Understanding Pain Management in Cancer

Despite our many progress and technological advances in medicine, cancer remains the second leading cause of death in the United States. However, Many are surviving a longer time than they did in the past and living full lives with cancer and in spite of cancer. Not everyone who is diagnosed with cancer will die from cancer, not right away, if at all. Did you know:

• Overall, cancer has taken on a more “chronic” long term diagnosis/effect, for those who survive initial treatment and are then diagnosed with recurrence/metastatic disease
• One of the most feared symptom in this category of patients is pain
• Overall, 50% to 70% of people with cancer experience some degree of pain, which usually intensifies as the disease progresses
• Less than 50% of these patients receive adequate relief of their pain, either because they are afraid to ask because they fear “addiction”, or physicians are unlikely to prescribe adequate medication to attain relief that will allow the patient continued good quality of life
• Sub-optimal pain control can be debilitating and caregivers are often times unsure how to address this issue

PAIN MANAGEMENT – You should know

What is the best pain management approach that will work for you? To find out, it requires teaming up with your doctor and cancer care team. 

Morphine has long been the ‘gold standard’ for the treatment of severe cancer pain. However, its side-effects, particularly sedation/drowsiness, and cognitive impairment have led to “opioid rotation” to alternatives such as methadone and hydromorphone.  The 72-h transdermal patch, such as Fentanyl, does offer some advantages of reduced side-effects and increased convenience over oral morphine.  However, morphine and its alternatives, are not the only way to treat cancer pain. Let’s start with the basics.

If you have been diagnosed with cancer and have any level of pain, there are several things that you need to know and do;

1. Become familiar with the pain scale and be honest with the level of pain you are in at any given time (0 = no pain and 10 = most excruciating pain)
2. Decide what level of pain you are willing to live with and/or tolerate
3. Understand and know that your tolerance for pain is different than others
4. Your level of pain tolerance is not associated with the color of your skin, culture, or race
5. Communicate with your cancer team your level of pain and ask about plans on how your pain will be managed
6. When possible, limit the number of doctors prescribing your pain medication to preferably 1, no more than 2
7. The opioid crisis does not apply to patients diagnosed with cancer; know and understand your rights for optimal pain management

PAIN MANAGEMENT: A Common Approach

The World Health Organization program for cancer pain control recognizes that 1 in 5 patients with cancer has uncontrolled pain and has a ‘three-step ladder’ for the rational use of analgesics including morphine (there is also a recommended adaption to 4-step-ladder).

Though pain management can be tricky, listening to my patient is the most important approach to pain management. I take the time to explain the pain scale in a format the patient can relate to (an early throbbing mild headache could be a 2-3/10, an infected tooth ache could be a 5-6/10, birth pangs would be a 10+/10). Depending on the situation, I typically start with non-steroidal anti-inflammatory drugs (NSAIDS), or narcotic-like medication ( such as Tramadol), or fast acting morphine, or a nerve type medication (such as neurontin). Depending on frequency, long acting medicine can be used with fast acting for break through pain. Remember, never take any morphine type medication without something for constipation. Pain medications slow down the bowels and lead to constipation every single time!

Quick Review of reasons behind common pain approach

• A swollen breast after radiation treatment will respond well to Ibuprofen 400-600mg two times a day with meals for ~one week (no longer!)
• Most patients treated with cancer of the head and neck respond well to Neurontin type medication. As pain worsens, other medication can be added. However, I have been successful in treating patients for some cancers with high nerve pain, mostly with nerve medication
• Starting with short acting pain medication will allow analysis of mg needed over a 24-48 hours time period. Conversion to a long acting can then be done with short acting medicine for break through pain
• Pain management is an art that requires full engagement with your prescribing doctor. Lately, I have been receiving more questions about marijuana and CBD oils; However, that is a conversation deferred for one-on-one with your cancer physician (oncologist)

Discuss Pain Management with your Cancer Doc/Team

What I have learned over the past 15 years, is that managing pain and prescribing pain medication for cancer requires a keen sense of awareness and a patient-physician partnership.  Oncologist are made aware of the patient’s needs, pain level, allergies, etc., through in-depth discussion. For me, that also includes a “no-shame discussion” with the patient’s pharmacist as well, especially for the geriatric population (65yrs and older). There is a single template for prescribing pain medication when caring for patient diagnosed with cancer – everyone is different. Remember, the opioid crisis restrictions do not apply to the cancer population, because addiction is a rarity… and a patient told me a decade ago, “this pain is real, Doc!” Don’t suffer. Talk to your oncologist – they are there to serve you!

Ask Your Cancer Care Team Questions

Remember, it is your life and you must  become your own advocate!

Life is beautiful and God is awesome. And know, you are pure awesomeness!

Until next time,

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Remember …

Ipsa Scientia Potestas est    ———  Knowledge itself is power!

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Queen, Your Family Friendly Cancer Doc!