Treating Cancer Pain

Surgery, radiation therapy, chemotherapy, and immune therapy all may provide substantial relief from pain as they rid the body of the underlying cancer. Surgery may also be used to prevent or control pain-causing complications of cancer such as bowel obstruction, compression of the spinal cord or peripheral nerves, or compression of organs. The chief purpose of most of these therapies is to treat the cancer, however, and not primarily to provide pain relief; also sometimes these therapies may themselves be a source of pain. For that reason, effective cancer treatment encompasses several other approaches primarily directed at relieving pain.

Pain-relieving medicines can be prescribed to meet various kinds of cancer-related pain. They can also be administered by different routes, depending on a patient's individual needs and preferences. Analgesics are given orally, rectally, transmucosally, intravenously, intrathecally, epidurally, subcutaneously, or transdermally. They may also be delivered by means of patient-controlled analgesia (PCA), in which patients help control the amount of pain medication by pressing a button on a computerized pump.

Mild to Moderate Pain

Non-opioid drugs such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen provide relief for many types of mild to moderate pain, including muscle pain, bone pain, and the pain of some incisions. Non-opioid analgesics may be prescribed in combination with opioids and other therapies for greater pain relief.

Moderate to Severe Pain

Opioids (such as morphine, fentanyl, codeine, oxycodone, and others) are highly effective medicines for relieving cancer pain. Opioids may be combined with non-opioid drugs such as acetaminophen or NSAIDs for treatment of moderate pain, and used alone or in combination with other drugs (adjuvant analgesics) and therapies for severe pain. Patients rarely become addicted when powerful pain medications such as opioids are prescribed for cancer-related pain and taken appropriately. Depending on need, opioids may be prescribed at any stage of treatment.

There is no need to "tough it out" early in treatment out of concern that strong pain medicines won't be effective if needed later on. Patients may receive increasing doses of opioids for years without becoming addicted, or psychologically dependent. When the need for pain relief subsides, physical dependence can usually be managed without withdrawal symptoms by tapering the opioid before discontinuing. Patients with cancer very rarely seek drugs beyond what is needed to control pain.

Breakthrough Pain

A doctor may prescribe a quick-acting potent analgesic called a "rescue medication" such as oral morphine to have available for times when pain "breaks through" normal pain control. These rescue doses act quickly and clear the body relatively soon, and are usually prescribed in addition to the dose taken regularly for persistent pain.

Adjuvant Analgesics

Several drugs besides non-opioid and opioid analgesics have been found to provide pain relief in specific situations and may be prescribed to help manage cancer-related pain. Many of these drugs are well known for their primary indications for conditions other than pain. A growing number of drugs, including antidepressants, anticonvulsants, and steroids as well as local anesthetics, are being used with excellent results. Some of these agents have been found to help relieve specific types of pain such as "tingling" and "burning" sensations, and pain caused by inflammation (swelling).

Nerve Blocks

For acute and postoperative pain and some chronic pain problems, temporary nerve blocks (neural blockades) can provide temporary relief. In this procedure, a physician injects a local anesthetic into or around nerves or below the skin in the area where there is pain. The anesthetic interrupts transmission of pain signals to the brain and may provide relief for up to several hours. In a procedure called a neurolytic block (neurolysis), a physician injects a substance, most often ethyl alcohol or phenol, into a nerve or into the spinal fluid so that nerve tissue in the pain pathway is destroyed. This technique usually has a long-lasting or permanent effect.

Epidural & Intrathecal Pumps

Nerve blocks work best for pain that occurs over a limited area involving one or two specific nerves. For pain that is more widespread, it is possible to interrupt pain signals using epidural or intrathecal pumps. ("Epidural" refers to the space just outside the spinal cord's outer membrane; "intrathecal" refers to the space between the sheaths covering the spinal cord.) These pumps are either carried in a pouch or placed under the skin and can deliver medication continuously to broad areas. Further, depending on the type of pump, patients can obtain additional medication by pushing a button. By delivering medicine directly to the nerves causing pain, less medication may be needed. For many patients, this can mean better pain relief with fewer side effects.

Most cancer-related pain can be effectively managed with medication, but when drug therapy does not provide adequate relief or when the side effects of medications become a problem, nonpharmacologic approaches are often effective.

In some instances when pain is not controlled by more conservative means, pain pathways can be cut or interrupted (ablated) by neurosurgery. Neurosurgical techniques are also sometimes used to implant drug-delivery devices and to stimulate nerve fibers to inhibit pain.

Focused psychological interventions are an important component of effective pain management. Short-term psychotherapy, structured support, and cognitive-behavioral therapy can help provide useful coping skills to enhance the effectiveness of other treatments. Relaxation and imagery, cognitive distraction (focusing attention on stimuli other than pain), support groups, and pastoral counseling are now widely used to help patients manage pain.

During all phases of cancer treatment, complementary approaches to pain relief may be integrated into therapy. These complementary therapies include relaxation techniques, meditation, movement therapies, and massage to supplement medical pain-control methods. These techniques can help relieve acute pain during some procedures, acute post procedural pain, and some forms of chronic pain.

Memorial Sloan-Kettering's Integrative Medicine Service offers individual therapies and group classes using the best of these complementary approaches.