Reviewed: December 2006
If your pain is not relieved with the medicines ordered, let your health care team know as soon as possible. Many medicines are available and everyone responds differently to each medicine. You may need to try several medicines before finding the one most effective for you.
Also, tell your health care team if you are having trouble getting your medicines or if you cannot afford them. British Columbia's Pharmacare Program has a Palliative Care Benefits category, which will cover the costs of symptom management medications if you are under sixty-five and being cared for at home, a hospice or a long term care facility. See BC Palliative Care Benefits Program for more information, or ask your care team about the program.
There are also many other resources available for information on cancer pain, including booklets, books, videos, and the internet. Ask your care team for further information.
Control of cancer pain is available in many different methods and medicines. You should seek treatment when you feel that you need help to control your pain. Your family doctor may refer you to a specialist if he/she is unable to control your pain. Among these specialists are medical oncologists, radiation oncologists, pain management physicians, physiatrists, anesthesiologists, neurologists, and neurosurgeons.
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Medications and Resources
Pain is managed using one or more medications. Sometimes in combination with other non-drug therapies. The World Health Organization put forward a model for cancer pain managament which classified cancer pain as:
- Mild pain - pain which can be managed with the use of non-opioid medications (i.e. Tylenol plain)
- Moderate pain - pain which is managed using combination medication involving non-opioid medication plus a narcotic (i.e. Tylenol #3)
- Severe pain - pain which is mangaed using pure opioid medications (i.e. morphine)
At any point on this model, adjuvant medications can be added - these are sometimes pain medications themselves (i.e. ibuprofen) or medication which help boost the effect of your pain medicine (i.e. prednisone).
Non-opioids
Acetaminophen, aspirin or other nonsteroidals (anti-inflammatory drugs, NSAIDS e.g. ibuprofen) are commonly used to treat mild to moderate pain. Most anti-inflammatory drugs except for aspirin or 200mg ibuprofen will require a physician's prescription. It is important for you to check with your healthcare team before taking these medicines. Aspirin and some nonsteroidals (anti-inflammatory drugs) can cause stomach irritation and problems with blood clotting or may interact with other medicine you may be taking.
Other non-opioid medications are used in combination with opioids or alone for specific types of pain.
- Nerve pain (usually described as shooting, stabbing, pins and needles) is often treated using medication that is usually indicated for other conditions: Antidepressants are often used for nerve pain - among these medications are amitriptyline, nortriptyline and desipramine. The use of these medications does not mean you are depressed or mentally ill. Antiseizure medications such as gabapentin, carbamazepine and phenytoin can also be used to treat nerve pain. These drugs require a physician's prescription.
- Visceral pain (pain in a body organ usually described as dull and is hard to locate) is often treated using NSAIDS (ibuprofen, aspirin) or corticosteroids (prednisone) to reduce the pain due to swelling in the organ. This group of drugs has the added benefit of increasing appetite and producing a feeling of general well being. These effects are temporary, lasting only while the drug is being taken.
Opioids
Opioids are used to control moderate to severe pain. All opioid pain medications require a physician's prescription.
Morphine is what is referred to as the "gold standard" in cancer pain management - it is literally the best medicine we have for this as it has no limit in terms of the amount we can give you. More pain can usually be handled by adding more morophine to the medication plan.
Morphine is available in short acting form, and as a long acting agent. With the long acting morphine, small, regular doses of morphine are released in your body after the drug is swallowed to provide control of pain. It is important for these medications to be taken on a regular schedule. Generally the schedule for the long acting morphine is every 8 to 12 hours based on your need. You should never stop these medications suddenly, and always discuss any changes with your healthcare team. These medications should never be chewed or crushed; they should always be swallowed whole.
Immediate release morphine is available in tablets, liquids, suppositories or injections. If you have to use immediate release morphine frequently, you should check with your healthcare team. The long acting morphine may need to be increased or there could be another problem causing the pain.
Oxycodone is also available in short and long-acting formats. This long acting oxycodone is available in tablet form and lasts for eight to twelve hours. This drug also requires a physician's prescription. This drug should not be broken or split, but swallowed whole.
Short acting oxycodone lasts for three to four hours. Forms available are tablets, liquid, and suppositories.
Hydromorphone is a synthetic opioid, like morphine but much more potent. Hydromorphone also comes in short and long-acting formats.
Methadone is another opioid used in cancer pain management. You may also recognize it a s the medicine that is used to treat heroin addiction. The uses in these two cases are not the same at all. If your doctor has advised you use methadone for your pain, remember, s/he is treating your cancer pain, not a drug habit. Methadone is available in tablets, liquid and injection. This medicine often needs quite a bit of adjustment to maintain pain control. This medication requires a physician's prescription, and not all doctors have the special license needed to prescribe it.
Fentanyl is another opioid medication commonly known as "the patch." The mechanism is that the drug is absorbed through your skin. The patch may last up to three days. Fentanyl is only ever used for cancer pain that is stable, as it is difficult to change patches and keep up with a unpredictable pain pattern.
Meperidine also known as Demerol® is a poor choice for cancer pain. The use of this drug for longer than three days can often be associated with agitation, irritability, restlessness, and seizure activity. These symptoms should be reported to the healthcare team immediately. This drug is only given with a physician's prescription, and is usually used for short term surgical or procedural pain for cancer patients.
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Complementary Therapies for Pain Management
This is only a brief description of non-medicine or alternative methods that may be used to help in the control of pain.
Pain relief methods as with medicines, vary from patient to patient. A method that might be effective for one patient may not be effective for another patient. For further information, please contact your health care team.
- Relaxation and guided-imagery exercises can be very helpful in addition to your pain medicines. Many tapes and books are available to help you learn these exercises. Ask your doctor or nurse for more information.
- Distraction can be a complement to your pain medicines. Music, a funny movie or videotape, or a computer or video game can help distract you from the pain. These can be especially useful when you have periods of increased pain.
- Massage can help reduce muscle tension and relieve pain. Ask your doctor or nurse for information on massage techniques. You may want to ask your family and friends for back rubs or massage of painful muscles. They may appreciate being able to help you feel better.
- Heat, cold, vibration, and other treatments can provide relief for some patients. Ask you doctor or nurse for assistance.
- Sharing your feelings - Pain can affect all parts of our lives. Many people find that talking about the pain can be very helpful. Support groups can also provide the opportunity to talk with others in your situation and learn what has helped them.
- Prevention - Add more fruits (including prunes) and juices to your diet, if you can tolerate these, to help prevent constipation and bloating from your pain medicines.
The BC Cancer Agency maintains a database on commonly used unconventional therapies available to cancer patients.