• No results found

Controlling Cancer Pain: What You Need to Know to Get Relief

N/A
N/A
Protected

Academic year: 2021

Share "Controlling Cancer Pain: What You Need to Know to Get Relief"

Copied!
20
0
0

Loading.... (view fulltext now)

Full text

(1)

Controlling Cancer

Pain: What You

Need to Know

to Get Relief

Presenter

Michelle Rhiner, RN, MSN, NP

Supportive Care/Pain/Palliative Medicine City of Hope National Medical Center Duarte, California

Find out about:

• Discomfort/pain of cancer • Causes/sources of pain • Barriers to pain management • Managing side effects

(2)

This booklet is based on information presented in a recent CANCER

care

® Telephone Education Workshop by nurse practitioner Michelle Rhiner. This workshop was a collaborative effort between CANCER

care

and the American Pain Foundation and was sponsored by an educational grant from Cephalon, Inc. Ms. Rhiner is the patient coordinator and manager for Supportive Care, Pain and Palliative Medicine at the City of Hope National Medical Center in Duarte, California.

On page 11 you’ll find a list of frequently asked questions. Definitions of boldfaced words in the text can be found in the glossary on page 15.

CANCER

care

was founded in 1944 to help those with cancer and their loved ones cope with the disease. Our services are free to people of all ages, with all types of cancer, and at any stage of the disease. CANCER

care

conducts 70 Telephone Education Workshops per year. The workshops are a way for people from across the country to learn about cancer-related issues from leading oncology experts. Many of the workshops even provide participants with the opportunity to ask questions. More information about the CANCER

care

Connect™ program can be found at www.cancercare.org, by calling 1.800.813.HOPE, or by e-mailing teled@cancercare.org. In addition to our Telephone Education Workshops, CANCER

care

has more than 40 trained oncology social workers on staff who provide assistance to more than 100,000 people each year. These services include:

n Professional counseling and support in person, over the telephone, or through the Internet

n More than 30 professionally facilitated support groups

n Assistance with obtaining funds for disease-related costs, such as pain medication, transportation, homecare, and childcare

n Information to help you make the best decisions

n A resourceful, interactive Web community (www.cancercare.org) that provides people with cancer and their loved ones comprehensive information about their disease. CANCER

care

Online™ also provides visitors with the opportunity to participate in a support group, listen to a Telephone Education Workshop, and locate additional resources in their local community.

National Office Services

275 Seventh Avenue Tel: 212.712.8080 New York, NY 10001 1.800.813.HOPE (4673) E-mail: teled@cancercare.org

Administration Tel: 212.712.8400 Fax: 212.712.8495

E-mail: info@cancercare.org An additional list of resources Website: www.cancercare.org may be found on page 16.

(3)

Pain is whatever

the patient says it is.

M

ost patients with pain wish they had never been born with the ability to experience pain. But pain receptors are impor-tant: they alert us to a problem and prompt us to seek medical attention. However, chronic or persistent pain has no biologi-cal value. Its detrimental effects may even interfere with survival.

There are two broad types of pain: acute pain and chronic pain. Acute pain is experienced immediately when the body is injured. Once healing occurs, acute pain generally disappears. Chronic pain continues beyond tissue healing. It’s present every day or nearly every day for more than three months. Such pain may be due to cancer or other diseases. Cancer patients who experience chronic pain may also have acute episodes of pain. That often indicates a new problem, such as an outbreak of herpes zoster (“shingles”).

Somatic Pain

nWell localized: You know exactly where it hurts and can pinpoint the area.

nOften described as aching or throbbing.

Visceral Pain

n“Referred” pain: Felt in an area other than where the problem occurs.

nOften described as deep and cramping.

Neuropathic Pain

nInvolves nerve endings: Can occur after an amputation, a shingles outbreak, or as a result of chemotherapy.

nOften described as sharp, stabbing, or shooting pain. Some experience a “pins-and-needles” sensation or numbness.

What causes pain in cancer patients? It can be related to the cancer itself if the disease spreads into soft tissues, organs, bones, or nerves. Chemotherapy, surgery, or radiation can also cause pain. A tingling or shooting sensation, for exam-ple, can develop in the hands or feet following some chemotherapy

(4)

mens. So-called “phantom pain” may follow surgical amputa-tion. Patients weakened by bedrest may experience painful muscle tightness, spasms, or loss of their range of motion.

Talking to Your Doctor About Pain

Pain can be a lonely and subjective experience. Neither knowledgeable clinicians nor caring family members can guess

the intensity of a patient’s pain. It’s up to you to describe your pain as precisely as possible. Here are some tools to do that: Begin by keeping a daily pain diary. When you write it down, you won’t have to rely on your memory. Specific informa-tion will help your medical team give you the best possible treat-ment. These are some of the things to record in your diary:

n Where and when the pain occurs.

n How often and how quickly the pain comes on.

n How long it lasts.

n What makes the pain worse.

n Whether anything alleviates the pain (heat, ice, drugs).

n For how long the painkilling method is effective and how much relief you get.

n How the pain is affecting your quality of life—whether it keeps you from sleeping, eating, walking, working, or exercising.

Note that even when doctors can control chronic pain, some patients may still experience breakthrough pain. These pain flares, which can occur suddenly, can be so intense that they “break through” chronic pain medication. But breakthrough pain can be controlled with short-acting drugs. It’s important to note in your diary how many times a day breakthrough pain occurs, and how well the short-acting medication is working.

(5)

When you see your doctor, describe your pain vividly. The more detailed and precise information you can give your health-care provider, the more it will help him or her treat you quickly and effectively:

n How intense is your pain? The simplest scale is from 0 to 10, with 0 equaling no pain and 10 equaling the worst pain pos-sible. (Make sure your

doctor understands that this is the scale you are using.) By assigning a number to your pain, you are also putting some-thing subjective into concrete, measurable terms that health-care providers understand. For information on other types of pain scales, see page 11.

n Does the intensity of the pain change during the day or night? When is it at its worst? When does it seem to ease?

n What does the pain

feel like? Is it dull, sharp, stabbing, pinching, burning, throb-bing, aching?

Barriers to Pain Management

It may surprise you to know that both health-care providers and patients can erect barriers to effective pain control. Here are some of the fears and facts about pain relief:

Fear: If I complain about pain, my doctor won’t treat my disease as aggressively.

Anyone with chronic pain knows that it can erode the quality of life and grind down the spirit. It’s not unusual for patients in pain to feel depressed, anxious, or angry. Pain can also test the family’s finances. If a patient was the primary breadwinner, his or her role in the family may change. Care-givers may have to take time off from work to help their loved one. A solid family support system is key; support groups can also help both patients and caregivers. Talk to your doctor about forming a good pain management team. Physicians, nurses, psychologists, psychiatrists, clergy, and social workers can all devise strategies to help patients and their families during a stressful time.

(6)

Fact: Pain can actually interfere with treatment. So it’s in your interest to seek relief from this symptom.

Fear: If I take opiates to relieve my pain, I’ll become an addict.

Fact: Addiction among drug abusers is a psychological depen-dence on a drug; that’s different from patients who need drugs physically to relieve pain. A patient can build up a tolerance to a drug, but his or her doctor can prescribe other medications or drug delivery methods to relieve discomfort. Once pain is gone, the need for the drug is gone.

Fear: The drugs will make me constipated, nauseated, and “dopey.”

Fact: Such side effects may occur. But they can be

counteract-ed or minimizcounteract-ed.

Fear: If the medication stops working, there won’t be any other way to relieve my pain.

Fact: There are a number of painkilling drugs and different ways to deliver them. Your doctor can tailor these drugs and methods to your needs, even if they escalate.

Fear: My oncologist is too busy treating cancer to spend time discussing my pain.

Fact: Doctor-patient communication is a two-way street. If your doctor doesn’t ask you about the pain you’re having, speak up!

Treating Cancer Pain

A variety of painkilling drugs are available to help cancer patients. Your doctor can also lessen pain by treating the tumor with chemotherapy, radiation, or surgery. He or she will advise you as to what approach is right for you. You might also want to talk to your health-care team about such tech-niques as relaxation, meditation, biofeedback, hypnosis, or physical therapy, all of which can enhance your treatment and reduce the stress of pain.

(7)

In 1990 the World Health Organization devised a logical approach to using painkilling drugs: More intense pain re-quires more powerful drugs. Adjunct medications (you can think of them as “helper drugs”) can be used at any point along the way. Not only do they relieve pain, they can help other pain-fighting drugs work better.

When pain persists for 12 hours or more per day, long-acting opiates are needed. These drugs include fentanyl (Duragesic), oxycodone (OxyContin), methadone (Dolophine), and slow-release morphine (Avinza and Kadian).

For chronic pain, a long-acting opiate has a number of

advan-Adjunct Medications ANTIDEPRESSANTS

Action: treat tingling and burning pain due to nerve damage (shingles,

for example) and phantom pain; help patients sleep

Examples: amitriptyline (Elavil, Endep), nortriptyline (Aventyl, Pamelor),

doxepin (Sinequan)

Side effects: dry mouth, sedation, anxiety, constipation

ANTICONVULSANTS

Action: treat nerve pain, muscle jerking; sharp, stabbing pains

Examples: gabapentin (Neurontin), carbamazepine (Tegretol), phenytoin

(Dilantin), lamotrigine (Lamictal), oxcarbazepine (Trileptal)

Side effects: dizziness, confusion, possible bone marrow depression,

sedation

CORTICOSTEROIDS

Action: treat bone pain, nausea and vomiting resistant to other

medications, and pain stemming from brain and spinal-cord tumors; boost appetite

Examples: dexamethasone (Decadron), methylprednisolone (Medrol),

prednisone

Side effects: increase in blood sugar, difficulty sleeping, yeast infections;

best to use for the short term or at the lowest dose possible when used long term

LOCAL ANESTHETICS

Action: treat nerve pain associated with shingles, for example Examples: lidocaine (Lidoderm) for topical anesthesia, intravenous

(8)

tages over a short-acting drug: while the short-acting opiate may relieve pain more quickly, it only lasts 3 or 4 hours. The long-acting opiates can be given in the form of tablets to be taken every 8 to 12 hours. Some capsules may be taken once daily. And a long-acting medicated skin patch can give relief for up to 72 hours.

BREAKTHROUGH PAIN

But even when pain is well controlled most of the time, breakthrough pain can still flare up suddenly. Episodes of breakthrough pain usually come on within 1 to 3 minutes, last

Painkillers for Every Level of Pain

Pain Intensity Drug Class Examples Comments

Mild (1–3)* Non-opiates Aspirin Exceeding the recom-Acetaminophen mended dosage may Ibuprofen cause ulcers, kidney Naproxen and liver problems, as Ketoprofen well as bleeding

Moderate Weak opiates Codeine Often combined with (4–6) Propoxyphene non-opiates, which

Hydrocodone limits daily dose; may be used with adjunct medications

Severe (7–10) Strong opiates Morphine Because these drugs Fentanyl are not combined Hydromorphone with non-opiates, Oxycodone their dosage can be

increased for pain relief, as needed

Breakthrough Strong opiates Same as above Immediate-release forms may take up to 45 minutes to provide pain relief; lozenge form takes effect within 15 minutes

* Level of pain intensity rated on a scale of 0 to 10, where 0 equals no pain at all and 10 equals the worst pain possible.

(9)

a short time (perhaps 30 minutes), and can occur several times a day.

There are different types of breakthrough pain:

Incident pain Caused by an activity. For example, persons with hip problems may be comfortable while sitting, but pain strikes when they rise out of a chair.

Spontaneous pain Caused for no apparent reason. This sort of pain can come on very suddenly, even if the patient is doing nothing.

End-of-dose failure Caused when long-acting medication wears off. For example, if you take a 12-hour medication at 8 o’clock in the morning and you notice that every afternoon at 4 o’clock the pain tends to come on, perhaps this is an end-of-dose failure: the drug has lasted only 8 hours instead of the expected 12. Your doctor can recommend a change in dosing to avoid this problem.

Doctors prescribe a number of short-acting opiates for breakthrough pain, including morphine, hydromorphone (Dilaudid), oxycodone (OxyFast, OxyIR), and hydrocodone (Vicodin). These drugs may take up to 45 minutes to become active. Fentanyl citrate, another strong opiate pain reliever, is available as a mild berry-flavored lozenge (Actiq) that begins to take effect within 15 minutes after being placed between the cheek and gum

and moved gently along the inside of the cheek. Dissolving

the lozenge in the mouth delivers fentanyl citrate quickly into the bloodstream. If opioid-related side effects occur, they can be managed or minimized by simply removing the lozenge from the mouth. The product works best when acidic drinks, such as cola or orange juice, are avoided before it is used. Drinking water before using Actiq will increase the amount of saliva in the mouth and help dissolve it. Actiq is the only

(10)

medication approved by the U.S. Food and Drug Administra-tion specifically for breakthrough pain in cancer.

You can use breakthrough medications as a preventive mea-sure, before any activity that usually causes pain. You can also use breakthrough drugs when pain occurs between regularly scheduled doses of long-acting pain medications. And you can certainly use breakthrough medication before or after under-going a painful procedure.

Even for uncontrolled pain, doctors have a strategy: Pain medication can be delivered directly into a vein (intravenously) or under the skin using a portable patient-controlled

analgesia (PCA) pump. A PCA pump operates continuously, dispensing frequent small doses of pain-relieving medication into the body throughout the day and night. If more medica-tion is needed for a flare-up, simply pushing a button to increase the dose temporarily can provide immediate relief. If delivering pain medication into the bloodstream through a vein or under the skin is not sufficient to relieve the severity of

© Medtronic, Inc.

your pain, your doctor may recom-mend intraspinal delivery—dispensing pain medication directly into the spine by injection or continuously through a small pump and a catheter (tube) inserted into the spine. De-pending upon what type of intraspi-nal delivery your doctor thinks is best for you, you may have a pump placed inside your body (see illustration) or the tubing may be attached to an external PCA pump.

Dealing With Side Effects

Constipation It’s probably the most common symptom and one of the most distressing. Doctors define constipation as less

(11)

than three bowel movements a week (although fewer than four or five may be a reduced number for some people). Many cancer patients taking opiates for pain relief experience abdominal or rectal discomfort, straining, and hard stools. They often report a new pain either in their abdomen or back and other digestive symptoms, such as nausea or vomiting. Some patients lose their appetite.

Oddly enough, even in cases of severe constipation, liquid can seep around a blockage, which some patients mistake for diarrhea. They make take an antidiarrheal medication such as loperamide (Lomotil), making the problem worse. With prolonged constipation, other symptoms, such as confusion and urinary retention, can occur.

So it’s very important to use stimulating laxatives whenever opiates are used. (Stool softeners, while helpful, are not enough.) Pharmacies carry a variety of stimulating laxatives, such as senna products and milk of magnesia, that are avail-able over the counter. When using “bulk formers,” such as Metamucil, drinking plenty of fluid is very important. Other-wise, you may become more constipated. A prescription-only powder laxative called MiraLax can help, without the need for large amounts of liquid. Talk with your doctor, nurse, or pharmacist. Let them know if you are having a problem with constipation.

Sedation Excessive sleepiness can be attributed to many causes. If it occurs with the start of a new opiate prescription, it generally disappears within a week. Medications such as antianxiety drugs and antihistamines can also cause sedation. But other, more serious causes, such as organ failure or infec-tion, could be at fault. Obviously, you should talk to your doctor if sedation persists. He or she may recommend switch-ing opiates, since not all of them have the same side effects. Taking adjunct medications (discussed on page 5) may enable patients to reduce the amount of opiate drug needed and thus

(12)

reduce sleepiness. Your doctor may also suggest stimulants, such as donepezil (Aricept) or methylphenidate (Ritalin), or wake-promoting agents, such as modafinil (Provigil), to help you stay awake during the day without affecting normal nighttime sleep. If these measures do not work, often chang-ing to a different pain medication or route of delivery (such as using a skin patch or switching to intravenous or intraspinal administration) might be helpful.

Nausea When patients begin using opiates, they may experi-ence nausea for a short time. Anti-nausea drugs, such as prochlorperazine (Compazine), a scopolamine patch (Trans-derm Scop), or metoclopramide (Reglan), may also help. It’s important to remember that nausea may also be a side effect of constipa-tion, and patients need to maintain regular bowel movements. If nausea continues, talk to your doctor about changing opiates.

Itching This opiate side effect is very common on the scalp, head, and neck. It’s not an allergy, it’s not generally a rash, and it usually lasts only a short time. But if itching persists for more than a few days, you may need to change opiates.

Be Good to Yourself

Using heat, ice, massage, distraction, biofeedback, relax-ation, meditrelax-ation, imagery, and gentle exercise are all ways you can make yourself feel better. Work closely with your health-care team to improve pain management, to mini-mize or prevent side effects, and to improve your quality of life. Enlist the support of your loved ones. Don’t be afraid to speak up! You do not have to suffer pain.

(13)

Frequently Asked

Questions

Q

What’s the best way for a patient to “rate” his or

her pain?

A

Depending on the person, his or her cultural background,

age, or other factors, some techniques work better than others. Earlier we talked about the 0 to 10 scale, with 0 equaling no pain and 10 equaling the worst pain possible. Another scale that works, especially with younger patients or those hampered by language problems, shows a series of expressive faces with differing degrees of discomfort (see below). Sometimes a thermometer-type scale is used. It’s best if one of these stan-dardized measures is used, but some patients report their pain in a scale of their own devising: through notes on the piano, or even types of fabric. The most important thing is to find the

(14)

way that most accurately describes how you are feeling, whether through words or pictures. The better you can pin-point your pain, its location, and its character, the better your doctor can help relieve that pain.

Q

I see several doctors for my treatment. Which one

should prescribe pain medication?

A

Your medical oncologist knows which cancer treatments

you are using and which pain medications would be best for your particular case. He or she will follow the profession’s pain guidelines.

Q

What’s the advantage of having a “pain

manage-ment team”?

A

Many hospitals and group practices employ a

multidisci-plinary group of health-care providers that uses the team approach to managing a patient’s pain. These teams include pain specialists, physical therapists, nurse practitioners, psy-chologists or psychiatrists, and people who specialize in “complementary care”—techniques such as meditation, hypnosis, or massage. This approach allows doctors to con-centrate on treating the cancer while the team manages pain and related symptoms.

Q

Is it safe for a cancer patient to have a massage?

A

Generally, yes. Massage can help with muscle tenderness

that results from too much bed rest. It can relax a patient and reduce the stress of chronic pain. Human touch is soothing, and we all need that. However, vigorous massage is not recommended. The massage therapist must be aware of and avoid tender surgical areas, tumor sites, and any other sensi-tive spots on a patient’s body. In some cases a massage may make matters worse, so it’s a good idea to first discuss getting a massage with your doctor or pain management team.

(15)

Q

I started experiencing pain long after I finished

my chemotherapy. Is this normal?

A

It’s not uncommon to have peripheral neuropathy—

numbness or tingling in the legs or arms, hands, or feet— well after treatment. But only your doctor can determine whether this is latent nerve damage from chemotherapy or pain due to a different problem. Consider asking for a neurological examination.

Q

I have severe pain in the morning when I awaken.

Can I take both my long-acting medication and my short-acting breakthrough medication at the same time?

A

Yes, each of these drugs has a different function in pain

relief. The long-acting medications take many hours to work but provide sustained relief. The short-acting medications work much more quickly but will be eliminated from your body within 3 to 4 hours.

Q

I need to take my short-acting pain medicine more

than 4 times a day. Is this OK?

A

You may need an adjustment in either your long- or

short-acting drugs or both. Talk with your doctor about how com-fortable you are most of the day and whether the break-through medicine is reducing your pain.

Q

My short-acting pain medicine doesn’t seem to

help. What should I do?

A

Record your pain intensity before you take your

break-through pain medication and again an hour later. If there is little or no change in your pain score, talk with your doctor. He or she may recommend either a change in the strength of your current medication or a new drug.

(16)

Q

Are there any risks to taking pain-killing drugs for

long periods of time?

A

Side effects such as nausea or constipation might be

considered “minor” risks—they can be dealt with and they aren’t life threatening. But there are potentially larger risks: Some patients may take it upon themselves to combine over-the-counter drugs with prescription medications, and that could cause problems. For instance, regularly taking more more than 8 tablets a day of acetaminophen (Tylenol, for example) can cause liver damage. If you are taking an opiate such as morphine or oxycodone and you also take aspirin or a non-aspirin pain-reliever, such as acetaminophen, ibuprofen (Advil and Motrin), or naproxen (Aleve and Naprosyn), to relieve headaches and other body aches, you may be increas-ing your risk for organ damage. To be safe, talk to your doctor and pharmacist about combining any drugs.

(17)

acute pain Pain that is experienced immediately when the body is injured. Once healing occurs, acute pain generally disappears.

adjunct medications “Helper drugs” that not only relieve pain but can help other pain-fighting drugs work better. breakthrough pain Pain flares that come on suddenly and “break through” chronic pain medication. These episodes can be controlled with short-acting painkillers.

chronic pain Pain that continues beyond healing of a bodily injury. Pain is considered chronic if it is present every day or nearly every day for more than 3 months.

end-of-dose failure A type of breakthrough pain, caused when long-acting medication wears off.

incident pain A type of breakthrough pain, caused by activity. For example, people with hip problems may be comfortable while sitting, but pain strikes when they rise up from a chair.

long-acting opiates Drugs used for pain that persists 12 hours or more each day.

patient-controlled analgesia (PCA) The delivery of painkillers directly into the base of the spine, under the skin of the abdomen, or through an intravenous line. A PCA pump operates continuously; if more medication is needed, the patient simply pushes a button to deliver a short burst. short-acting opiates Drugs taken for sudden flare-ups or breakthrough pain.

spontaneous pain A type of breakthrough pain, caused for no apparent reason. Can come on very suddenly, even if the patient is doing nothing.

(18)

Resources

CANCERCARE, Inc. 275 Seventh Avenue New York, NY 10001 212.712.8080 1.800.813.HOPE (4673) E-mail: teled@cancercare.org Website: www.cancercare.org

The American Cancer Society

1.800.ACS.2345

Website: www.cancer.org

American Pain Foundation

201 North Charles Street, Suite 710 Baltimore, MD 21201-4111 1.888.615.PAIN (7246)

E-mail: info@painfoundation.org Website: www.painfoundation.org

American Society of Clinical Oncology

Website: www.peoplelivingwithcancer.org

Department of Pain Management and Palliative Care Beth Israel Medical Center, New York

Website: www.stoppain.org

National Cancer Institute (NCI)

Cancer Information Service 1.800.4.CANCER

The NCI website offers three excellent publications online:

Pain

http://cancer.gov/cancerinfo/pdq/supportivecare/pain

Understanding Cancer Pain

http://cancer.gov/cancerinfo/understanding-cancer-pain

Pain Control

(19)

The information presented in this patient booklet is provided for your general information only. It is not intended as medical advice and should not be relied upon as a substitute for consultations with qualified health professionals who are aware of your specific situation. We encourage you to take informa-tion and quesinforma-tions back to your individual health-care provider as a way of

(20)

National Office Services

References

Related documents

If you need further pain medications after that time, contact your primary care doctor or you pain specialists. Taking

It is important that, even when the pain has subsided, you take the right amount of pain relief to control your pain.. When the pain reduces, or you no longer need the drugs,

Ben Schepf (cousin of Jason & Shannon Frugia) Nolan Shepherd (friend of Charis & Jon Outlaw) Blake Singleton (son of Mike & Charlotte Singleton) Jacob Vogel (grandson

Under relatively mild conditions, an entire class of information criteria that allow the use of both proper and improper priors behaves asymptotically as classical Bayesian methods

Due to the increasing diversity found within the United States, and the lack of diversity found within the occupational therapy profession, are occupational therapists

You can expect some pain for a while and you will need pain relief medication for one or two weeks after discharge from hospital, however this varies from person to person.. You

File with testimonies of deliverance marine kingdom members to control the enemy and play into my husband ruling over my life to pharaoh had originally planned only.. High and

Chimney Rock “Tomahawk” Vineyard Cabernet Sauvignon 1 .5L (’14 Stags Leap District,