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Supportive care statement for Patients


Pain (PDQ®)

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General Information About Pain
Assessment of Pain
Using Drugs to Control Pain
Radiation Therapy for Pain
Other Treatments for Pain
Treating Pain in Older Patients
Changes to This Summary (04/10/2014)
About This PDQ Summary
Questions or Comments About This Summary
Get More Information From NCI

General Information About Pain

Cancer or treatment for cancer may cause you to feel pain.

Tumors, surgery, chemotherapy, or radiation therapy may cause you pain. Patients with advanced cancer have more severe pain, and many cancer survivors have pain that continues after cancer treatment ends.

Pain control can improve your quality of life.

Pain can be controlled in most patients with 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.

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.

This summary is about ways to control cancer pain in adults, including the following:

Assessment of Pain

You and your healthcare team work together to assess cancer pain.

It's important that the cause of the pain is found and treated quickly. The first step in controlling pain is to assess and measure it. 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:

This information will be used to decide how to help relieve your pain. This may include drugs or other treatments. Your healthcare team will work with you to decide how much pain you can stand and how much improvement you should expect. After pain control is begun, the doctor will continue to assess how well it is working for you and make changes if needed.

The family or caregiver may be asked to give answers for a patient who has a problem with speech, language, or understanding.

A physical exam and tests will be done to help plan pain control.

The assessment will include the following:

Your healthcare team will also assess your mental and spiritual needs.

Using Drugs to Control Pain

The doctor will prescribe drugs based on whether the pain is mild, moderate, or severe.

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 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 drug. The doctor will adjust the drug dose for your needs.

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to relieve mild pain.

NSAIDs help relieve mild pain. They may be given with opioids for moderate to severe pain. Acetaminophen also relieves pain, although it does not have the anti-inflammatory effect that aspirin and other NSAIDs do.

Patients, especially older patients, who are taking acetaminophen or NSAIDs need to be closely watched for side effects. See Treating Pain in Older Patients for more information. Most NSAIDs affect the blood platelets so that it takes longer for blood to clot and stop any bleeding. Aspirin should not be given to children to treat pain.

Opioids may be used to relieve moderate to severe pain.

Opioids work very well for the relief of moderate to severe pain. Some patients with cancer pain stop getting pain relief from opioids during long-term therapy. 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). Opioid doses can be safely increased by your doctor as needed for your pain, without causing addiction.

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.

Most patients with cancer pain will need to receive opioids on a regular schedule.

Receiving opioids on a regular schedule helps manage the pain and keeps it from getting worse. The amount of time between doses depends on which opioid is being used. 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, it can be overcome by increasing the dose or changing to another opioid.

Sometimes, the opioid dose needs to be decreased or the opioid is stopped. This may be done when you no longer have pain because of treatments such as nerve blocks or radiation therapy. The doctor may also decrease the dose if it makes you too sleepy or if your kidney function decreases.

Opioids may be given in different ways.

Opioids may be given by the following ways:

Common side effects are nausea, sleepiness, and constipation.

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:

Sleepiness and nausea 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. The 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 added to help treat your pain.

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 are drugs that are sometimes used when cancer has spread to the bones. They are used to decrease pain and reduce risk of broken bones. However, bisphosphonates sometime 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.

The use of cannabinoids given with pain medicine is being studied for cancer-related pain.

Radiation Therapy for Pain

Radiation therapy may be used to relieve bone pain.

Radiation therapy is used to relieve pain in patients with 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 single or divided dose radiation therapy may depend on how convenient the treatments are and how much they cost.

Stereotactic body radiation therapy

Stereotactic body radiation therapy (SBRT) is a type of external radiation therapy that uses special equipment to position a patient and give a single large dose of radiation to a tumor. This type of radiation therapy causes less damage to nearby normal tissue. SBRT may be used to treat tumors that have spread to the bone, especially spinal tumors. SBRT may also be used to treat areas that have already received radiation.

Radiopharmaceuticals

Radiopharmaceuticals are drugs that contain 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 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.

Radiofrequency ablation

Radiofrequency ablation uses a special probe with tiny electrodes to kill cancer cells. Sometimes the probe is inserted directly through the skin and only local anesthesia is needed. In other cases, the probe is inserted through an incision in the abdomen. This is done in the hospital with general anesthesia. This procedure may relieve pain in patients who have cancer that has spread to the bone. More studies are needed to learn about possible risks and benefits.

Radiation therapy with bisphosphonates

The use of radiation therapy given together with bisphosphonates is being studied in patients with cancer that has spread to the bone. More studies are needed to find out if this relieves pain better than radiation therapy alone.

Other Treatments for Pain

When radiation therapy does not relieve pain, other treatments may be used.

Other therapies can be used along with drugs and radiation therapy to manage pain. You can help decide which methods work best to relieve your pain.

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 implant 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.

Physical treatments, such as heat, cold, and exercise, can help relieve pain.

Physical methods to treat weakness, muscle wasting, and muscle and bone pain include the following:

Integrative treatments include massage therapy, acupuncture, and music.

Integrative therapy combines conventional (standard) medical treatment with complementary and alternative (CAM) therapies that have been shown to be safe and to work. CAM therapies treat the mind, body, and spirit.

Massage therapy

Massage therapy has been studied as supportive care in managing pain related to cancer. Massage may help you relax and improve your mood. Studies show that massage therapy may do the following:

Massage has a direct effect on body tissues and should be used with care in patients with cancer. Studies show that massage therapy may be safe in patients with cancer. However, when massage is used in cancer patients, the following precautions should be taken:

(For more information on massage, see Exercise 2 in the following section.)

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 manage pain, including pain related to cancer. See the PDQ summary on Acupuncture for more information.

Music

Music has been used to relieve pain and anxiety caused by cancer and cancer treatments. Studies have reported that music may work on areas of the brain that increase pleasant feelings and decrease unpleasant responses. Your favorite music may help you the most. Music is more helpful if you begin listening before a procedure than it is during or after a procedure. Music may be used along with pain medicine.

There are two main types of music treatments—music therapy and music medicine:

The use of music for pain related to cancer is still being studied.

Music is also used in relaxation exercises.

Some methods help relieve pain by changing how you think about pain and teaching you ways to relax.

Treatments that change how you think about pain and respond to it are also helpful in treating pain. These are called psychological interventions. Psychological interventions give you a sense of control and teach you coping skills to deal with the disease and its symptoms. Staying calm when you feel pain may keep you more comfortable. You may try several methods and choose one or more to use regularly.

Treating Pain in Older Patients

Older patients with cancer pain may have special needs.

Some problems are more likely in older patients. For caregivers of older patients, the following possible problems should be kept in mind:

Having 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.

Problems with vision, hearing, movement, or ability to communicate

Older patients may need simpler and more frequent tests to find out how much pain they are having.

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.

Effects of opioids

Older patients may be more sensitive to the effects of opioids. This can give better pain relief that lasts longer. The dose of the opioids may need to be adjusted.

Patient-controlled pain relief

Patient-controlled pain relief must be used carefully in older patients, since drugs are slower to leave the body and older patients are more sensitive to the side effects.

Changes in living arrangements

When older patients move (for example, from hospital to home or nursing home), their needs for pain control may change. These needs should be checked so that pain control methods can be adjusted if needed.

Changes to This Summary (04/10/2014)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Editorial changes were made to this summary.

About This PDQ Summary

About PDQ

Physician Data Query (PDQ) is the National Cancer Institute's (NCI's) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish.

PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH.

Purpose of This Summary

This PDQ cancer information summary has current information about the causes and treatment of pain. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Date Last Modified") is the date of the most recent change.

The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials are listed in PDQ and can be found online at NCI's Web site. Many cancer doctors who take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237).

Permission to Use This Summary

PDQ is a registered trademark. The content of PDQ documents can be used freely as text. It cannot be identified as an NCI PDQ cancer information summary unless the whole summary is shown and it is updated regularly. However, a user would be allowed to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks in the following way: [include excerpt from the summary].”

The best way to cite this PDQ summary is:

National Cancer Institute: PDQ® Pain. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/supportivecare/pain/Patient. Accessed <MM/DD/YYYY>.

Images in this summary are used with permission of the author(s), artist, and/or publisher for use in the PDQ summaries only. If you want to use an image from a PDQ summary and you are not using the whole summary, you must get permission from the owner. It cannot be given by the National Cancer Institute. Information about using the images in this summary, along with many other images related to cancer can be found in Visuals Online. Visuals Online is a collection of more than 2,000 scientific images.

Disclaimer

The information in these summaries should not be used to make decisions about insurance reimbursement. More information on insurance coverage is available on Cancer.gov on the Coping with Cancer: Financial, Insurance, and Legal Information page.

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Physicians version: CDR0000062738
Date last modified: 2014-04-10

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