Topic Overview

Can cancer pain be controlled?

Cancer pain can be controlled in almost every case. This does not mean that you have no pain, but it does mean that the pain stays at a level that you can bear.

Cancer and its treatments can be painful. A tumour that presses on bones, nerves, or organs can cause pain. Surgery for cancer can cause pain. So can chemotherapy and radiation. Some medical tests, such as bone marrow aspiration, can also cause pain. There are a number of ways to control each of these kinds of pain.

There are different kinds of cancer pain. These include:

• Acute pain. This is bad pain that lasts a short time.
• Chronic pain. This is mild-to-intense pain that comes and goes over a long time.
• Breakthrough pain. This is sudden, severe pain that lasts for a short time while you are taking medicines that usually control your pain.

There are a number of ways to control each of these kinds of pain.

You are the only person who can say how much pain you have or if a certain pain medicine is working for you. Telling your doctor exactly how you feel is one of the most important parts of controlling pain.

What does your doctor need to know?

The more specific you can be about your pain, the more your doctor will be able to treat it. It often helps to write everything down. Include:

• When your pain started, what it feels like, and how long it has lasted.
• Any changes in your pain.
• If the pain is constant or if it comes and goes.
• If you have more than one kind of pain. Use words such as dull, aching, sharp, shooting, or burning.
• What makes your pain better or worse.
• A rating of your pain on a scale of 0 to 10, with 10 being the worst pain you can imagine.

Tell your doctor exactly where you feel pain. You can use a drawing. Say if the pain is just in one place, if it is in several places at the same time, or if it moves from one place to another.

How is cancer pain managed?

Pain control often starts with medicine. Many drugs are used to treat pain. You and your doctor may need to adjust your medicine as your pain changes. Your doctor may suggest different drugs, combinations of drugs, or higher doses.

For a tumour that causes pain, removing or destroying all or part of the tumour, if possible, often helps. Doctors use radiation, surgery, and other treatments to do this.

For nerve pain, doctors may use nerve blocks. With a nerve block, medicine is injected right into the nerve that affects the painful area. They provide short-term pain relief by preventing the nerve from sending pain signals. Or sometimes medicine is delivered directly to the spine, as with spinal anesthesia or an epidural.

There are many other ways to control cancer pain, including:

• Heat or cold.
• Massage, exercise, and physiotherapy.
• Relaxation exercises, biofeedback, or guided imagery.
• Acupuncture.

Older adults are at risk for not getting enough pain medicine. If you are a caregiver for an older adult who has cancer, talk with that person to make sure that the pain is under control. Talk with the person's doctor, too, about a pain management plan.

Learning as much as you can about your pain may help. Talking to a counsellor can help you manage your cancer pain or the discomfort from cancer treatments. Emotional support from your friends and family may also help.

What is a pain control diary?

This is a record of your pain treatment and how it helped or did not help you. You can write down when you used each treatment, how it worked, and any side effects it caused. Having it written down helps you let your health care team know exactly how well your treatment is working.

Am I likely to develop opioid use disorder while taking opioid pain medicine?

Many people who take opioid pain medicines worry about developing opioid use disorder. Moderate to severe opioid use disorder is sometimes called addiction. Your doctor will monitor you closely for signs of this disorder. When you no longer need these medicines, your doctor will slowly lower the amount you are getting until your body no longer needs the medicine.

Do not let this fear get in the way of pain relief. Ask for pain relief if you need it. Pain is easier to control when you treat it as soon as it starts. You may also be able to predict pain and treat it before it begins, such as before physical activity. Pain is harder to control if you wait until it is bad.

Cause

Cancer pain may be caused by the cancer or by the treatments and tests used. The kind of pain may vary depending on the cause. The first step in managing your pain is understanding what is causing it.

Pain from the cancer itself can happen when:

• A cancer growth, or tumour, presses on bones, nerves, or organs.
• Cancer cells spread to the bone and destroy it.
• A tumour presses on the spinal cord, causing pain in the back, legs, or neck.
• A tumour causes organs to swell or be blocked. For example, a bowel obstruction can be caused by a tumour.

Because some cancer spreads far and fast, treatments have to be strong. As a result, they often cause pain and other side effects that require more treatment. Pressure on or damage to a nerve may cause tingling or burning. Treatments such as surgery, radiation, and chemotherapy may also cause pain.

What Does It Feel Like?

The type of cancer pain you feel depends on the type of cancer you have and how it affects your body. For example:

• Deep, aching pain. A tumour that presses on your bones or grows into your bones can cause deep, aching pain. Bone pain is the most common type of cancer pain.
• Burning pain. A tumour that presses on a nerve can cause a burning feeling. Sometimes chemotherapy, radiation, or surgery damages nerves and causes burning pain. Nerve pain is the second most common type of cancer pain.
• Phantom pain. Pain that is felt in the area where an arm or a breast has been removed is phantom pain. Although the body part is gone, nerve endings at the site still send pain signals to the brain. The brain thinks the body part is still there.

Acute pain is bad pain that lasts a short time. Chronic pain is pain that comes and goes for a long time. It is a side effect of the cancer or treatment. Chronic pain can range from mild to severe. Breakthrough pain is strong pain that occurs while you are taking medicines that usually control your pain. This kind of pain usually begins suddenly and lasts for a short period of time.

Not everyone feels pain in the same way. Only you can describe how much pain you have. The key to getting your pain under control is being able to tell your doctor what it feels like and what does and doesn't work for you.

When to Call a Doctor

If you have cancer, call your doctor if any of the following occur:

• You have new pain.
• Your drugs or other treatments are no longer working.
• Your pain medicine is not working long enough after each dose.
• You have new symptoms, such as having a hard time walking, eating, or urinating.
• You notice an unusual rash, or bowel or bladder changes.
• You have unexpected or poorly controlled side effects, such as nausea or vomiting, constipation, or diarrhea.
• Your pain makes it hard for you to do your daily activities, such as eating or sleeping.

Who to See

The following health professionals can help treat cancer pain:

• Internist
• Family doctor
• Surgeon
• Medical oncologist
• Radiation oncologist
• Anesthesiologist
• Nurse practitioner
• Physician assistant
• Neurologist

Your pain may be managed by a team that may include doctors (including pain specialists or hospice palliative care specialists), nurses, psychologists, social workers, and pharmacists. Be sure that all the members of your health care team know about any changes in your pain control diary. You may wish to use one person, such as your medical oncologist, as a team leader who will make sure that all team members share information.

Treatment Overview

You are the only one who knows how your cancer pain feels. You may need different combinations of treatments. Don't be surprised if your pain control plan needs to be changed often. Don't let that discourage you. Be honest and specific about what does and does not work for you. Staying on top of your pain and in control of your pain will improve your quality of life during every stage of your disease.

Non-prescription drugs

Drugs that you can buy without a doctor's prescription may be enough to relieve your pain at times. Acetaminophen, such as Tylenol, relieves pain, while other drugs such as ibuprofen and aspirin relieve pain and also decrease swelling. But talk with your doctor before you take any non-prescription medicines. And don't take more than the label says unless your doctor tells you to.

Prescription drugs

Drugs that need a doctor's prescription may be stronger or work differently than non-prescription drugs. Follow your doctor's orders about taking them. Prescription drugs include:

• Anti-inflammatory drugs and corticosteroids.
• Bisphosphonates and other medicines, to slow bone changes related to cancer.
• Opioid pain relievers.
• Drugs for depression, to treat burning pain. Plus they can help you sleep.
• Certain drugs for seizures, to help control nerve pain, like burning and tingling.

Medicines for breakthrough pain

This is extra medicine for when strong pain comes on suddenly. These prescription medicines are usually fast-acting opioids given by mouth, such as morphine or oxycodone. Or you may be given fentanyl in tablets that dissolve under your tongue.

Other treatment options

Medical treatments can help relieve pain from tumours and nerve pain.

• Ways to shrink, remove, or destroy painful tumours include:
  • Surgery.
  • Chemotherapy.
  • Radiation.
  • Hormone therapy.
  • Radiofrequency ablation, which uses heat to destroy the tumour.
• Ways to treat nerve pain include:
  • Surgery to cut the nerves that relay pain.
  • Nerve blocks to help with very bad pain.
  • Pain medicine delivered to the spine. This can be done by:
    • Spinal anesthesia, which delivers pain medicine directly to the spine.
    • An epidural, which delivers pain medicine to the nerves around the spine.

Non-medical ways to relieve pain are often used along with pain medicine. These include:

• Physical treatments, such as physiotherapy, light massage, heat or cold, and braces or splints. Other treatments include transcutaneous electric nerve stimulation (TENS), in which a mild electrical current from a power pack is used to relieve pain.
• Stretching, yoga, and exercises to help you keep your strength, flexibility, and mobility.
• Behavioural treatments, such as cognitive-behavioural therapy (CBT), relaxation, biofeedback, meditation, or guided imagery.
• Short-term crisis therapy or cognitive-behavioural therapy (CBT) with a counsellor. This may help you manage your cancer pain or the discomfort from cancer treatments.
• Education and emotional support. Your doctor can refer you to the social services department of your local cancer treatment centre or hospital.
• Complementary therapies, such as acupuncture, aromatherapy, prayer, and humour therapy.

You can find more information about controlling pain online at the:

• Canadian Cancer Society website at www.cancer.ca.
• U.S. National Cancer Institute website at www.cancer.gov.

Hospice palliative care

Hospice palliative care is a kind of care for people who have a serious and chronic illness. Its goal is to improve your quality of life—not just in your body but also in your mind and spirit.

You can have this care along with treatment to cure your illness. You can also have it if treatment to cure your illness no longer seems like a good choice.

Hospice palliative care providers will work to help manage pain and other symptoms or side effects. They may help you decide what treatment you want or don't want. And they can help your loved ones understand how to support you.

If you're interested in hospice palliative care, talk to your doctor.

Keeping a Pain Control Diary

The best way to control cancer pain is to tell your doctor exactly how your pain feels, where it is, and what works or does not work to control it. A written pain control diary will help you do this.

Your family and health care team can help you create a pain control diary . This diary will help you keep track of when you use each treatment, how it works, and any side effects that you may have. This written record will track your progress, and will help your health care team know what you need. It will be easier for your doctor to see how well your pain treatment is working.

You can also use your pain control diary to write down questions for your doctor, the answers to your questions, and any changes that you and your doctor have made to your treatment. Be sure to include information such as clear instructions about who and when to call if you have problems or questions.

Cancer pain in older adults

Older adults are at risk for not getting enough pain medicine. If you are a caregiver for an older adult who has cancer, talk with that person to make sure their pain is under control. Talk with the person's doctor, too, about a pain management plan.

Home Treatment

There are many things you can do at home to reduce your cancer pain, manage side effects, and feel better in your mind and body. Follow your doctor's advice. Talk to your doctor about any home treatment you want to try.

You may find that drugs you can buy without a prescription are enough to ease your pain at times. Acetaminophen, such as Tylenol, relieves pain. Anti-inflammatory drugs, such as ibuprofen and aspirin, relieve pain and also decrease swelling. Be sure you know how to safely use these drugs. Talk with your doctor before taking these medicines, especially if you have a fever or have had kidney or liver disease, gastrointestinal bleeding, or a stomach ulcer. And don't take more than the label says, unless your doctor tells you to do so.

Some pain medicines may cause problems like nausea, sleepiness, and constipation. Nausea and sleepiness usually go away in the first couple of days, but constipation may be an ongoing problem. To help manage these side effects at home, the following may help:

• Home treatment for fatigue: You can choose the most important things you want to do if you feel a tiredness that doesn't go away with rest or sleep. For example, if taking a shower is a priority and mornings are when you have the most energy, plan to take your shower at that time.
• Home treatment for nausea: Drink fluids to stay hydrated. Eating smaller meals may help. A little bit of ginger candy or ginger tea can help too.
• Home treatment for constipation: Follow your doctor's orders to prevent getting constipated. And check with your doctor about whether exercise might help.
• Sleepiness. Don't walk up or down stairs alone. Wait until you feel more alert before driving or using machines or other tasks where you need to pay attention. If you can't stay awake at all or the sleepiness lasts for more than a week, talk to your doctor.
• Home treatment for mouth sores: Keep your mouth and teeth clean. Rinsing out your mouth will help, but use a mouthwash without alcohol. Your doctor can prescribe a mouthwash for mouth pain.

Other home treatments for pain include:

• Heat or cold therapy to relieve muscle aches and pains.
• Stretching, yoga, and exercises to help you keep your strength, flexibility, and mobility.
• Mind-body treatments, such as relaxation, biofeedback, meditation, or guided imagery.
• Healing touch and light massage.
• Cognitive-behavioural therapy (CBT) with a trained counsellor to reduce your response to pain.

Handling the stress of having cancer

Having cancer can be very stressful, and it may feel overwhelming to face the challenges of cancer. Finding new ways of coping with the symptoms of stress may improve your overall quality of life. These ideas may help:

• Get the support you need. Spend time with people who care about you, and let them help you.
• Take good care of yourself. Get plenty of rest, and eat nourishing foods.
• Talk about your feelings. Find a support group where you can share your experience.
• Stay positive. Do things each day that will help you stay calm and relaxed.

It is not unusual for people who have cancer to become depressed. If you are feeling depressed, talk with your doctor. Depression can make your cancer pain harder to treat. And treating your depression will help you with managing your pain.

Emotional support is important when you are dealing with cancer pain. If you feel like you need help, talk with your doctor. He or she can refer you to the social services department of your local cancer treatment centre or hospital.

Learning all you can about your condition and treatments for pain can help you understand your options. It can also help you when you talk with your doctor about your pain management plan.

For more information about managing cancer pain, read "Pain Control: Support for People With Cancer" from the U.S. National Cancer Institute. This booklet is available online at www.cancer.gov/cancertopics/coping/paincontrol.

Medications

Many different drugs are used to treat cancer pain. If you are already taking pain medicine for another problem, tell your doctor how often you are taking it and how well it works.

The key to controlling cancer pain is to take your medicine on a regular schedule. Do not wait until your pain gets bad. Pain is easier to control when you treat it just after it starts. Painkilling drugs work to control cancer pain in most people.

Non-prescription medicines

Be careful when taking non-prescription medicines. Talk with your doctor before you take these medicines, especially if you have a fever or have had kidney or liver disease, gastrointestinal bleeding, or a stomach ulcer. And don't take more than the label says, unless your doctor tells you to do so.

Medicines you can buy without a prescription may be enough to relieve your pain at times. These medicines include:

• Acetaminophen, such as Tylenol.
• Anti-inflammatory drugs, such as ibuprofen and aspirin, which also reduces swelling.

Prescription medicines

People who have cancer pain often need stronger medicines that their doctors prescribe. Be sure to follow your doctor's orders when you take these stronger medicines. If you still have pain, call your doctor.

Prescription medicines may be used alone or with other medicines. Depending on your pain, some of these medicines work better than others. Prescription medicines include:

• Opioid pain relievers, such as fentanyl, hydromorphone, methadone, morphine, oxycodone, and tramadol.
• Other medicines that may be used with opioid pain relievers. These medicines may be given to help your pain medicine work better or to treat your symptoms. Or they may be given for certain types of pain. These include:
  • Anticonvulsants, to help control nerve pain like burning and tingling.
  • Antidepressants, to relieve pain and help you sleep.
  • Anti-inflammatory drugs and corticosteroids (for example, prednisone or dexamethasone).
  • Bisphosphonates, such as pamidronate and zoledronic acid, to treat bone pain.
  • Local anesthetics, such as skin creams with capsaicin or lidocaine, to help relieve pain in the skin and surrounding tissues.

Medical cannabis (marijuana) also may help relieve cancer pain. It is available as cannabis cigarettes or as cannabidiol, which is made from an active ingredient of cannabis. Cannabidiol is available as an oral spray.

Ways medicine is given

Medicines for cancer pain are usually given by mouth. When a person is having trouble swallowing or faster pain relief is needed, medicine can be taken in other ways. Here are ways that medicine may be given:

• By mouth. This includes pills, capsules, liquids, and medicines that dissolve on the tongue or under the tongue.
• With a shot (injection). Usually the medicine is injected under the skin into the tissue between the skin and the muscle. Sometimes medicine is injected into a muscle.
• With a needle into a vein (IV). A person with an IV may be able to use a (PCA) pump, which lets him or her control pain medicines.
• With a pain pump, also called an infusion pump. This kind of pump is placed under your skin to deliver pain medicine directly to your spine.
• Using skin patches. These have medicine in the patch that is absorbed into the body through the skin.
• With rectal suppositories. Medicine in capsules or pills are put inside the rectum and absorbed into the body.
• Into the spine. Medicine can be put into the area around the spinal cord, such as with spinal anesthesia or an epidural.
• Through the nose. Medicine in a nasal spray can be absorbed into the body quickly.

Surgery

Surgery is sometimes used to relieve cancer pain. Removing a tumour that is pressing on nerves, bones, or your spinal cord can help your pain. Surgery can also remove tumours that block the intestine and cause pain. The type of surgery that you may have depends on the type of cancer you have, which parts of your body are affected, and what treatments you have had before.

Other Treatment

When medicines are not enough to relieve cancer pain or when they cause troublesome side effects, other treatments may help.

• Radiation is the use of X-rays to destroy cancer cells and shrink tumours. It is used to destroy cancer growths that press on your nerves, bones, or spinal cord. The type of radiation that you receive depends on your cancer diagnosis, the area of your body that is affected, and your previous history of radiation therapy. Destroying growths relieves pressure on organs and nerves and reduces pain.
• Nerve blocks usually are used only after other treatments have not worked. A nerve block is a drug that is injected into or around a nerve to temporarily prevent the nerve from telling your brain about the pain. In some cases, deadening the nerve may not only reduce the pain but also lower the amount of medicine you need.
• Transcutaneous electric nerve stimulation (TENS). This uses a mild electrical current from a power pack to relieve pain.
• Physical treatments, such as physiotherapy, heat or cold, and braces or splints.

Exercise can help reduce pain and fatigue. It can also prevent muscle spasms and stiffness in your joints. But be sure to talk to your doctor before increasing your level of physical activity.

Being physically active also can help with your emotional and mental health. It can be hard to be active when you don't feel well. But if you are able, going for a walk or going swimming may help you feel better, especially during cancer treatment.

Short-term crisis counselling or cognitive-behavioural therapy (CBT) may help you manage cancer pain or the discomfort from cancer treatments. Counselling may also help your partner or family members.

Complementary therapy

People sometimes use complementary therapies along with medical treatment to help relieve symptoms and side effects of cancer treatments. Some of the complementary therapies that may be helpful include:

• Acupuncture to relieve pain.
• Meditation or yoga to relieve stress.
• Massage or biofeedback to reduce pain and ease tension.
• Breathing exercises for relaxation.

These mind-body treatments may help you feel better. They can make it easier to cope with treatment. They also may reduce chronic low back pain, joint pain, headaches, and pain from treatments.

Before you try a complementary therapy, talk to your doctor about the possible value and potential side effects. Let your doctor know if you are already using any such therapies. They are not meant to take the place of standard medical treatment.