A Comprehensive List of Strategies for Managing Cancer-Related Pain
by Julie Knight, PharmD; Charlene Whittlesey, PharmD, BCPS; and Sorin Buga, MD, FACP, FAAHPM
Pain, as defined by the International Association for the Study of Pain, is “an unpleasant sensory and emotional experience associated with actual or potential tissue injury or described in terms of such damage.”
In other words, pain is whatever it’s perceived to be. We all feel pain differently; therefore, the experience of pain is unique to each person. Pain can be acute (lasting less than six weeks), subacute (lasting six weeks to three months), or chronic (lasting for more than three months).
People with cancer may experience pain caused by the disease itself or by treatments such as chemotherapy, radiation therapy, and surgery. The intensity of pain varies from person to person. It can occur any time during the cancer journey and may persist even after there is no evidence of disease.
Researchers estimate that 40 to 85 percent of people diagnosed with cancer will experience pain. Clinical studies have shown that quality of life, and even survival, are linked to good symptom control and pain management. Therefore, it is important to seek and receive appropriate treatment for cancer-related pain, as suffering from pain can have a negative impact on the success of cancer treatments.
Enlisting the expertise of an acupuncturist can help relieve nerve pain after surgery and chemotherapy.
Using a holistic team approach, your oncologist will likely work with various specialists in palliative care, pain management, psychiatry, and psychology to help you find the best treatment strategies to manage your cancer-related pain. Treatment options for pain can include nonpharmacologic therapies, medications, and certain medical procedures.
Nonpharmacologic Pain Management Options
A variety of strategies can be used to help manage cancer-related pain without (or in addition to) the use of medications.
• Support groups A cancer support group offers access to a network of cancer survivors, locally or online. Support groups provide social support systems, encouragement, and advice from other survivors to help you cope with cancer’s effects, including cancer-related pain.
• Psychological support services Working with a mental health professional can help improve your ability to cope with cancer and its side effects. A psychotherapist or licensed mental health professional trained in cognitive behavioral therapy, hypnosis, biofeedback, or mindfulness-based stress reduction may be most beneficial for cancer survivors who have a history of depression, anxiety, or any other psychiatric illness.
• Physical or occupational therapy Exercise has been shown to prevent physical weakness that can lead to painful joint stiffness and muscle tightness. It can also help with cancer-related
fatigue and lymphedema or swelling after surgery. A physical therapist can design an individualized exercise plan that can help you build strength, maintain flexibility, and prevent muscle atrophy.
• Acupuncture Enlisting the expertise of an acupuncturist can help relieve nerve pain after surgery and chemotherapy, as well as joint pain, for example, from hormonal therapy used in the treatment of breast cancer. It can also help minimize the amount of medication needed to treat cancer-related pain.
Researchers estimate that 40 to 85 percent of people diagnosed with cancer will experience pain.
• Transcutaneous electrical nerve stimulation (TENS) Transcutaneous electrical nerve stimulation involves the use of a battery-powered device that delivers electrical currents through electrodes placed on the skin to stimulate the nerves for therapeutic purposes. TENS may be an additional option for treating cancer-related pain with minimal adverse effects. It is, however, not indicated for people with active cancer because the direct effect of TENS on malignant tumors is unknown.
• Supplements and vitamins It is important to always discuss supplements and vitamins with your oncologist or pain specialist before taking them. Many supplements are easily purchased without a prescription, but this does not imply that they are without adverse effects or risks.
• Medical marijuana The American Cancer Society supports the need for more scientific research on the use of medical marijuana for the cancer population; however, there are some studies suggesting it does have benefits for cancer survivors in improving pain, nausea, vomiting, and appetite. It is important to understand hospital regulations regarding use of medical marijuana while in the hospital and to always consider state or federal regulations if you are planning on traveling with any forms of marijuana. Marijuana is an illegal substance in the United States at the federal level and in many countries across the globe.
Various medications can be used to treat cancer pain.
• Non-steroidal anti-inflammatory drugs (NSAIDs) These medicines can be useful in treating pain associated with cancer. However, when using NSAIDs, it is important to consider the risks of this type of medication, as overuse can lead to serious kidney, stomach, and cardiac complications. Consult with your oncologist before using NSAIDs to manage cancer pain, especially if you are currently undergoing chemotherapy.
• Acetaminophen This common over-the-counter medication often is used in conjunction with opioid medications. In fact, some prescriptions contain a combination of an opioid (for example, hydrocodone or oxycodone) with acetaminophen. Liver toxicity is possible when acetaminophen is taken in high doses, so it should always be taken as directed. Of note, other medications can also contribute to liver toxicity, so it is important to talk to your doctor about all the medications you are taking to make sure they are safe to use in combination.
• Muscle relaxants Muscle tightness and spasms are common in cancer survivors. Muscle relaxants can effectively relieve these symptoms, but they may cause drowsiness and dizziness.
• Topical medications In some situations, medications in the form of creams, ointments, and patches can alleviate localized pain. These medications may take some time to work, so you should use them for several days before deciding whether they are helpful.
• Antiepileptics and antidepressants These agents are recommended as first- or second-line treatment for chemotherapy-induced peripheral neuropathy.
• Corticosteroids Chronic use of corticosteroids should be avoided if possible, but these medications may be used to treat certain types of pain, particularly bone pain.
• Opioids Marked improvement in cancer-related pain control can be achieved with proper use of opioid medications. However, with prolonged use, you can develop tolerance to these medications. Therefore, your treatment plan should include regular assessment by your doctor to make sure the drugs are working effectively. After some time, adjustments in dosage or changes in medication may be necessary. Keep in mind that stopping opioid medications abruptly can cause withdrawal symptoms, including nausea, vomiting, diarrhea, and sweating, so it is important to follow your doctor’s instructions if you plan to discontinue opioid treatment.
Some people worry they will become addicted if they use opioids to relieve their cancer pain. This is not necessarily true. However, people with cancer are at risk for developing tolerance and even becoming dependent with extended opioid use. The potential for addiction should be considered in all people who are prescribed opioids or any other potentially habit-forming substances. This should be part of the important conversation you have with your doctor when formulating a cancer pain treatment plan. Moreover, it is imperative that these medications be taken only as prescribed. Your physician may ask you to sign an opioid agreement or a pain contract clearly outlining expectations pertaining to the use of opioid medications and other types of therapy.
A variety of medical procedures can be done to improve cancer-related pain. Interventional approaches, such as nerve blocks, implanted intrathecal pumps, and spinal cord stimulators, can provide significant pain relief, especially if there is little to no response to pain medications or if the side effects of pain medications are intolerable. Surgically removing a tumor that’s causing pain or other discomfort may also be an option. In addition, radiation therapy has proven to be helpful in relieving bone pain. The goal for these types of medical procedures is to provide pain relief while minimizing the need for oral pain medications.
Talking with Your Doctor
If you are experiencing pain that is caused by your cancer or its treatment, you should discuss your cancer pain management options with your doctor. It is important to keep the lines of communication open so that you have a clear and trusting relationship with your physician. Your pain management plan should include ongoing assessment of changes in symptoms, as well as the need to modify the treatment plan. Getting your cancer pain under control can markedly improve not only your quality of life but also your survival.
Dr. Julie Knight (left) is a clinical consultant pharmacist at Tidwell Hospice and Palliative Care in Sarasota, FL, and a clinical assistant professor of pharmacotherapy and translational research at the University of Florida College of Pharmacy in Gainesville, FL. Dr.
Dr. Charlene Whittlesey (right) is a clinical pharmacist with the Internal and Hospital Medicine Service at the H. Lee Moffitt Cancer Center in Tampa, FL.
Dr. Sorin Buga (below) is an associate clinical professor in the Department of Supportive Care Medicine, chief of the Supportive and Palliative Care Division, and program director for the ACGME fellowship in Hospice and Palliative Medicine at City of Hope Comprehensive Cancer Center in Duarte, CA.
This article was published in Coping® with Cancer magazine, May/June 2019.