Managing Cancer Pain

Talking to Your Doctor About Pain

It’s important that you report any pain or discomfort you experience to your health care team right away—don’t wait for your next appointment. Doing so will improve your quality of life and allow you to stick with your treatment plan.

Following are key points that you should discuss with a member of your health care team:

• Where the pain occurs. Is the pain in one or multiple locations in your body?
• The nature of the pain. Is it dull, sharp, stabbing, burning or pinching?
• When the pain occurs. Was there a specific event that preceded the occurrence of the pain?
• How long it has lasted. When did it first occur?
• How strong it is. How would you rate the strength of the pain on a scale of 1 to 10, with 1 being the least amount of pain and 10 being the most intense?
• Whether anything makes the pain worse. Does standing or sitting make it hurt more? Is it worse at night and better during the day?
• Whether anything makes the pain better. Do you feel better if you apply ice or heat to the area? Does it help if you lie down or walk around? Do over-the-counter medications help?
• Whether the pain is “breakthrough.” Is your pain normally well-controlled but has now flared, in spite of the medication you are taking?
• How the pain is affecting your everyday life. Is your sleep or appetite affected? Are you able to perform your normal activities?

There are a number of options for pain relief, including prescription and over-the-counter medications. It’s important to talk to a member of your health care team before taking any over-the-counter medication to determine if it is safe and will not interfere with your treatment.

Fear of becoming addicted is common among people who are prescribed medications for cancer pain. This fear can keep people from talking with their health care team about the pain they are experiencing. It can also keep them from taking medications as prescribed. It’s important to talk with your health care team about any concerns you may have. This will help ensure that pain medications are used safely and effectively.

Medications to treat pain include:

Non-opioids. These include over-the-counter medications such as acetaminophen (Tylenol and others) and aspirin or aspirin-like pain relievers (such as Advil or Aleve).

Opioids. Opioids—such as morphine, hydromorphone, oxycodone, fentanyl and methadone—are the strongest pain relievers available.

Cannabinoids. Cannabinoids contain the active ingredient found in marijuana, and many states have legalized medical marijuana for chronic pain.

Medicines used to treat other conditions. Some antidepressants or seizure medications are also effective against pain in certain situations.

Important Considerations When Opioids Are Used to Treat Cancer Pain

During cancer treatment, there are certain situations in which opioid medications provide the best pain relief if used very carefully in collaboration with your health care team. Opioids can be highly addictive, and so following your doctor’s exact instructions is very important.

Certain personal and family history characteristics must be brought to the attention of your health care team. It is vital to share this information with the prescribing provider if you are not specifically asked:

• If you or a close blood relative has had alcohol or drug dependence, experienced excessive anxiety or depression (whether treated or not), or if a close blood relative died by suicide.

• If you have had trouble reducing the dose or stopping opioids or sedatives in the past.

• If you have used pain medicine more than prescribed, used medications prescribed for someone else, received pain medication through non-medical sources or had multiple prescriptions from different providers at the same time.

When used at the proper doses at the prescribed times and for only the advised duration, opioids can be used safely and effectively. Common side effects such as constipation, sedation (drowsiness or sleepiness) or tremors can be minimized when your health care team is aware of the effect the medication has on you.

When it is time to stop any type of pain medication, your healthcare team can help you reduce the dose slowly so that the dose reduction is comfortable and safe.

Managing Bone Pain

Many types of cancer have the potential to metastasize (spread) to the bone. If this occurs, the resulting collection of cancer cells is called a bone metastasis. This can cause bone pain and increase the risk of complications, including weakening of the bone, fractures and high calcium levels in the blood (which can further damage bones).

Usually, the first step in treating bone complications is to get any bone pain that exists under control. Over-the-counter medications include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, naproxen and ibuprofen.

If the pain is severe, opioids are sometimes prescribed. The right pain medication, dose and schedule can relieve pain without causing further problems.

It’s important that you tell your doctor immediately if you have severe back pain, or back pain that develops or changes rapidly. This may mean that a bone metastasis is pressing against your spinal cord. If that is the case, urgent medical care is required. Treatment options for this condition include steroids, radiation and surgery.

Asking questions at the time you are prescribed any new medicine—including pain medicine—will open the lines of communication with your health care team and help you get the most from the treatment.

Following are a few questions that you can ask. There are likely others, based on your specific situation. Ask your doctor or another member of your health care team to share any other guidance they may have.

How does this medicine work? As an educated consumer, having a basic understanding of the medicine’s “mechanism of action” (the way it works) is good information to have.

How should I take this medicine? Some medications should be taken with food, while others work better if taken on an empty stomach. Some may need to be taken with a certain amount of liquid, or they may be most effective if taken at a specific time of day.

What are the possible side effects of this medicine? All medication can cause side effects. Ask your doctor or another member of your health care team about the possible side effects you may experience, and their potential seriousness.

What should I do if I miss a dose? Even with all of your best efforts, you may occasionally forget to take your medication on time. At the time of prescription, ask your doctor what you should do if this happens.

Can I still take my other medicine? Make sure your doctor has a list of all of the medicines you are taking, including over-the-counter medication, vitamins and supplements. They may recommend a change or adjustment. Your doctor can also provide guidance on how to “space” your pills throughout the day.

Should I change my diet? Ask if there are any specific foods, drinks or spices that you should avoid or limit while taking the prescribed medicine. Also ask if there is any particular type of diet plan that would be beneficial for you to follow.

After your initial discussion with your doctor, be sure to contact a member of your health care team if anything is unclear or if you need additional information. They want to be of help to you.

It is important to stay on schedule with your prescribed pain medication. The following tips may help. Note: Pain medicines taken by mouth come in different forms—pills, tablets and capsules. The term “pill” is used in this section to refer to all forms of oral medication.

• Ask your doctor if it’s appropriate for you to be prescribed a 60- or 90-day supply of pills, which minimizes the risk of you running out of your medication.

• Set an alarm on your watch, smartphone or computer to remind you when it’s time to take your pill. You could also try a medication reminder app. There are a number of free and highly-rated apps that can be easily found by a quick internet search. (A low-tech approach could be as simple as keeping a running list of the date and time each pill was taken.)

• Note the date you will need to refill your prescription (a few days before you run out of pills) and create a reminder in a place you are sure to see it.

• When you pick up a new supply of pills, check the label for the number of refills that remain on your prescription. If there are zero refills, call your doctor’s office to renew your prescription (or ask your pharmacy to do that for you).

• Sign up for any reminder services that your pharmacy offers. Many pharmacies will send you text messages and/or place automated calls when a refill or renewal is due.

• Consider using your insurance company’s mail service pharmacy. You can receive convenient home delivery if your specific medication is part of this service, often in supply amounts larger than 30 days.

Pharmacists are highly accessible members of the health care community. While pharmacists are often employed by independent or chain drug stores, they also work in clinics, hospitals and specialty pharmacies (organizations which manage the dispensing, reimbursement, resource navigation and other services specific to medications for complex or chronic conditions).

Regardless of the type of medicine that a doctor prescribes, pharmacists help people by:

• Explaining how the medication works. Your doctor or another member of your health care team may have reviewed the ins-and-outs of the medication when you received your prescription, but hearing the information more than once is helpful—especially at what can be a stressful time.

• Reinforcing how the medication is to be taken. For example, some medications should be taken with meals; others should be taken on an empty stomach. If the medication is self-administered via an injection, the pharmacist can explain the proper injection technique.

• Reviewing what side effects might occur. This information is provided in the Package Insert (PI) that accompanies the medication, but it can be valuable to hear it explained in everyday language. The pharmacist can also monitor any side effects you may experience and offer guidance (in collaboration with your health care team) on possible ways to relieve the symptoms these side effects may cause.

• Explaining what your insurance covers. An insurer may require that the generic version of the drug be dispensed, if one exists. Your pharmacist can help explain any differences between the original drug and the covered drug, including any out-of-pocket cost implications.

• Ensuring patients take their medication as prescribed. Pharmacists can provide tips to help you take your medication as prescribed, such as using a pill sorter to stay organized, and signing up for automated refill reminder calls or text messages from the pharmacy. They may also suggest that you download a medication reminder app for use on your smart phone or tablet. Many of these apps are available for free or at a small cost.

• Recommending financial resources. There are a number of financial aid organizations and patient assistance programs available to help patients with their out-of-pocket expenses. Your pharmacist can be a good source of information about these resources.

Q. My pain is well-controlled, but I am tired no matter how much I sleep. Do you have any guidance for me?

A. Fatigue (extreme tiredness not helped by sleep) is one of the most common side effects of many cancer treatments. If you are taking a medication, your doctor may lower the dose of the drug, as long as it does not make the treatment less effective. If you are experiencing fatigue, talk to your doctor about whether taking a smaller dose is right for you.

There are a number of other tips for reducing fatigue:

• Take several short naps or breaks during the day.
• Take short walks or do some light exercise, if possible.
• Try easier or shorter versions of the activities you enjoy.
• Ask your family or friends to help you with tasks you find difficult or tiring.
• Save your energy for things you find most important.

Fatigue can be a symptom of other illnesses, such as anemia, diabetes, thyroid problems, heart disease, rheumatoid arthritis and depression. So be sure to ask your doctor if they think any of these conditions may be contributing to your fatigue.

Q. What treatments are available for peripheral neuropathy?

A. People living with cancer and coping with its treatment may experience peripheral neuropathy (nerve damage). Neuropathic pain is often described as pain, tingling, burning or numbness. The medications used to relieve the pain of peripheral neuropathy include:

Antidepressant medications. Doses prescribed for the treatment of neuropathic pain are often smaller than the doses typically used to treat depression.

Anticonvulsants. Anticonvulsants alone or in combination with antidepressant medications can be helpful in treating neuropathic pain.

Patches or creams. Patches or creams can be applied directly to the painful site.

Steroids. Steroid medications are sometimes used in the short term to relieve severe neuropathic pain until a long-term treatment plan is in place.

Opioids. Opioids are often used in combination with other medications to manage severe neuropathic pain.

In addition, physical, occupational and relaxation therapy can be effective for neuropathic pain. In some cases, acupuncture or biofeedback, a technique in which a person measures their own bodily functions (such as heartbeat, blood pressure and muscle tension), can also be helpful.

Q. I’ve noticed that the pain I occasionally experience is made worse by constipation. How can I avoid becoming constipated?

A. Here are some tips for preventing constipation:

• As hydration is important to avoid constipation, make sure to drink plenty of fluids. Also, limit your intake of caffeine and alcoholic beverages, as they can cause dehydration.
• Include foods high in fiber in your daily diet, such as fruit (especially pears and prunes), vegetables and cereals. If your health care team approves, you may want to add synthetic fiber to your diet, such as Metamucil, Citrucel or FiberCon.
• Be as physically active as you can, after checking with your health care team on the level of physical activity that is right for you.

Additionally, if your doctor has prescribed a “bowel regimen,” make sure to follow it exactly. A bowel regimen is a schedule for taking laxatives regularly to prevent or relieve constipation.