There are numerous approaches to treating cancer pain: medications of many kinds, surgery, radiation, complementary and alternative techniques, and more. This section will review these approaches.

At the heart of successful pain relief will be the partnership between you and your health care team. Your forthright discussion of your pain, along with accurate reporting of symptoms, pain levels, side effects and degree of pain relief will be essential to your care team in managing all aspects of your pain.

Medications

Don't forget: To help your health care team manage your pain with medications, don't forget to inform them of all medications (and the dosages and frequency) you are currently taking — both over-the-counter and prescription — for any reason. Also tell them about any herbs or other supplements you take. In selecting medications to manage your pain, the health care team must be sure to avoid drug interactions between medications you are already taking and those prescribed for your pain.

The Arsenal Against Pain
There are three main categories of pain medications used to treat cancer pain:

• Non-opioid pain medications. These medications, non-prescription and prescription, do not contain opioids. Major kinds are NSAIDs (non-steroidal anti-inflammatory drugs like aspirin, ibuprofen, naproxen) and acetaminophen (Tylenol). It's important to know that these medications are dose-limited, meaning that it is unsafe to exceed the recommended amounts of these medications at any time. You should not exceed recommended doses of NSAIDs or acetaminophen. The fact that some of these medications can be purchased over-the-counter does not mean they can be taken without risk.
  
  
  • NSAIDs include ibuprofen, naproxen, aspirin and COX-2 inhibitors, like Vioxx and Celebrex.
    
    
  • NSAIDs are anti-inflammatory medications, reducing swelling and relieving pain. They work by blocking the body's manufacture of prostaglandin, a hormone-like substance that sensitizes pain receptors.
    
    
  • Some people taking NSAIDs experience gastrointestinal problems. This can be eased in some cases by eating or drinking before taking these medications, or by taking another medication designed to protect the stomach. If you think you may be at risk for this side effect of NSAIDs, speak with your physician before taking these medicines.
    
    
  • Acetaminophen, which is less likely to cause gastrointestinal side effects, should be used cautiously by anyone who consumes alcohol, or anyone with significant liver problems.
    
    
  • People taking chemotherapy should not use any medication without the knowledge of their health care team.
    
    
• Opioids. These are the most powerful pain medications, and are only available by prescription.
  
  
  • Most frequently prescribed opioid medications for managing ongoing cancer pain include:
    
    
    
    • Fentanyl (transdermal Duragesic patches, intravenous; Actiq)
    • Hydrocodone (Lortab, Vicodin)
    • Hydromorphone (Dilaudid)
    • Methadone (Dolophine)
    • Morphine (MS Contin, Oramorph SR, Kadian)
    • Oxycodone (Roxicodone, Oxyir, Oxyfast)

     

    Choices of opioid medications made by health care professionals depend on the severity, frequency and cause of the pain involved, as well as other factors such as other medications a patient is taking.
    
    Opioids are also categorized by the speed with which they begin to work, and how long they remain effective. These are important factors in deciding which medications to prescribe for each patient.
    
    If one opioid medication is not effective for you, others can be tried. It may take several tries to find the most effective opioid medication for you.
    
    A special note: two opioids, propoxyphene (Darvon, Darvocet) and meperidine (Demerol) are generally not used to manage cancer pain, because they are short-acting and can have serious interactions with other medications. Both medications also have side effects that are undesirable for cancer patients. These medications can sometimes be useful in managing pain expected to last only a short time, such as that associated with procedures.

  • Opioid medications are often prescribed in combination with NSAIDs and acetaminophen for mild to moderate pain. Some of these combination include opioids like codeine, oxycodone and hydrocodone, combined with NSAIDs and acetaminophen:
    
    
    • Tylenol 1, Tylenol 2, Tylenol 3 — Codeine and acetaminophen
    • Percoset, Tylox — oxycodone and acetaminophen
    • Percodan — oxycodone and aspirin
    • Vicodin — hydrocodone and acetaminophen
    • Vicoprofin — hydocodone and ibuprofen
      
      
  • People with mild to moderate pain may also be prescribed an adjuvant medication (a medicine created for a different purpose but which has pain relieving capabilities as well; see below for more information) in addition to an opioid or opioid/NSAID or opioid/acetaminophen combination.
    
    
  • Generally, people just starting to take opioids are prescribed an initial low dose, which is increased until the pain is relieved. Usually these medications are taken on a regular schedule, rather than waiting until pain comes back. Keeping a steady level of pain medication in the blood works better than waiting until pain returns and then taking more medicine.
    
    
  • Side effects of using opioids occur, but these can almost always be well-managed and should not prevent you from taking the medication you need to manage your pain. Your health care team is able to help you cope with side effects — and compared to these measures, pain is often far harder to bear and disruptive of your quality of life. Remember, no side effect is too trivial if it is bothering you — and you should keep in close communication with your health care team for support, advice and assistance.
    
    
    • Constipation is the most common side effect, and for this reason health care providers should tell patients taking opioids of the steps to take to prevent opioid-caused constipation. It is better to prevent constipation than to wait for it to happen and then start treating it. If your health care team doesn't mention constipation to you, raise the topic. For most people, constipation will remain a problem as long as opioids are being taken — so there is no benefit in delaying treatment for the problem.
      
      
    • Drowsiness — temporary, for most people — may occur as a person's body adapts to the opioid medication. This usually does not last more than a few days. Sometimes adjusting your dose might be necessary to balance pain relief and drowsiness. Caffeinated drinks can help a bit, and if there is need for you to be fully alert during this initial period, your health care team can help.
      
      
    • Nausea happens in some people just starting to take opioids. This, like drowsiness, usually stops in a few days. For some people, taking opioids with food eases the problem. Other people find improvement if they remain in bed for an hour or so after taking the medication. Your health care providers may also provide you with anti-nausea medication if needed, usually taken 30 minutes before the opioid medicine is taken. Feeling nausea connected to taking an opioid medication does not mean you are allergic to the medication.
      
      
  • Less common side effects:
    
    
    • Shortness of breath occurs in some people when first starting on opioids. This feels like fewer breaths, and more shallow breaths than usual, and often the patient will also feel sleepy. If you experience this and are having trouble staying awake, get immediate help from your health care provider.
      
      
    • Itching can occur on occasion when first taking opioids. Let your health care provider know about this so the cause can be found. Ask your care provider for advice on managing the itching. If you are allergic to a particular pain medication, others can be substituted.
      
      
    • Dry mouth sometimes occurs. Drink more fluids, and try sucking on hard candies to stimulate saliva. If this isn't working, talk with your health care provider.
      
      
    • Sleep problems sometimes occur when a person begins taking opioids. If this doesn't go away in a few days, get advice from your health care team.
      
      
    • Mental confusion. This rare side effect can be frightening, but your health care team can help with dose management or changing to another pain reliever. Let your care team know about this side effect at once.
      
      
    • Twitching and muscles spasms (myoclonus) sometimes occur in some people using opioid medications. Generally, this is managed by changing the dose of medication, possibly administering the medication differently or changing to another opioid medication altogether.
      
      
  • If you no longer need opioid medications to manage your pain, it will be necessary to go through a period of gradually reducing the dose before stopping entirely. Your body has become used to the presence of this medication, and, as is the case with a number of other medications, it is necessary to taper the medication amount before quitting. Should you accidentally stop taking your opioid medication all at once, you may find yourself experiencing side effects of sweating, and feeling flu-like symptoms. Contact your health care team for assistance.
    
    
• Adjuvant medications. These are prescription medications — such as antidepressants, anticonvulsants and others — that were created for a purpose other than treating pain, but which help in relieving pain. They are often used in combination with other medications, such as NSAIDs, acetaminophen and opioids and can also be used by themselves. There are several different classes of adjuvant medicines used to treat cancer pain:
  
  
  
  • Antidepressants — these are especially helpful in managing pain from nerves damaged from chemotherapy, surgery or radiation. Antidepressants can also help ease sleep — and for this reason, they are often prescribed to be taken at night. These medications may take weeks before their full effect as pain relievers is felt, but the sedative effect can happen very quickly. Sometimes antidepressants are also used in combination with anticonvulsants for pain management. Some frequently prescribed antidepressants include:
    
    
    
    • Amitriptyline (Elavil)
    • Desipramine (Norpramin)
    • Doxepin (Sinequan)
    • Nortriptyline (Pamelor)
    • Trazodone (Desyrel)
      
      
  • Anticonvulsants — these are also helpful in managing nerve (neuropathic) pain. Some can cause drowsiness and dizziness when initially taken. These medications can lower red and white blood counts and cause liver damage, so frequent blood tests are needed to make sure problems are not developing. Frequently prescribed anticonvulsants include:
    
    
    
    • Carbamazepine (Tegretol)
    • Clonasepam (Klonopin)
    • Gabapentin (Neurontin)
    • Phenytoin (Dilantin)
      
      
  • Corticosteroids. These medications excel at relieving swelling and the pain that swelling can cause, and are also helpful in managing bone pain. Steroids can cause short-term side effects such as fluid retention and unusual appetite; longer-term side effects include a swollen "moon" face, irritability and other mental/emotional reactions, sleep problems and gastric symptoms like indigestion. If possible, steroids are used for short periods of time. Like opioids, it is best to slowly taper off corticosteroids, to reduce the side effects of stopping the medication. Commonly used steroids are:
    
    
    
    • Prednisone (Deltasone)
    • Dexamethasone (Decadron)
      
      
  • Antianxiety medications. These medicines reduce anxiety, but also can help with muscle spasms that are sometimes part of pain. These drugs have a relaxing, sedative effect and are generally prescribed to be taken at night:
    
    
    • Diazepam (Valium)
    • Lorazepam (Ativan)
      
      
  • Radiopharmaceuticals are medications that are sometimes used to help relieve the pain of cancer that has spread to the bones. The use of these medications, usually given intravenously, require a special setting designed for handling radioactive medications. Advantages here include long-acting pain relief, and few side effects. One downside is that relief may come only after a brief period of increased pain. One radiopharmaceutical used for pain relief is Strontium-89.

Treating breakthrough pain. It is not unusual for people experiencing cancer pain, even when it is generally well-controlled, to feel what is called breakthrough pain — or pain that "breaks through" the pain medications provided. Generally, it's a good idea for any patient taking pain medications on an around-the-clock basis to also have a fast-acting pain medication prescribed that is specifically intended for use in the event of breakthrough pain.

This pain is generally sharp, happens fast and is intense in nature. Sometimes it happens for no known or obvious reason, and other times it may be triggered by a specific activity like moving rapidly or coughing.

Medications for breakthrough pain should be both quick-acting and not remain in the bloodstream long, so as not to interfere with regular pain medications. One such medicine is the opioid fentanyl administered in the form of a lozenge (Actiq) that dissolves rapidly in the mouth when the lozenge is rubbed against the cheek and gums. Other medication used for breakthrough pain can be administered under the tongue.

A note of caution: if you are experiencing breakthrough pain frequently just before it is time to take another dose of your usual pain medicine, it may be time for you and your health care team to adjust your medication to provide better coverage.

How Pain Medications are Given

There are a number of methods used to administer pain medications — and your health care team will work with you to select those right for your pain. Many cancer patients with pain will use several of these methods (called routes by health care providers) throughout the course of treatment.

• Orally
  This includes anything taken by mouth — tablets, capsules and liquids. This is generally the easiest way to take medications for the patient, and it is almost always the first approach your health care team will try. Most cancer pain medications are given by mouth. A special caution: some pain medications, especially those in capsules or coated tablets, are timed-release, and should never be chewed or crushed. Chewing timed-release medications is dangerous.
  
  Oral medications can also be administered in other ways. Medicines placed under the tongue (sublingual) are quickly absorbed. Sometimes tablets are placed in the mouth between the surface of the cheek and your upper molars (buccal) where the medication dissolves slowly; don't chew these. Finally, a medication used for managing breakthrough pain, Actiq (fentanyl in lozenge form) is designed to be rubbed against the inside of the mouth, where it dissolves and provides quick pain relief.
  
  
• By injection (parenteral)
  This method is used when oral medications aren't the right approach.
  Medications can be:
  
  
  • injected into a vein (IV) or, if a patient has a catheter or port, these can be used as well.
    
    
  • injected under the skin (SQ — subcutaneous) — used for medications that should not be given via the digestive tract, or when IV access isn't available.
    
    
  • injected into muscle (IM — intramuscular) — not a usual approach for pain medications because muscles absorb these medications unevenly and sometimes slowly.
    
    
  • intrathecally — into the fluid around the spinal cord
    
    
  • epidurally — into the space around the spinal cord
    
    
• By patch (transdermal)
  Transdermal means "through the skin," and this is how your body absorbs medications provided by a patch that adheres to your skin. These provide medicine for a long period of time, usually 48-72 hours, from a single patch, and are effective and simple to manage for people with continuing pain. Patches should never be cut or altered in any way.
  
  
• Rectally
  Medications administered in this way are in the form of a suppository, which dissolves inside the rectum, slowly releasing the medication. This is sometimes a good route for people who cannot swallow well, or who are having nausea and vomiting problems.
  
  
• By infusion pump
  A PCA pump — meaning patient-controlled analgesia — is an effective way to deliver pain medication, allowing the person receiving the medication to push a button to receive additional medication (in addition to that programmed into the pump to be administered over time) when needed. The route used can be though your vein, through the spinal area or under the skin. Pumps delivering pain medications can also be implanted under the skin.
  
  One advantage to pumps connected directly by catheter into the spinal area is that the amount of medication can be lower than that needed through other routes.

Other Methods of Relieving Cancer Pain

1. Surgery
   Sometimes pain is best relieved by surgery. These include the need to relieve blockage of the bowel, to remove a tumor or part of a tumor pressing on vital organs or nerves, and to reduce the size of the tumor to provide other treatments time to work. Surgical methods are also used to drain fluids that are causing discomfort.
   
   
2. Nerve blocks
   Nerve blocks are designed to stop the nerves from transmitting pain messages to the brain. To do this, a local anesthetic medication, sometimes combined with a steroid medication, is injected either into or near a nerve, or into the spinal cord area, to block pain. A successful block means that the pain is no longer present.
   
   
3. Radiation
   Radiation therapy is primarily used as pain relief when cancer has spread to the bones. This is a relatively simple and very effective method of pain management in this situation, requiring only a few treatments for relief to be felt. Radiation can also help in alleviating pain of cancer that has spread to the spine, nerves and blood vessels.
   
   
4. Radiofrequency ablation
   Radiofrequency ablation (RF) directs radiation directly into a tumor, often in the liver, where it destroys cancer cells. RF does this by using alternating electric current. RFA can be repeated as needed, requires very minimal outpatient surgery, and has no significant side effects.
   
   
5. Chemotherapy
   Sometimes chemotherapy, normally used to treat cancer, can be used to reduce the size of an existing tumor that is causing pain. Various chemotherapy medications are used for this purpose.

Non-Medical Treatments

There are a number of non-medical techniques that cancer patients and their health care teams can use to relieve pain. These are among the most commonly used techniques:

• Acupuncture, traditional Chinese medicine that uses needles at specific contact points in the body to try to help a person overcome various conditions, including pain. The needles used do not hurt. Acupuncture appears to work by stimulating the nervous system in ways that release chemicals into the central nervous system that help reduce pain. Acupuncture is also credited with helping to relieve nausea caused by chemotherapy and other conditions. Acupuncture should be performed by a licensed acupuncture practitioner; almost all states have established acupuncture certification standards.
  
  
• Biofeedback involves working with a small electronic monitoring device that gives you data on what stress (such as pain) may be doing to your body's functions, such as blood pressure and heartbeat. Observing what the machine tells you can enable you to consciously work to reduce the stress you're experiencing, gaining some measure of control over these basic body functions. In time and with practice, you won't need the biofeedback machine, and will be able to defuse stress more easily. People in pain report mixed results with using biofeedback — but it can be helpful for other forms of stress.
  
  
• Cold — usually a cold pack applied to the skin — can help a person manage nerve pain and reduce inflammation. Make sure your cold pack is wrapped in something like a towel to prevent direct contact with skin, and don't use it longer than 20 minutes at a time.
  
  
• Distraction is just what it sounds like — finding a way to distract yourself from what is going on around you. The methods you choose to distract yourself should be things you enjoy, such as reading, watching television, talking with a friend, or listening to music.
  
  
• Heat relaxes. This can be helpful for sore muscles, easing spasms, and provide a sense of comfort that is helpful. Heat increases blood circulation to the area where the heat is applied, and this can relieve pain. Make sure you talk with your health care team about using heat, as it not intended for use by all patients. Keep heat on only in 10-minute cycles, and then remove it for at least 10 minutes before reapplying. Never sleep using a heating pad, as a burn can occur. For some people, alternating heat and cold is helpful.
  
  
• Imagery is a technique where a person with cancer forms a mental imagine of something very pleasant to her or him. The idea is to really sense, smell, touch, see and hear this pleasant experience, to immerse yourself in it. Imagery, sometimes called visualization, can be effective for short-term pain management, such as enduring an injection or waiting for other medications to become effective.
  
  
• Massage can be a wonderful relief to people experiencing muscle tension and stress. Massage can ease tension and improve circulation — producing a sense of well-being along with these benefits. Deep massage should only be performed by a certified massage therapist. Gentle massage can be performed by anyone willing to take a little time to help you relax.
  
  
• Relaxation is an approach, not a single technique — and each person will find the most appropriate means for him- or herself. This is not, for most people, an effective approach for managing severe pain. For some people, a simple deep breathing exercise — inhale and tense muscles/exhale and relax muscles — can help. Other techniques, including rhythmic breathing, can be effective.
  
  
  • Rhythmic breathing involves concentrating on an object, then closing your eyes, and concentrating on breathing. Take a deep breath in slowly, and tense you muscles. Then breathe out, relaxing the muscles, and tension drains away. Continue this for a period of time, depending on how you are feeling. When you are finished, say to yourself, "I feel relaxed," and slowly open your eyes.
    
    
  • Relaxation tapes can also be useful. Ask your health care team for a recommendation, or check at an area music or bookstore.
    
    
• TENS — transcutaneous electrical nerve stimulation — sounds strange when described, but can prove effective in pain management. The TENS is a portable battery-operated control box with electrodes that are placed on a patient's skin, near the site of the pain. A current is sent from the control box to the patient's skin (this is adjustable), and pain at that site is reduced. Your health care team will show you how to use this simple machine, which can provide hours of pain control without side effects.

Questions for Your Doctor

1. What is your general approach to cancer pain management?
   
   
2. What methods will you use to control my pain? Please explain why you are recommending these approaches.
   
   
3. What medications are likely to be used?
   
   
4. What methods will be used to take these medicines? Will I be able to take pills, or will you recommend other approaches?
   
   
5. What side effects are likely from these medications? How will they be managed? Who should I contact to discuss managing side effects?
   
   
6. Will I be able to have around-the clock pain relief?
   
   
7. I have trouble swallowing pills. Can I cut my pain medications in half or crush them to put in food or drinks? Should any of my medications not be cut or crushed?
   
   
8. I take medications for other medical conditions. Will these interfere with my treatment for cancer pain?
   
   
9. Does the need to take opioid medications mean that my cancer is getting worse?
   
   
10. I don't want to take opioids unless there is no other choice. Can we try other approaches?
    
    
11. Sometimes the pain medications I take don't work very well, and I get pain again before it is time for the next dose. What can be done to control this?
    
    
12. Why should I take an antidepressant for pain when I am not depressed? Please explain how this works.

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