Cancer Pain: Beyond the Usual Pain Medications

Cancer Pain: Beyond the Usual Pain Medications

Different types of pain problems require targeted approaches when treating cancer patients. Pain along a nerve, nerve ending pain, or bone pain are optimally treated with a variety of different types of pain medications.

Dr. Stewart Fleishman

Dr. Stewart Fleishman

But relief from pain due to cancer or its treatment can also be greatly enhanced through properly administered massage, acupuncture or exercise.

No matter what type of pain or treatment, make sure to thoroughly address pain management with your cancer treatment team. Even experienced providers are not clairvoyant, and should be as aggressive in relieving pain as they are in controlling cancer.

Neuropathic Pain Requires a Different Approach

Certain types of pain, especially when connected to nerve damage or impairment, are not relieved by acetaminophen, opioid analgesics or NSAIDs.

Neuropathic pain that is transmitted along a nerve tract is most often helped using one of two groups of medications originally intended for other purposes. This type of pain 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 shoot down the nerve tract (like sciatic pain) can also be helped by anti-seizure medications or antidepressants, with good evidence from clinical trials to do so. Duloxetine (Cymbalta), gabapentin (Neurontin), pregabalin (Lyrica) or amitriptyline (Elavil) are all used, usually starting with smaller doses than used to treat depression or seizures.

Tapering off these medications is essential, rather than abruptly stopping them and risking serious withdrawal effects that could be life-threatening.

Bone pain and strength may also be helped by bone-strengthening drugs used to treat osteoporosis (zolendronate or Zometa). Aching pain in bones may also be alleviated with corticosteroids, which are a different type of steroids that muscle builders use.

Pain Management Involves More than Medications

Beyond the many medications used to treat cancer pain, certain non-drug techniques can also be effective for certain types of pain. Acupuncture, various massage techniques, physical therapy (with heat/cold), portable electric nerve stimulators, and injections of steroids and analgesics directly into the painful area can all be of tremendous help, and should be considered wisely to minimize the doses of medications used.

Diversionary techniques likewise help focus attention off pain, and those coupled with flexibility training (such as yoga) provide solace that transcends spiritual spheres for those with a 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 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 and when to 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 have informative services that include one-on-one counseling, webcasts of 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 can help with referrals.

Make Your Needs Known to Providers

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 disciplines in oncology.

Pain scores are now considered a vital sign, along with blood pressure, temperature, pulse and respiratory rate. Patients are now 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, will answer, “Fine” when asked how we are doing at appointments. This may be socially acceptable, but it is unhelpful. Cancer specialists want you be candid.

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.

Attention to pain management should be a top priority during and after cancer surgery, or during chemotherapy and radiation. Pain relief is 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 are an ever more important part of the our health care delivery system.

KMBT_C454-20130313113949Stewart Fleishman, MD, is the former Director of Cancer Supportive Services at the Continuum Cancer Centers of New York and the Associate Chief Medical Officer of Continuum Hospice Care-Jacob Perlow Hospice.

His practice was focused on pain management, symptom control and palliative care. Dr. Fleishman’s was actively involved in research focused on quality of life and symptom control in people with cancer, and serves on national committees dedicated to this work. He is Board Certified in both Hospice and Palliative Medicine and Psychiatry/Neurology.

Dr. Fleishman’s book Learn to Live Through Cancer: What You Need to Know and Do presents a step-by-step guide to improve the length and quality of life for cancer survivors, helping them to manage the variety of physical, emotional, and spiritual issues they face proactively.

Dr. Fleishman also writes for Demos Health Publishing’s blog.

Authored by: Dr. Stewart Fleishman

There are 6 comments for this article
  1. Dave at 6:29 am

    Steve- Wisdom consists of knowing a great many things- Heraclitus. There is research showing morphine can spread cancers- like breast cancer. Just as there is research showing the effectiveness of nonpharmacological treatments for cancer like tens. We all have to do as much research on pain as we can to help people obtain better pain care.

  2. Steve at 5:42 pm

    QT is a risk with methadone, but methadone is rarely used in pain management compared to pure mu-opioids, despite it’s benefits (price, efficacy for hard to treat & nerve pain).

    Like any medication, it’s about balancing the benefits and the risks for each individual patient.

  3. Steve at 5:36 pm

    Opioids spread cancer, really? Where did you get that idea?

    Also, you can seriously doubt whatever you want, but 90% of the pain patients that I talk to and 80% of the cancer patients have doctors that don’t want to even consider opioids.

    If your wealthy, you get opioids, if your on Medicare or Medicaid, you get poisonous NSAIDs or acetaminophen/paracetamol, especially in states like Florida. NSAIDs only work for inflammatory pain, theta WORTHLESS for neuropathy and bone pain.

  4. dave at 10:07 am

    Dr Fleishman has acknowledged the uses of opioids for cancer pain. I sincerely doubt that medicine is ignoring opioids- especially for cancer. Projections for opioid sales worldwide- include the U.S. show decent growth through 2017. But I disagree with your suggestion that opioids are more effective than other modalities- I assume you are basing your beliefs on population studies- and not on what may work for any one individual. The fact that opioids can spread cancer and lower immunity-not to mention endocrinopathies and QT syndrome- I don’t consider them a Godsend compared to anti-inflammatories.

  5. Steve at 9:30 am

    Although this article is called beyond the usual pain medications, this guy doesn’t even acknowledge the most efficacious modality for CP/IP (chronic/ intractable pain), opioids. Even fewer cancer pain patients respond to interventional pain management alone than non-cancer IP patients.

    Aside from corticosteroids being extremely dangerous longterm (Cushings is just the beginning), they are painful and ineffective for many pain patients.

    There is a growing trend of completely ignoring the entire modality of opioids.

    That being said, TENS, PT, and therapy are extremely helpful, but they also have their limits.

    Neurontin/gabapentin is only used because the drug company brain washed most doctors into thinking it’s efficacious during their bribery before it lost it’s patent.

    Antidepressants are a mixed bag. Some people benefit, but they’re ineffective for many types of pain and many pain patients. They’re essentially a placebo, they only help in the short-term for mild symptoms. Even the alleged placebo controlled Cymbalta/duloxetine trials aren’t truly double blind because Cymbalta causes side effects, which makes the patient think that something strong enough to cause side effects must be the duloxetine. These trials took place after Cymbalta had been available for years, many patients were aware of the potentials side effects (antidepressants have many). The placebo effect is powerful, but it only works in the short term (like the trials). Yes, some people benefit from adding antidepressants to opioids or other pain management. However, ice never know a cancer or non-cancer pain patient to benefit from antidepressants unless they already suffered from clinical depression (not caused by the pain itself).

    Personally, I benefit from opioids, Wellbutrin/buproprion XL, muscle relaxants (tizanidine/Zanaflex), and clonidine. I also had an intrathecal pain pump trial a while back and benefited from extremely reduced pain from 2-3mg/day intrathecal morphine. Unfortunately, my neurosurgeon doesn’t manage the pumps and the interventional pain management office they partner with only do pumps for patients who they can make money on. Intrathecal pumps aren’t well reimbursed by Medicare, Medicaid, or most private insurance. I wouldn’t benefit from the high reimbursement procedures (steroid injections). Although pumps are abuse proof, they still utilize opioids, which necessitates extra record keeping. Antidepressants and steroids are not controlled substances, so they don’t require additional, costly record keeping. It’s all about the almighty dollar.

    These doctors need to stop playing the victim and stand up to the DEA and District Attorneys who harass them. They need to stop cow-towing to their ridiculous demands while the real victims suffer. And they DEFINITELY need to stop trying to justify this malpractice.

    Suggested Reading
    Intractable Pain Patients’ Handbook for Survival
    http://bit.ly/PainGuidePDF
    Overcoming Opiophobia
    http://bit.ly/Opiophobia
    SCS & Intrathecal Pumps
    http://TameThePain.com

  6. dave at 8:02 am

    Kudos to you Dr Fleishman for departing from the received view that cancer pain should be only treated with pharmacological treatments.