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How Cancer Pain can be Relieved

by Dr Gordon Coates

Second Edition, published in 2013 by Wanterfall eBooks

Series Context

This article is one section of the book "How Cancer Pain is Treated: A non-technical guide for patients and their carers". You will find links to the other articles in the series at the bottom of this page. Alternatively, you may download the whole book in various formats HERE. (All downloads are free.)

Disclaimers

This article, written by a senior medical practitioner with considerable experience in palliative medicine and hospice care, is offered purely for educational purposes. Nothing in it should be taken as therapeutic advice for any particular patient. Mention of any trade (brand) name should not be taken as an endorsement of the brand or its manufacturer.

Cautions

If you read the articles in this series carefully, and think about the information in them, in relation to a particular pain management problem affecting you or someone you love, you may sometimes be able to think of modifications to the current treatment which might be expected to improve the situation.

However, it is very dangerous to make changes to a patient's medication without first discussing them with the prescribing doctor. The doctor must always know exactly what the patient is taking, as virtually all medications can cause unwanted side effects and interact in various ways with other medications.

Importantly, this also applies to "natural", "alternative" or "complementary" therapies, many of which have significant interactions with prescribed medications. Therefore, even if you feel that the current pain management is not optimal, never make any changes without first discussing them with the doctor.

Introduction

It is bad enough to have an illness which requires a great deal of tiresome treatment, and which may ultimately prove fatal, but suffering frequent or constant pain as well makes matters much worse. Fortunately, however, this extra problem can be managed. Cancer pain can usually be relieved by quite simple methods, and in the approximately fifteen percent of cases where these simple treatments are not fully effective, more complex methods of pain management can be used.

This last point is tremendously important. Although cancer pain is initially treated in relatively simple ways, as discussed below, in about fifteen percent of cases these standard treatments are not effective. However, that does not mean that the pain cannot be relieved. It simply means that more complex methods of treatment are necessary. Any patient who is told that nothing more can be done for a pain caused by a cancer is therefore being misinformed, and should immediately request referral to a Pain Management or Palliative Care specialist.

In general terms, good pain management involves prevention (whenever possible), assessment (always), and then either cure or palliation. When the cause of a pain can be cured, this is obviously the ideal solution, but when cure is not possible, palliation takes centre stage. I will give prevention, assessment and palliation their own headings, below, but I will deal with palliation at greater length, as it can be very helpful to patients if they and their loved ones understand how it can be achieved.

Prevention

When it is possible, prevention is always better than cure, and this has important implications for cancer pain. Of course, prevention of cancer itself is also important, but that topic is outside the scope of this series of articles. However, even if a person has a cancer which cannot be cured, active therapy for that cancer may often prevent predictable future problems.

For example, surgery to remove a primary bowel cancer can prevent future problems due to intestinal obstruction, even if secondary tumours which are already present in other organs mean that cure is difficult or impossible. Radiotherapy may help to prevent a future pathological fracture, thus preventing the pain so caused, as well as avoiding the need for orthopaedic surgery. Excision of a primary cancer close to the skin may prevent the later development of ulceration and "fungation" (growing out from the skin in a way reminiscent of a fungus).

There are many other examples of treatments designed to prevent a possible future problem, and they should always be considered by the medical and surgical specialists involved in the patient's care. From the point of view of the patient, the main thing is to understand that some recommended treatments may be aimed at prevention of future symptoms, rather than complete cure of the cancer itself.

Assessment

The first step in any endeavour is assessment, and the relief of cancer pain is no exception to this rule. It cannot be assumed that either the presence or the characteristics of pain will be obvious. Some people, especially those whose personality is not very extroverted, do not mention pain at all unless they are asked about it. This is particularly so near the end of life.

When gathering information about pain, or indeed any other important matter, non-verbal communication is very important. I have discussed this in some detail in my earlier ebook entitled "Notes on Communication"[7] , so I will not go into it here. However, in the present context, I particularly recommend the chapters on non-verbal communication and active listening.

Health care professionals assessing a patient with pain would normally take a detailed "pain history", followed by physical examination and, in many cases, one or more investigations. At the end of this process, it should be possible for the doctor to determine the cause of the pain (which may, of course, not be due to the cancer at all, though it very often is). Knowing the cause, the most likely pain mechanism(s) can be deduced, and the most suitable method of pain relief can then be chosen.

It is often very helpful if the patient or a relative or friend can present the basic facts about a pain to the medical or nursing staff. The simple mnemonic "6 Shots PAR from the Tee" may be helpful in remembering to ask the following questions.

Pain Assessment Questions

Site: where is each pain felt?

Sort: what does it feel like?

Severity: how bad is it?[8]

Starting: when and how did, or does, it start?

Shooting: does it "go" anywhere else?

Sleep: does the pain prevent or interrupt sleep?

Precipitating factors: does anything precipitate or aggravate it?

Associated symptoms: do other symptoms, such as sweating, nausea, diarrhoea or breathlessness, occur at the same time as the pain?

Relieving factors: have you found anything which helps it?

Time factors: when was this pain first experienced? Is its severity constant, or does it vary in intensity? If it is intermittent, how often does it occur, and how long does each episode last? If it is relieved by any treatment, how long does that relief last?

In addition to the basic information outlined above, it is also helpful for the doctor to know about any changes which the pain has brought about in the patient's daily activities, work or relationships, and what meaning the patient ascribes to the pain. Then, all of the information collected about the pain can be considered in the context of the status of the cancer and any other physical or psychological conditions which are present.

The success or otherwise of previous treatments, where applicable, is also important. Attitudes and beliefs in relation to pain and its treatment also need to be discussed with the doctor, as they may have a considerable influence on the acceptance, and in some cases the effectiveness, of the treatments recommended.

Palliation

Palliation simply means relieving something unpleasant without curing its cause. Whenever assessment shows that a patient is experiencing pain, the cause of which cannot be cured, the next step should always be palliation. The remainder of this series of articles will be about the palliation of cancer pain.

There are a number of methods by which pain caused by primary or secondary cancer deposits can be relieved. These methods could be classified in various ways, but I will look at them under the following general headings:

  • Shrinking the tumour deposits themselves
  • Reducing the local effects of tumour deposits
  • Immobilising structures which cause pain when moved
  • Interrupting the "pain pathway" to the brain
  • Elevating the "pain threshold" in various ways
  • Prescribing analgesic and co-analgesic medication

Shrinking tumour deposits to relieve pain

It should come as no surprise that one approach to reducing pain caused by progressively enlarging deposits of cancer is to make those deposits smaller. This can be done by surgery, radiotherapy, chemotherapy, hormone therapy or various other methods. The choice of method used should be made in consultation with the appropriate specialist. More than one method is usually helpful, and different methods are often recommended at different times in the course of the illness.

Reducing the local effects of tumour deposits

Some of the local effects of tumour deposits can be reduced in fairly simple ways. For example, if a tumour breaks through the skin to cause an ulcerated growth, it will be much more comfortable if it is kept clean and covered with a suitable dressing, and if any infection occurring within and around it is treated appropriately. Special dressings which absorb unpleasant odours may be very helpful in some cases.

On other occasions, the best treatment for the local effects of a tumour deposit may involve more complex interventions. For example, if a hollow organ, such as the intestine or a bile duct, becomes obstructed by a tumour deposit, the severe colic which results from the body's attempts to force a way through the obstruction may be completely relieved by bypassing the obstruction. This can sometimes be done simply by passing a tube (called a "stent") through the obstructed region at endoscopy[9], but sometimes a surgical operation is required.

The effects of obstruction of a hollow organ can also be relieved to a considerable extent by the use of medications alone, and sometimes this is preferable. For example, if multiple or recurrent bowel obstructions are not suitable for either stenting or open surgery, then a combination of medications which reduce local inflammation, swelling, production of secretions, and spasm of the "smooth muscle" fibres in the walls of the organ, in conjunction with antiemetic and analgesic medications, can be extremely effective.

These are just three examples of the relief of pain by reducing the local effects of a tumour deposit, even when it may not be possible to shrink it. There are many other similar examples.

Immobilisation to relieve pain

Many pains are made worse by moving the painful part, and the minimisation of painful movements is a normal part of nursing care. In many cases, elevation of the painful part, to reduce swelling, also helps. Sometimes, both of these things can be achieved simply by resting a limb on some carefully arranged pillows. However, there are also more specific methods of immobilisation, and sometimes they are essential.

For example, in the case of a pathological fracture, which can occur when cancer invades a bone and weakens it, complete immobilisation of the bone fragments is almost always necessary in order to relieve the pain. This is usually best achieved by "internal fixation" of the fracture by an orthopaedic surgeon, which should be done with as little delay as possible, and ideally on the same day as the fracture. Even if strong fixation is impossible, because of the extent of bone destruction, it is usually possible to reduce movement of the bone fragments by using acrylic cement to glue them together.

Interruption of the pain pathway

Another way of relieving pain is to interrupt the transmission of pain stimuli along their pathway towards the part of the brain which is responsible for the experience of pain. Actually, a number of parts of the brain interact to produce the experience of pain, but for the sake of simplicity we can nominate the cerebral cortex, which is the folded outer part of the brain composed of "grey matter" (mainly nerve cell bodies).

In the case of nociceptive pain, this "pain pathway" starts with individual nerve fibres, each of which has a nociceptor at its peripheral end in some part of the body. A pain stimulus, created by the nociceptor as a response to local tissue irritation or damage, passes along each of these nerve fibres, which later join other nerve fibres to become part of a peripheral nerve.

The peripheral nerve ultimately connects via spinal nerve roots to the spinal cord. The pain stimuli then travel upward along certain spinal tracts until the spinal cord joins the brain. They then continue along cerebral tracts, passing through various parts of the brain and finally reaching the cerebral cortex.

The pain pathway just described could theoretically be interrupted at any point between the nociceptors and the cerebral cortex. However, in order to interrupt all of the pain stimuli emanating from a painful part of the body, the interruption must occur after they have all conveniently come together. In practice, this means blocking transmission along a fairly large peripheral nerve, or else further up the pathway.

A temporary interruption of this sort can be achieved by injecting a local anaesthetic near a peripheral nerve, a nerve plexus, a spinal nerve root, or the spinal cord itself. If the local anaesthetic is infused continuously, the duration of analgesia can be extended for days, weeks or even months. However, extended local anaesthesia can cause various complications, such as infection at the infusion site, so although it can be very useful in certain cases, it is certainly not a panacea.

Another way of reversibly inhibiting the transmission of pain stimuli is transcutaneous nerve stimulation (TENS). This technique has the great advantage of having very few side effects, which are mostly very minor if they occur at all. However, its effect is not nearly as strong as that of a local anaesthetic injection. TENS may be very helpful to a minority of patients, but in most cases it either provides part of the overall pain control or is not found to be helpful at all.

Various neurosurgical procedures which interrupt pain pathways permanently are also available. However, various recently developed non-destructive techniques, such as neuromodulation (electrical stimulation) of the spinal cord, or sometimes of a part of the brain called the cingulum, have superseded many of the irreversible neurosurgical pain control techniques which were previously used.

The details of modern neurosurgical and neurophysiological techniques are outside the scope of this series of articles. The important point is that, if simpler interventions have been tried and have failed, there are always many further options to consider. Assessment by a multidisciplinary pain clinic is sometimes very helpful when considering these further options.

Elevation of the pain threshold

Because pain is an entirely subjective experience, the term "pain threshold" is inevitably vague and imprecise. However, it can be useful to doctors as a starting point when considering two very important aspects of pain management. The first of these aspects is that apparently similar injuries or illnesses can result in very different degrees of pain in different people. The second is that a person with an apparently unchanged injury or illness can suffer very different degrees of pain from it under different circumstances.

An individual's pain threshold was traditionally envisaged as the lowest intensity of a potentially painful stimulus which resulted in pain being experienced by that individual. Simple experiments in which the subjects were tested with harmless but painful stimuli of varying intensity showed that some people reported pain at a lower stimulus intensity than others. If a stimulus of low intensity caused pain, the pain threshold was said to be low. If a stimulus of higher intensity was needed before pain occurred, the pain threshold was said to be higher.

Further experimentation showed that the pain threshold could also be influenced by various changes in the circumstances under which the test was carried out. In other words, a single individual could have a lower pain threshold under some circumstances, and a higher pain threshold under others.

The fact that only the stimulus can be measured, while the pain itself can only be reported and described, makes it unlikely that such experiments will ever yield much more information than the basic observations described above. However, knowing that a person's pain threshold can be influenced by various circumstances, immediately suggests the possibility of relieving pain by altering any factors which affect the pain threshold.

There is broad agreement among health professionals with experience in pain management that many different factors can indeed be modified in ways which appear to elevate a patient's pain threshold. Some of these factors exert their influence by a physical (including physiological) mechanism, while others act on the other four aspects (intellectual, emotional, social and spiritual) of what is often referred to as the "whole person".

I will look briefly at various examples of factors which can affect the pain threshold, grouping them under five subheadings, one for each of the five aspects of the whole patient referred to above. After that, I will suggest some further reading for those who may wish to explore this "holistic" (whole person) approach to elevation of the pain threshold further, or perhaps apply a similar approach to other aspects of the challenge of living with advanced cancer.

Physical Factors

A wide range of physical factors can affect the pain threshold. Firstly, basic aspects of physical comfort, such as temperature, humidity, furnishings, and levels of noise or other forms of pollution, create the environment in which the patient's own innate resources work. If these environmental factors are optimised, those innate resources can work better.

Secondly, adequate rest and sleep, and exercise and nutrition suitable to the patient's needs, are necessary if these same innate resources are to be maintained in as good a state as possible. Thirdly, various physical interventions, such as massage, acupuncture, and changes in the temperature of painful parts of the body, also appear to help in various ways.

In addition, any other physical symptoms the patient may have, such as nausea, constipation, breathlessness, cough, or the presence of disagreeable odours from an open wound or a stoma, are bound to reduce the overall tolerability of the situation. Relieving these other symptoms, regardless of whether they are due to the cancer itself or some other illness, is therefore very likely to raise the patient's pain threshold.

Intellectual Factors

It is natural to think a great deal about a serious illness such as cancer, and it is well established that thought interacts closely with both emotion and sensation. In particular, uncertainty tends to breed anxiety, so a lack of understanding about the illness and its effects can interact with the emotional factors discussed next. Cognitive therapies are sometimes helpful in changing the ways that thoughts influence the pain threshold.

The meaning ascribed to symptoms is also strongly influenced by thoughts about their origin and likely effects. If the meaning of a symptom is clouded in mystery, it is very easy for it to assume a terrifying aspect. This can usually be ameliorated by simple, clear and honest discussion with the patient's doctor.

Doctors often provide fairly limited information unless specific questions are put to them. Therefore, it is a good idea for the patient to decide before a consultation what information he or she would like to know and is ready to hear, and then to ask the appropriate questions directly, repeating them if necessary. It can be helpful to write down the main points during the consultation, as it is often difficult to remember the details later. If the patient is accompanied by a friend or relative, their recollections of the consultation will also be helpful later.

Emotional Factors

Perfectly normal, but nonetheless distressing, emotions, such as non-specific anxiety, more specific fears, or the sadness and anger which are felt while grieving over an adverse diagnosis or prognosis, can make any aspect of life seem worse, and pain is no exception. I have written elsewhere about various aspects of normal emotions[10], and also about some communication techniques[11] which are helpful when discussing difficult subjects, so I will not go into the details here.

For now, I will just say that I am quite certain that pain is much more easily controlled when a person's questions have been honestly addressed, and the emotions which may result have been "encouraged, expressed, explored and evaluated", as described in the first of the two books just mentioned.

The overall emotional environment created by the attitudes and behaviour of those providing care is also important in facilitating the resolution of painful emotions. Good teamwork and effective staff support in a clinic, hospital ward or hospice may not always be obvious to an external observer, but they contribute greatly to the welfare of patients and their loved ones.

Specific mental illnesses, such as the various types of anxiety and depressive disorders, must be distinguished clearly from the normal emotions which accompany adversity. However, mental illnesses have adverse effects on the patient's emotional state, so treating them can also elevate the pain threshold.

In addition, a wide range of strategies which are sometimes used as adjuncts in the treatment of mental illnesses, such as relaxation therapy, cognitive, behavioural and mindfulness therapy, meditation, guided imagery, hypnotherapy, music therapy and diversional therapy, may also be of great help in relieving the normal emotional responses to illness and loss.

Social Factors

The social factors which are most relevant to effects on the pain threshold are usually the patient's relationships and communication with family and other loved ones. There is considerable overlap and interaction between emotional and social factors, so they usually need to be considered together.

Family communication problems, and especially a "conspiracy of silence" regarding the diagnosis, can sometimes thwart the most expertly conceived analgesic regimen, as well as causing much other avoidable distress. Health professionals can help in this situation, but it can be avoided in the first place if the patient and family discuss matters openly and honestly, and do not try to avoid the inevitable strong emotions which arise.

Spiritual Factors

Although a "spiritual" aspect of the whole person is a difficult concept to define, it is nevertheless considered important by many patients, including many who do not consider themselves religious. Those who are religious may receive great comfort from the attendance of a chaplain or other suitable person, and also from their own prayers and the prayers of others. Those who do not consider themselves religious may nevertheless wish to discuss questions such as the possible meaning and purpose of life, and the nature and significance of death.

Detailed discussion of such matters is outside the scope of this series of articles. However, I have noticed that patients who view death as a natural part of life, and life as some sort of continuum, however vaguely conceived, often approach their own death with relative equanimity. Not all patients wish to discuss these issues, but those who do should be encouraged, as it may help them greatly in coming to terms with their situation.

Further Reading

The previous five subheadings, though here only applied to examples of possible strategies for elevation of the pain threshold, could equally well be used as a framework for the "holistic" approach to the overall challenge of living with advanced cancer, or indeed any other challenging life situation.

For readers who would like to explore the remarkable possibilities offered by a holistic approach to the stress, fear and grief which inevitably accompany any serious problem, I recommend the book "Full Catastrophe Living" by Jon Kabat-Zinn. Although now in its fifteenth anniversary edition, this book is as applicable today as when it was first published.

If you would like to purchase this book, or borrow it from a library, the full reference is as follows: Kabat-Zinn, J. 1990. Full Catastrophe Living. New York: Bantam Dell. ISBN 978-0-385-30312-5. For information about courses and self-help materials based on the book, see the Center for Mindfulness in Medicine, Health Care, and Society page at the University of Massachusetts Medical School's website.

Although many other books which are based on the same principles have since been written, and many more surely will be written, I very much doubt whether any of them will ever surpass the clarity and comprehensiveness of this one. For any person who is faced with a serious illness, bereavement or any other devastating life event, and would rather feel better than worse, I recommend this book without reservation.

Relieving pain with medications

Although the five methods of palliation already discussed are very important, I will say much more in this series of articles about relieving pain with medications than I have said about the previous five headings. However, rather than doing so in the present article (which would make it very long) I have devoted the next article in this series to the three main groups of medications used to relieve cancer pain, and the following one to the optimal use of one of those groups (opioid analgesics).

This emphasis on relieving pain with medications is partly because the five methods already discussed often involve quite complex interventions by a range of medical and allied specialists, the details of which are best left to those specialists, but more importantly it is because medication is very often the mainstay of palliation.

Incidentally, although I have given the use of medications a separate heading in this article, and will discuss it in more detail in the following articles, the actions of pain medications could equally well have been considered under three of the previous headings, namely:

  • Reducing the local effects of tumour deposits (because both opioid and non-opioid analgesics often reduce the local effects of tumour deposits on peripheral nociceptors)
  • Interruption of the pain pathway (because opioid analgesics inhibit transmission of pain stimuli along the spinal cord)
  • Elevation of the pain threshold (because opioid analgesics also act within the brain to reduce the perception of pain)

However, for practical purposes, I think it is most helpful to consider the use of medications as a distinct method of pain control, even though their various mechanisms of action (some of which are very incompletely understood) overlap with some of the methods already described. As mentioned above, the next two articles in this series (see the series links near the bottom of this page) are about the medications used to relieve cancer pain.

Reassessment

Regardless of the method (or usually methods) employed to prevent or relieve pain, frequent reassessment of each individual patient is crucial to continuing success. No amount of knowledge or experience on the part of the doctor and allied health care professionals can substitute for regular review of each individual patient. This is especially true in the terminal phase of cancer (or any other illness), but it is also very important for all patients at every stage of any illness, and so patients should expect to be reviewed frequently.

What about symptoms other than pain?

There are, of course, many unpleasant symptoms other than pain, and most of them can sometimes be caused by cancer. These other symptoms, such as cough, breathlessness, hiccups, nausea, vomiting, constipation, diarrhoea, ulcerated lesions and generalised itching, can also be treated very effectively.

The general approach to the treatment of any symptom caused by a cancer is broadly similar to that which I have discussed in relation to cancer pain, though the actual treatments are, of course, different. If symptom control is not successful, referral to a Palliative Care (Palliative Medicine) specialist is always advisable. As this series of articles is devoted to the treatment of cancer pain, the actual details of the treatment of other symptoms are outside its scope, and will therefore not be covered.

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Declaration of Interest

None.

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Comments

If you have any comments about this article, please address them to cancerpain@wanterfall.com.

Second Edition, published in 2013 by Wanterfall eBooks

Footnotes: (Click the number of a footnote to return to its reference in the text)

[7] Coates, G.T. 2009. Notes on Communication. Wanterfall eBooks, Sydney. (Like all Wanterfall eBooks and articles, this book is free to read or download, and also to remix or redistribute for any non-commercial purpose, in any format and in any quantity.)

[8] Severity is impossible to measure exactly, but is, nevertheless, very important. Various semi-quantitative pain assessment tools are available, such as comparison with past experiences, placement on a numerical or visual analogue scale, and choosing from a range of images of facial expressions.

[9] Endoscopy is a procedure in which an instrument called an endoscope is passed through a natural orifice such as, for example, the mouth, anus or urethra, in order to gain access to, for example, the gastrointestinal or urinary tract, without the need for open surgery.

[10] Coates, GT, 2008. Wanterfall. Wanterfall eBooks, Sydney.

[11] Coates, G.T. 2009. Notes on Communication. Wanterfall eBooks, Sydney.


Articles in the Cancer Pain Series

1. Myths and Facts about Cancer Pain

2. How Cancer Pain can be Relieved (this page)

3. Medications used to Relieve Cancer Pain

4. Optimal Use of Opioid Analgesics

5. Appendices:


For more free articles and ebooks by the same author, on a wide range of topics, visit http://www.wanterfall.com

Pink Azaleas

Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 2.5 Australia License

 

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