects?

Should I try alternative procedures to alleviate my pain?

Your physician will also have a better idea of how to treat the pain if you let him or her know where it hurts, how strong the pain feels, what makes the pain increase, what eases the pain, and how much your current medications help you. A variety of pain assessment tools have been developed, which include simple self-reports about pain intensity and specific descriptive information. Your physician may also conduct a detailed history, a physical examination, a psychosocial assessment, and a diagnostic evaluation. It has also been suggested that a patient use a "pain diary" to record the characteristics of his or her pain and the effectiveness of treatment protocols. Effective pain management is commonly achieved by a "team approach" involving patients, their families, and health care providers.

Keep in mind that continual assessment of your pain is vital. A few people have side-effects, such as dizziness or feeling confused when they take pain medication. In this case, changing the dosage of your prescription or choosing an alternative medication can solve the problem. You may feel sleepy when you first take some pain medicines, but this response usually subsides within a few days. Persistent pain or development of pain in a new area may call for a modification in the diagnosis and/or treatment plan.

Elderly patients require special consideration. Like other individuals who experience cancer pain, they require aggressive drug therapy. However, aging patients are at an increased risk for drug reactions because they may have multiple chronic disease and sources of pain that are not directly associated with cancer. They may also have visual, hearing, motor, and cognitive impairment that may impede certain pain assessment instruments. Older patients are more likely to be sensitive to the analgesic effects of pain medication for a longer period of time. Consequently, physicians should use simpler pain management tools and maintain frequent direct contact with their elderly cancer patients.

Drug therapy is effective, low risk, often inexpensive, and usually works quickly. However, alternative methods can be used in addition to medication. The purpose of behavioral modification techniques is to alter a patient's perception by shifting his or her attention to something other than the pain. They are not to be considered a substitute to prescribed medication; rather, they are intended to help the patient relax. The goal of pain management is to provide pain relief as well as improve the patient's quality of life. You can work productively, spend time with your family, enjoy recreation, and function normally in society if you take an active role in your care.

Cognitive-behavioral methods give the patient a sense of control and help him or her develop coping skills to manage the pain. However, alternative pain management techniques are more likely to succeed if they are introduced early in the course of the illness. Family members can assist you by obtaining the proper information and encouraging you to try several different strategies. Simple relaxation techniques can be used during episodes of brief pain or anxiety. Focusing your attention on something other than the pain, including counting, praying, listening to music, talking to a friend, or repeating statements such as "I can cope," can help you replace negative thoughts with more positive images or activities.

I want to encourage you to remain as active as possible while you still have the strength and energy to do so. I am not talking about intense exercise or difficult aerobic activity. Generalized weakness and aches and pains associated with cancer and its treatment can be improved by physical interventions other than medication. Low-impact exercise will help mobilize stiff joints and restore coordination and balance. For example, ambulatory patients can simply walk around the block with help of a friend or loved one. This activity will get you out of the house and strengthen your muscles. Physical therapists and caregivers can help the functionally limited patient with range-of-motion exercises to restore muscle strength. Other physical interventions include acupuncture, massage and vibration therapy, and immobilization (e.g. using braces to help maintain correct body alignment).

The patient also needs to distinguish physical pain from-qiental anguish. Psychological problems, which are also addressed in Psychological and Medical Aspects of the Final Days or Weeks, are often experienced by a cancer patient as his or her disease progresses. The relationship between poor pain management, depression, and suicidal thoughts should not be ignored. Anxiety, fear, and depression are common reactions and can be relieved by psychotropic medication and therapy. Also, patients often feel more self- assured by participating in support groups. You can ask your physician, nurse, religious guide, or other health care professional for information about services available in your area. Your "team," which includes family members, friends, and health care providers, may also want to participate in these sessions to discuss your needs and treatment.

In a small number of cases, the above mentioned behavioral, physical, and drug treatments do not alleviate pain and invasive therapies need to be used. Your physician will recommend various procedures that can be used in addition to pain medication and nonpharmacological methods. For example, radiation therapy is aimed directly at the cause of the pain to reduce primary and metastatic tumors, and surgery to remove a tumor has the potential to reduce pain or relieve tumor compression. These methods decrease the tumor mass and are conducted for palliative purposes only. For chronic, intense cancer pain, a neurosurgeon can apply a local anesthetic or neurolytic agent, such as a nerve block, that will provide local relief for a longer period of time. However, these methods should be considered only after drug and cognitive therapy are no longer effective. The risks and benefits of neurosurgical interventions should be discussed thoroughly with your physician and family.

In summary, effective and reliable pain management is something you should not be afraid to seek from your physician. The earlier you express your needs the easier it will be to control pain in its early stages. You can be confident that the proper use of drug therapy will help you enjoy daily activities, sleep easier, and experience a better quality of life.

© Copyright 1997, National Kidney Cancer Association