You are the only one who knows about your pain level.
Unfortunately, we cannot tell by looking at you whether you are having pain or not. It is very important for you to be clear with your health care team when talking about your pain. Do not be afraid to talk with them, whether your pain is unrelieved, partly relieved or completely relieved.
Why pain happens is very much connected with how we treat it. You will find that your care team will ask you many questions about your pain:
- Location - where does is hurt?
- Intensity - how bad is it?
- Quality - what words best describe your pain - aching, throbbing, stabbing, burning, tingling?
- Other factors - what makes it better? what makes it worse?
Often people with cancer fear pain, but most patients can get relief with proper treatment. Control of cancer pain is achieved through many different methods and medicines. You should seek treatment when you feel that you need help to control your pain.
One of the key principles of good pain management is open and honest communication with your doctor, nurse or other healthcare professional.
Patients and families often don't report pain because they don't want to bother the doctor or nurse, and also because they may not want to appear to be complaining. Patients are often fearful of telling their health care team that they are having pain. They are afraid that if they use the strong medicines now there won't be any other medicines left to use later.
Fear of addiction (an emotional need for pain medication because of the feeling that is received from the medicine) and tolerance (drug is no longer effective at the present dose because the body had adjusted and now needs a higher dose) may interfere with proper use of pain control medications for many patients. A good plan for pain management outlined by your doctor, pharmacist or nurse helps you better participate in your treatment and will also improve your quality of life.
Many pain medicines are available to relieve your pain. If the pain medicines do not provide the relief you need, the doctor can increase your dose, or change your present medication and try to find one that works better for you.
When using the medication morphine (or it's relatives) referred to as opioids in other sections, it is important for you to know that there is no maximum amount of morphine that can be prescribed - if your pain gets worse, we can just increase your dose until you get the desired pain relief. It will be different for every person, so you cannot compare your amount of medication to someone else's even if they have a similar situation as you.
When assessing your pain, your care team will use a pain scale. This tool is helpful to allow all parties to have the same "pain language" to describe the intensity of your pain.
Description or Measurement of Pain
Each person has a different response to pain. At different times and under different circumstances you may feel varying levels of pain with the same illness. Communication with your health care team and family is necessary for best pain control. The use of a consistent pain scale (0 = no pain, 10 = worst pain imaginable) helps to best communicate the intensity of pain you are feeling.
Pain Intensity Scale
0 1 2 3 4 5 6 7 8 9 10
I I I
No Pain Moderate pain Worst Pain
Take your medicines as prescribed. If they do not relieve your pain, contact your doctor or nurse. It is important to let your healthcare team know about your pain. A helpful way of recording is to keep a journal of your pain level and treatment and medications. It is important to tell your healthcare team members:
- Where the pain is
- What it feels like: sharp, dull, achy, or tingly
- How long the pain lasts
- What helps the pain, what makes it worse
- What medications you are taking, how much and how long do they help for
- What things have you tried in the past that work for you (massage, heat, other medicines)
- All the medicines including prescriptions or over the counter medications you are taking (it is helpful to keep a written list in your wallet or purse)
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 to direct you to these resources.
Control of cancer pain is available in many different methods and medicines. You should seek treatment from your health care professional (family doctor, nurse) when you feel that you need help to control your pain. If further expertise is needed please ask for a referral to the pain and symptom management/palliative care clinic located within each cancer centre.
Medications and Resources
Pain is managed using one or more medications and sometimes in combination with other non-drug therapies. The World Health Organization put forward a model for cancer pain management 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 managed 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 medications that help boost the effect of your pain medicine (i.e. prednisone).
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 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 morphine 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 as 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 an 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.
Some people decide to use natural supplements for pain relief. For more information about safe use of natural supplements visit the CAMEO program's list of useful websites or resources they have developed.