Pain Management of Cancer Pain for Patients with MBC
Steven Passik, Ph.D. - Director of Clinical Addiction Research and Education, Millennium Laboratories, San Diego, California
1. What is the one thing you most want the newly diagnosed patient to know about pain management?
The single most important thing for the patient to know is that you do NOT have to endure the suffering of pain or other symptoms in silence. To help your doctor determine the best course of pain management, you should describe the location and intensity of your pain and any factors that aggravate or relieve the pain. If you are not getting the desired relief from your pain treatment, you need to request a referral to a pain specialist.
2. Pain associated with cancer can be controlled in most patients but is frequently untreated. Please comment.
Pain is treatable. Many times, However, we do see patients whose pain has been poorly treated or not treated at all. There sre several patient-related barriers to treatment: fear of addiction, fear of distracting the doctor from the treatment of the cancer, fear of being a bad patient, fear of side effects, fear that a pain medication taken "too early" won't work later on when it is "really needed," These fears are misguided and could make you a less vocal advocate for your own pain treatment. Don't be afraid to speak up and seek treatment and referral to experts.
3. What class of pain medication is most effective? Is constipation always a side effect?
Opioids* are the cornerstone of cancer pain management. They are powerful analgesics, and with a certain amount of trial and error, your doctor can identify and prescribe an opioid that will agree with you from the perspective of tolerability. Constipation is always an issue. Opioids slow down the muscle contractions and movement in the stomach and intestines, resulting in hard stools.
*There are several types of opioids. Morphine is the most commonly used in cancer pain management. Others: Hydromorphone, Oxycodone, methadone, fentanyl, and tapentadol. The availability of several different opioids allows your doctor flexibility in prescribing a medication regimen to meet your pain needs.
4. What can be done about constipation?
You should be started on bowel regimens of stool softeners and laxatives when opioids are begun, and you should get exercise and drink plenty of water.
5. What if the stool softeners and laxatives don't work?
If the more conservative treatments are ineffective, there is a new treatment of methylnaltrexone in a subcutaneous injection thet can block the receptors for opioids in the bowels and produce a bowel movement in about 40% of patients within 30 minutes.Side effects and other problems should be reported to your doctor. Your doctor can switch to a different opioid or switch the way it is given (for example, intravenous or injection rather then by mouth) to attempt to decrease the side effects.
6. How much of a concern are tolerance and addiction for the patient taking pain medication?
There is no need to delay taking pain medicines "until I really need them" or that you will develop tolerance. Opioids have no ceiling. The opioid can be started early and raised as high as needed to accommodate worsening pain. Your body can adjust gradually to almost all of the side effects of opioids including slowed breathing (respiratory depression), nausea, and sedation. Since your body adjusts, overdose becomes unlikely if the dose is raised slowly over time.
The body, however, does not adjust to the constipating effects of opioids, making it necessary to use stool softeners and laxatives throughout the course of treatment.
A patient's tolerance of (physical dependency on) an opioid is not the same as addiction (psychological dependence). Mistaken concerns about addiction can result in your under-treating pain and enduring unnecessary suffering.
Addiction is extremely rare in cancer patients who take opioids, if those patients have no prior history of drug problems. Even individuals who have had addiction problems in the past can be managed with certain safeguards, and you should not be embarrassed to be honest with your doctor about any addiction issues.
7. Which natural products can help relieve pain?
Nutritional supplements for pain relief should be used only after consultation with your oncologist or a pain or integrative medicine specialist. Fish oil can help with inflammatory pain problems. L-carnitine has been shown to help with some neuropathies, and calcium/magnesium combinations can help with neuropathies as well.
8. Do you recommend any alternative/complementary treatments to help relieve pain?
Integrative medicine approaches can be used to augment, but almost never replace, medical treatments for cancer pain. Nearly all such treatments can be helpful for some patients either by giving direct relief (e.g., massage for muscle pain), by providing deep relaxation (e.g., Reiki or visualization), or by acting as a distraction (e.g., hobbies). Be open to trying a variety of approaches as these generally have minimal to no side effects and can be helpful and rewarding.
9. Where is the threshold between "bear it" pain and "time for meds" pain?
Pain is highly subjective. Each patient has a different pain threshold, and there is no one point for all patients that defines when medicine is needed. Some patients will take less medicine because they prefer some residual pain to any drug side effects, although side effects can also be treated. If your pain is fairly consistent, that is to say even if you experience no big spikes of breakthrough pain, it is best to take medications before the pain reaches full intensity or gets to be unbearable.
10. What works best for the pain from bone metastasis (bone mets) and for the joint aches sometimes associated with aromatase inhibitors (AIs)?
Bone mets pain, particularly when it is in a weight bearing area, is often very quickly relieved with radiation therapy (RT). Pain medications such as opioids and steroids also work quickly. NSAIDs (non-steroidal anti-inflammatory drugs) can be helpful alone or in combination with opioids, if not disallowed by the oncologist because of their effects on platelets. RT and NSAIDs may also be used to treat the joint aches and arthritic type pain associated with AIs. Those who cannot take a systemic NSAID may use topical NSAIDs, such as the Flector patch or Voltaren gel, both of which have minimal systemic absorption.
11. What can be done to relieve finger and toe neuropathy?
The adjuvant analgesic drugs (antidepressants and anticonvulsants) are often used for peripheral neuropathies, though their efficacy can be highly variable. Opioids can also be used to treat neuropathy if the pain is severe. Some new work is going on looking at L-carnitine and calcium/magnesium combinations as treatment for neuropathy.
12. Best advice for nausea?
Nausea can be treated with a range of medications. Chemotherapy-induced nausea is treated with 5HT3 drugs such as Zofran, Kytril, or Aloxi. Aprepitant (trade name Emend) can also help with delayed emesis (vomiting). Chemotherapy-induced nausea can also respond to acupuncture added to the regimen. Chronic nausea can respond to Reglan, Ativan, or Compazine. Zyprexa can be helpful with chronic nausea particularly when its side effect of weight gain is wanted. Talk with your doctor to determine which of these drugs works best for you.
13. Best tips for fatigue?
Fatigue is best managed by exercise. You are encouraged to exercise throughout treatment as best as possible. Psychostimulants (Ritalin or Provigil) can be beneficial as well, and can sometimes help you get enough energy to undertake exercise. Specific medical problems such as hypothyroidism, anemia, and low testosterone from chronic opioids can cause fatigue, and these conditions have specific interventions that can reverse them. Ask your doctor to test for these medical conditions.
14. What new developments for pain relief can we look forward to?
There are always new medications and non-medication interventions coming along for pain. Anesthetic interventions (nerve blocks) are being used more and more in cancer pain management, and new ones are in development.
15. What resources do you recommend for the patient who wants to learn more about pain management?
I highly recommend several websites:
NCI: www.cancer.gov (Scroll down to Cancer Topics. Click on PDQ.)
American Pain Society: www.ampainsoc.org
American Pain Foundation: www.painfoundation.org
American Society of Clinical Oncology (ASCO) www.asco.org
What is Palliative Care: video from ASCO featuring Dr. Robert Miller on pain management (palliative care) from diagnosis through hospice care.