Pain remains one of the major fears of cancer patients.
Adequate pain control takes time but can be achieved in a majority of
In the minority of cases when pain cannot be eliminated, it can
be controlled so as to allow the patient to perform activities
important to him or her.
Pain is a totally subjective experience. Pain is "whatever the
experiencing person says it is, existing whenever he says it does."
The cause of pain cannot always be determined.
Pain management can be a frustrating and stress provoking
experience for the patient and the individuals who attempt to provide
Fear of addiction is a barrier to adequate pain management.
Addiction occurs when all thoughts are consumed in when the next dose
is or how to get it, it is a psychological dependence. Far less than
1% of cancer patients receiving narcotics will become addicted. The
overwhelming majority of people stop taking narcotics when the pain
Physical dependence is often confused with addiction. After
repeated administration of a narcotic, withdrawal symptoms occur when
it is not taken.
Tolerance occurs frequently in cancer patients taking
narcotics. After repeated administrations of a narcotic, a given
dose begins to lose its effectiveness. For equal effectiveness,
increase the dose or decrease the interval. When the patient is
taking morphine for pain, it is important to note that there is no
ceiling dose due to tolerance. Therefore, cancer patients may be on
very high doses of this drug.
Health care providers are often concerned about the respiratory
depressive effects of high doses of narcotics, however, tolerance to
narcotics usually assures tolerance to respiratory depressant effects
of the drugs.
Sources of pain in the cancer patient include pressure of the
tumor on a nerve , invasion of a bone, obstruction of the GI or GU
Anxiety and depression are often associated with physical pain.
Pain is seldom purely psychogenic or purely physical.
Pain assessment can be difficult since it is a subjective
assessment, only the person with the pain can assess it.
Acute pain is usually associated with accepted expressions of
pain ( increased heart rate and blood pressure, moaning,
sleeplessness, inability to work, absence of laughter)
Chronic pain may have no observable characteristics, the
patient may "appear" comfortable and it is important for the
caregiver and health care provider to believe the patient's
complaints of pain.
The most commonly used pain assessment scale is a scale of 0 to
10, with 0 being no pain at all and 10 being the worst pain
Pain assessment should include location and duration of pain,
characteristics (throbbing, sharp, steady, dull, aching, stabbing),
relieving and aggravating factors.
Assess current pain medication regimens including effectiveness
and tolerance of side effects.
Drug therapy is the cornerstone of cancer pain management. It
must be individualized to each patient.
The World Health Organization has developed a three step
hierarchy which is proven to be effective in relieving pain in about
90% of cancer patients:
use the simplest dosage schedules and least invasive pain
management modalities first
for mild to moderate pain use aspirin (unless
contraindicated), acetaminophen, or non- steroidal
anti-inflammatory drugs (Step 1)
when pain persists or increases, add an opioid (Step 2)
if pain continues or becomes moderate to severe, increase the
opioid potency or dose (Step 3)
schedule doses on a regular schedule to maintain the level of
drug that will help prevent recurrence of pain
administer medications for long-term cancer pain on an
around-the-clock basis (usually sustained release preparations)
with additional doses for breakthrough pain as needed.
All patients on narcotics should be on a bowel regimen to
prevent constipation (see Constipation module for sample bowel
When patients cannot tolerate oral routes of medication,
consider rectal administration, IV infusion, subcutaneous infusion,
patient controlled analgesia by pump or intraspinal narcotic
Non-pharmacologic interventions may include relaxation
techniques, distraction, hypnosis, topical stimulation of skin
(heat/cooling, massage, vibration, menthol, accupuncture).