Pain is one of 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Likewise, many non-cancer physicians harbor biases that are based on outdated practices they learned in training, sometimes decades ago.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 are 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, either physically or chemically. Pain is particularly bad when there is pressure on a nerve in or near the bones, skin or muscles, where there are many pain receptor cells.
Cancer exerts pain in a variety of ways, growing tissues that compress nerves or that replace bone. Pain along nerve tracts themselves is often described as “electric” and “shooting”.
These descriptions are important, as different types of pain are treated in different ways, with different medications and 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 or a burn from a hot stove. 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: zero for no pain and 10 for the worst pain imaginable. 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 approach to 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) 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. It’s 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 maximum dose for acetaminophen over a 24 hour period of about 2000 mg (six regular strength or four extra-strength tablets), as the liver works hard to digest these 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, but 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 anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen do control inflammation, as well as pain and fever.
Ibuprofen or aspirin last 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, so caution must be taken when cancer or treatments also affect platelet count. Bleeding or easy bruising can complicate treatment.
NSAIDs or acetaminophen become much more useful again after treatment is completed when the side effect overlap is no longer as important.
In my next column, I’ll focus on moderate and severe levels of cancer pain, and the non-drug approaches so that the least amount of medications can be used to control pain.
Stewart 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.