Cancer Pain: Beyond the Usual Pain Medicationsfleishman
By Dr. Stewart Fleishman

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.

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.

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.
bookHis 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.