Pain is one of the most common symptoms in cancer patients. Pain can be caused by cancer, treatment for cancer, or a combination of factors. Tumors, surgery, intravenous chemotherapy, radiation therapy, targeted therapy, supportive care therapies such as bisphosphonates, and diagnostic procedures may cause you pain.
Younger patients are more likely to have cancer pain and pain flares than older patients. Patients with advanced cancer have more severe pain, and many cancer survivors have pain that continues after cancer treatment ends.
This summary is about ways to control cancer pain in adults.Pain control can improve your quality of life.
Pain can be controlled in most patients who have cancer. Although cancer pain cannot always be relieved completely, there are ways to lessen pain in most patients. Pain control can improve your quality of life all through your cancer treatment and after it ends.Pain can be managed before, during, and after diagnostic and treatment procedures.
Many diagnostic and treatment procedures are painful. It helps to start pain control before the procedure begins. Some drugs may be used to help you feel calm or fall asleep. Treatments such as imagery or relaxation can also help control pain and anxiety related to treatment. Knowing what will happen during the procedure and having a relative or friend stay with you may also help lower anxiety.Different cancer treatments may cause specific types of pain.
Patients may have different types of pain depending on the treatments they receive, including:
Pain that is severe or continues after cancer treatment ends increases the risk of anxiety and depression. Patients may be disabled by their pain, unable to work, or feel that they are losing support once their care moves from their oncology team back to their primary care team. Feelings of anxiety and depression can worsen cancer pain and make it harder to control.Each patient needs a personal plan to control cancer pain.
Each person's diagnosis, cancer stage, response to pain, and personal likes and dislikes are different. For this reason, each patient needs a personal plan to control cancer pain. You, your family, and your healthcare team can work together to manage your pain. As part of your pain control plan, your healthcare provider can give you and your family members written instructions to control your pain at home. Find out who you should call if you have questions.
It's important that the cause of the pain is found early and treated quickly. Your healthcare team will help you measure pain levels often, including at the following times:
To learn about your pain, the healthcare team will ask you to describe the pain with the following questions:
Your healthcare team will also take into account:
This information will be used to decide how to help relieve your pain. This may include drugs or other treatments. In some cases, patients are referred to pain specialists or palliative care specialists. Your healthcare team will work with you to decide whether the benefits of treatment outweigh any risks and how much improvement you should expect. After pain control is started, the doctor will continue to assess how well it is working for you and make changes if needed.
A family member or caregiver may be asked to give answers for a patient who has a problem with speech, language, or understanding.Physical and neurological exams will be done to help plan pain control.
The following exams will be done:
Your healthcare team will also assess your psychological, social, and spiritual needs.
Your doctor will prescribe drugs to help relieve your pain. These drugs need to be taken at scheduled times to keep a constant level of the drug in the body to help keep the pain from coming back. Drugs may be taken by mouth or given in other ways, such as by infusion or injection.
Your doctor may prescribe extra doses of a drug that can be taken as needed for pain that occurs between scheduled doses of the drug. The doctor will adjust the drug dose for your needs.
A scale from 0 to 10 is used to measure how severe the pain is and decide which pain medicine to use. On this scale:
Acetaminophen and NSAIDs help relieve mild pain. They may be given with opioids for moderate to severe pain.
Pain relievers of this type include:
Patients, especially older patients, who are taking acetaminophen or NSAIDs need to be closely watched for side effects. See Treating Cancer Pain in Older Patients for more information.Opioids are used to relieve moderate to severe pain.
Opioids work very well to relieve moderate to severe pain. Some patients with cancer pain stop getting pain relief from opioids if they take them for a long time. This is called tolerance. Larger doses or a different opioid may be needed if your body stops responding to the same dose. Tolerance of an opioid is a physical dependence on it. This is not the same as addiction (psychological dependence).
Since 1999, there have been four times the number of prescriptions written for opioids and four times the number of deaths caused by drug overdose in the United States. Although most patients who are prescribed opioids for cancer pain use them safely, a small percentage of patients may become addicted to opioids. Your doctor will carefully prescribe and monitor your opioid doses so that you are treated for pain safely.
There are several types of opioids:
The doctor will prescribe drugs and the times they should be taken in order to best control your pain. Also, it is important that patients and family caregivers know how to safely use, store, and dispose of opioids.Most patients with cancer pain will need to receive opioids on a regular schedule.
Receiving opioids on a regular schedule helps relieve the pain and keeps it from getting worse. The amount of time between doses depends on which opioid you are using. The correct dose is the amount of opioid that controls your pain with the fewest side effects. The dose will be slowly adjusted until there is a good balance between pain relief and side effects. If opioid tolerance does occur, the dose may be increased or a different opioid may be needed.Opioids may be given in different ways.
Opioids may be given by the following ways:
Your doctor will discuss the side effects with you before opioid treatment begins and will watch you for side effects. The following are the most common side effects:
Nausea and drowsiness most often occur when opioid treatment is first started and usually get better within a few days.
Opioids slow down the muscle contractions and movement in the stomach and intestines, which can cause hard stools. To keep the stool soft and prevent constipation, it's important to drink plenty of fluids. Unless there are problems such as a blocked bowel or diarrhea, you will be given a treatment plan to follow to prevent constipation and information on how to avoid problems with your intestines while taking opioids.
Other side effects of opioid treatment include the following:
Talk with your doctor about side effects that bother you or become severe. Your doctor may decrease the dose of the opioid, change to a different opioid, or change the way the opioid is given to help decrease the side effects. See the following PDQ summaries for more information about coping with these side effects:
Other drugs may be given while you are taking opioids for pain relief. These are drugs that help the opioids work better, treat symptoms, and relieve certain types of pain. The following types of drugs may be used:
There are big differences in how patients respond to these drugs. Side effects are common and should be reported to your doctor.
Bisphosphonates (pamidronate, zoledronic acid, and ibandronate) are drugs that are sometimes used when cancer has spread to the bones. They are given as an intravenous infusion and combined with other treatments to decrease pain and reduce risk of broken bones. However, bisphosphonates sometimes cause severe side effects. Talk to your doctor if you have severe muscle or bone pain. Bisphosphonate therapy may need to be stopped.
The use of bisphosphonates is also linked to the risk of bisphosphonate-associated osteonecrosis (BON). See the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information.
Denosumab is another drug that may be used when cancer has spread to the bones. It is given as a subcutaneous injection and may help prevent and relieve pain.
Most cancer pain can be controlled with drug treatments, but some patients have too many side effects from drugs or have pain in a certain part of the body that needs to be treated in a different way. You can talk to your doctor to help decide which methods work best to relieve your pain. These other treatments include:Nerve blocks
A nerve block is the injection of either a local anesthetic or a drug into or around a nerve to block pain. Nerve blocks help control pain that can't be controlled in other ways. Nerve blocks may also be used to find where the pain is coming from, to predict how the pain will respond to long-term treatments, and to prevent pain after certain procedures.Neurological treatments
Surgery can be done to insert a device that delivers drugs or stimulates the nerves with mild electric current. In rare cases, surgery may be done to destroy a nerve or nerves that are part of the pain pathway.Cordotomy
Cordotomy is a less common surgical procedure that is used to relieve pain by cutting certain nerves in the spinal cord. This blocks pain and also hot/cold feelings. This procedure may be chosen for patients who are near the end of life and have severe pain that cannot be relieved in other ways.Palliative care
Certain patients are helped by palliative care services. Palliative care providers may also be called supportive care providers. They work in teams that include doctors, nurses, mental health specialists, social workers, chaplains, pharmacists, and dietitians. Some of the goals of palliative care are to:
See the PDQ summary on Planning the Transition to End-of-Life Care in Advanced Cancer for more information.Radiation therapy
Radiation therapy is used to relieve pain in patients with skin lesions, tumors, or cancer that has spread to the bone. This is called palliative radiation therapy. It may be given as local therapy directly to the tumor or to larger areas of the body. Radiation therapy helps drugs and other treatments work better by shrinking tumors that are causing pain. Radiation therapy may help patients with bone pain move more freely and with less pain.
The following types of radiation therapy may be used:External radiation therapy
External radiation therapy uses a machine outside the body to send high-energy x-rays or other types of radiation toward the cancer. External radiation therapy relieves pain from cancer that has spread to the bone. Radiation therapy may be given in a single dose or divided into several smaller doses given over a period of time. The decision whether to have a single or divided dose may depend on how easy it is to get the treatments and how much they cost. Patients may have a pain flare (a temporary worsening of pain in the treated area) after receiving palliative radiation therapy for cancer that has spread to the bone, but this side effect is only temporary.Radiopharmaceuticals
Radiopharmaceuticals are drugs that have a radioactive substance that may be used to diagnose or treat disease, including cancer. Radiopharmaceuticals may also be used to relieve pain from cancer that has spread to the bone. A single dose of a radioactive agent injected into a vein may relieve pain when cancer has spread to several areas of bone and/or when there are too many areas to treat with external radiation therapy.Physical medicine and rehabilitation
Patients with cancer and pain may lose their strength, freedom of movement, and ability to manage their daily activities. Physical therapy or occupational therapy may help these patients.
Physical medicine uses physical methods, such as exercise and machines to prevent and treat disease or injury.
Physical methods to treat weakness, muscle wasting, and muscle and bone pain include the following:
Some patients may be referred to a physiatrist (a doctor who specializes in physical medicine) who can develop a personal plan for them. Some physiatrists are also trained in procedures to treat and manage pain.Complementary therapies
Complementary and alternative therapies combined with standard treatment may be used to treat pain. They may also be called integrative therapies. Acupuncture, support groups, and hypnosis are a few integrative therapies that have been used to relieve pain.Acupuncture
Acupuncture is an integrative therapy that applies needles, heat, pressure, and other treatments to one or more places on the skin called acupuncture points. Acupuncture may be used to control pain, including pain related to cancer. See the PDQ summary on Acupuncture for more information.Hypnosis
Hypnosis may help you relax and may be combined with other thinking and behavior methods. Hypnosis to relieve pain works best in people who are able to concentrate and use imagery and who are willing to practice the technique.Support groups
Support groups help many patients. Religious counseling may also help by offering spiritual care and social support.
For more information, see a list of PDQ summaries about Integrative, Alternative, and Complementary Therapies.
Some problems are more likely in patients 65 years and older. For caregivers of these patients, the following should be kept in mind:Lower doses
Pain medicine should be started at lower doses in older patients and adjusted slowly to allow for differences in their pain threshold and the ways they respond and function.
Older patients may need lower doses of opioids since they are more sensitive to their effects. Side effects of opioids, such as drowsiness and constipation, are more likely in older patients.
Opioid doses may need to be lower in older patients for either acute or chronic pain. Lower doses may give older patients better pain relief that lasts longer than in younger patients.
Meperidine, and some drugs often used with opioids, are not given to certain older patients.More than one chronic disease and source of pain
Older patients may have more than one chronic disease and take several drugs for different conditions. This can increase the risk of drug interactions. Drugs taken together can change how they work in the body and can affect the patient's chronic diseases.Side effects of nonsteroidal anti-inflammatory drugs (NSAIDs)
Side effects of NSAIDs, such as stomach and kidney damage, memory problems, constipation, and headaches, are more likely in older patients.
NSAIDs and tricyclic antidepressants are not given to certain older patients. When NSAIDs are used, older patients should be watched closely for side effects. Other drugs may be given with NSAIDs to help protect the stomach.
To avoid side effects from certain NSAIDs, some patients may be given the following:
In older patients there is a risk of undertreatment (not receiving enough treatment). This may be caused by the following:
Poor pain control may cause other problems in older patients, including the following:
Treating depression in patients can also help with pain treatment.
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