Supportive Care Clinic
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A common problem for patients is pain. Pain may be mild, moderate, or severe and may last a short or long period of time. Pain can be caused by the cancer or by the treatment. Whatever the cause of your, it is important that you tell your doctor or nurse about it. They will do all they can to ease your pain and make you as comfortable as possible.
If you have cancer pain, there are some important things for you to know:
- For most patients, pain can be controlled.
- Pain is an individual experience which means only you can describe it. This makes talking with your doctor very important.
- It is important to take the pain medicine as you are told. If your medication is not working or if you have side effects, please contact your doctor.
- Writing down the pain medication you took and rating your pain level will help your care team control your pain.
On this website, you can download a pain diary (in PDF format...download the free Acrobat Reader to access the file). The pain diary gives you an effective way to tell us how well your medication is working. It gives you a place to rate the pain you are feeling on a scale of 0-10 (0 = no pain; 10 = extreme pain). Your doctor can look at this to see if changes need to be made in your pain medication. Please print out this form and bring it to each visit.
What is Causing Your Pain?
It is important that the cause of your pain is identified. Some causes of pain are treatable; for example, a broken bone. Other causes of pain may be a sign of a medical emergency. Furthermore, different types of pain respond to different treatments. In order to identify the cause of your pain, your doctor may request special tests such as x-rays or scans. Discuss your pain with your doctor and make sure that you have a clear understanding of what is causing the pain.
What Type of Pain Do You Have?
There are two major types of pain: pain caused by activation of pain receptors and pain that is caused by damage to nerves. These two types of pain may respond differently to treatment.
What Type of Treatment is Available for Your Pain?
The treatment required for control of cancer-related pain is very individualized. Some patients will have pain problems that are easily controlled with minimal amounts of medications. Other patients may have difficult pain control problems that require more than one type of treatment. Pain may also change over time; thus, treatments may need to be adjusted on a frequent basis. It is important that you work carefully with your physician to develop a treatment plan that works for you. Listed below are some of the commonly used treatments for cancer-related pain.
Aspirin and aspirin-like medications, such as Ibuprofen (Motrin) and Naproxen (Aleve), are commonly used to treat mild pain especially when pain is due to inflammation. Aspirin-like medications are very helpful for patients who have tumors involving the bones. Overall, these are safe agents when taken as directed. Side effects of these drugs include: stomach upset, stomach ulcers, damage to the kidneys and decreased platelet function. Steroids, such as prednisone or Decadron, may also be used to decreased inflammation and pain.
Tylenol: Tylenol is frequently used for mild pain. Although generally safe when taken as directed, excessive amounts of Tylenol can cause liver failure. Do not take Tylenol or Tylenol-containing medications more frequently than prescribed by your physician.
What are Opioids? Many patients with cancer-related pain require opioids. Opioids are a type of drug that takes advantage of your body’s natural pain control system. Cells in the body have receptors called mu receptors. When activated, these receptors can decrease the sense of pain. The body produces natural chemicals (such as endorphins) that bine mu receptors. These natural chemicals are produced in response to a variety of circumstances including exercise. Synthetic opioids work in a similar way by activating the mu receptors and decreasing the send of pain.
Should I be concerned about taking opioids? There are many myths and concerns expressed by patients and their families about using opioid pain medication. It is important to dispel these myths.
- Patients are often concerned about becoming drug addicts. It is very uncommon for cancer patients without a history of drug abuse to become addicted to their pain medications. The body can become accustomed to having the pain medications in the system. Thus, it is important not to stop pain medications abruptly or withdrawal symptoms may develop.
- Patients often express concern that they will “use up the ability of the pain medications to work.” The effectiveness of pain medications is not “used up.” If you are in pain, take your pain medications now! The dose of medication can be adjusted at a later time if the pain worsens.
- Patients are often concerned that they should not complain to the doctor about pain because it will take his or her attention away from the cancer treatment. Your doctor needs to know about your pain because it may provide important information about your disease. In addition, your doctor is not just concerned about treating your cancer, but is also concerned about making you comfortable.
- Patients may think that “a little pain won’t hurt them.” However, pain results in many harmful effects on body function including: decreased immune function, increased fatigue, poor sleep quality, decreased physical functioning, slowing of mental processing, and increase in mood disorders such as depression.
- Some patients think that pain medications are for patients that are dying. This is not true! Newly diagnosed patients, patients undergoing treatment and patients who are cured may need pain medications as well.
What if my pain is only moderate? For patients with moderate pain or for patients whose pain is not controlled with aspirin-like medications or Tylenol, opioids are needed. A number of medications are available that combine low doses of opioids with either an aspirin-like medication or Tylenol. These medications can be very beneficial for moderate levels of pain. It is important that you take these medications as prescribed to avoid side effects. Examples include:
- Hydrocodone with an aspirin-like medication
- Hydrocodone with Tylenol
What if my pain is more severe? Patients whose pain is not controlled with the above medications may require pure opioid medications. Pure opioids do not have any aspirin-like mediation or any Tylenol. Thus, the dose of the opioid can be increased without concern for side effects from the aspirin-like medication or from the Tylenol. A partial list of opioids is provided below. Please note, there are immediate release medications that work quickly and sustained release medications that last longer:
- Immediate Release: Pill size - 10 mg, 15 mg, 30 mg
- Immediate Release: Liquid concentration - 1 mg per ml or 20 mg for ml
- Sustained Release:
- MS Contin pill size - 15 mg, 30 mg, 60 mg, 100 mg
- Duramorph - 15 mg, 30 mg, 60 mg, 100 mg
- Avinza -
- Kadian -
- Immediate Release: Pill size - 5 mg and 20 mg
- Immediate Release: Liquid concentration - 5 mg/ml
- Sustained Release - Pill size - 20 mg, 40 mg, 60 mg, 80 mg
- Immediate Release: Pill size - 5 mg
- Duragesic Patch:
- Patch Size: 25 :g, 50 :g, 75 :g, 100 :g
- Immediate Release: Pill size - 2 mg, 4 mg, 8 mg
- Immediate Release: Liquid concentration -
- Pill Size:
How often should I take my opioid pain medication? Oftentimes, patients with cancer will have pain that is constant. If pain is constant, then it is necessary to take your pain medication on a routine basis so that there is pain medication in the bloodstream at all times. This is called fixed dosing or around-the-clock dosing. That means that you take your medication at specific times whether or not you are having pain at that time. The purpose of around-the-clock dosing is to prevent the pain. The frequency that you must take your medication is dependent on the medication that your doctor prescribes. Your doctor will tell you how often you must take your around-the-clock medication. It is important that you take your pain medication as prescribed. Remember, an ounce of prevention is worth a pound of cure!!!
What happens if I have a pain event, though I am taking my fixed dose mediation as my doctor prescribed? In addition to your fixed dose medication, your doctor will give you a medication for “breakthrough pain.” Breakthrough pain is defined as pain that occurs despite taking your around-the-clock dose. When you have breakthrough pain, you need a “rescue dose” of medication. “Breakthrough” or “rescue” medications are fast acting medications. They should take effect with 1 to 2 hours. If the medication does not work within this time period, then you may take another dose. It is important that you keep track of how many doses of rescue medication that you are taking. If you are taking more than 4 rescue doses per day, contact your physician so that adjustments can be made in your around-the-clock dosing.
What happens if the pain becomes very severe? If the pain becomes very severe, contact your doctor so that you can be seen immediately. If the pain is accompanied by any concerning problems such as muscle weakness, numbness, or problems with bowel or bladder function, go immediately to your nearest emergency room for evaluation.
Can opioids cause side effects? Opioids are vital to control cancer-related pain. Unfortunately, opioids have a number of side effects. The good news is that the side effects can be treated. If you have side effects, it is important that you contact your doctor immediately. Do not stop your pain medication without talking to your physician or nurse. The following list explains some of the side effects and how to minimize them.
- Sedation/Confusion: Many patients will feel sleepy or slightly confused when taking opioids. After taking your medicine for 3-10 days, these side effects usually subside as the body gets used to the medication. If your sleepiness does not get better after 7-10 days, contact your physician so that he/she can prescribe a medication to help counter the sedating effects of opioids. If, at any time, you become very confused or very sleepy, contact your physician immediately. Care should be taken not to conduct activities that require careful attention if you feel sedated from your medication. Driving if you are impaired puts you and others at risk.
- Nausea/Vomiting: Opioids frequently cause loss of appetite, nausea, or vomiting. Again, these symptoms usually go away after 3-10 days when the body gets used to the medication. During that period of time, your physician can prescribe anti-nausea medications to help control these side effects. If you experience nausea or vomiting after starting your pain medicine, contact your physician immediately.
- Constipation: Opioids can cause severe constipation. Unlike the other side effects caused by opioids, constipation does not go away over time. Stool softeners and laxatives may be required to treat constipation.
- Itching: Opioids may cause itching. If this happens, over-the-counter antihistamines such as Benadryl may help. Contact your physician before starting any new medications.
- Muscular Jerking (myoclonic jerks): Opioids may result in muscular jerking. This may be frightening; however, it is not harmful. If this jerking becomes severe, contact your physician. Medications are available to treat this side effect.
Opioid Refill Guidelines
To prevent any misuse of opioids, the Federal government has set up guidelines regarding refilling narcotic prescriptions. When you follow these rules, we can insure that your medications are available with a minimum of inconvenience.
- Opioids may only be prescribed by your physician or a nurse practitioner.
- Opioids cannot be phoned in to your pharmacy. A written prescription is required in order to dispense these medications. The prescription must be hand delivered by the patient or family member filling the prescription.
- Keep a close count on the amount of opioids on hand. Call 4-5 days in advance to get an opioid prescription. Many pharmacies need to order opioids several days in advance.
- Always be sure that you have enough medication to last over weekends or holidays, because it is especially difficult to get emergency supplies during this time.
- Each opioid refill requires a new prescription slip. You will not be given refills when an opioid is prescribed. When you need to refill your prescription, you must obtain a new slip.
- Opioid prescription refills are only available from 8:00 - 5:00 p.m., Monday through Friday, through your treating physician.
Psyschological Aspect of Pain Control
Patients with poorly managed pain may feel more stress, anxiety, fatigue, anger, depression or sadness, and guilt. They may withdraw from loved ones and some daily activities and have fewer everyday pleasures to enjoy. Similarly, a patient’s loved ones may also experience distress when the patient has pain. At Vanderbilt-Ingram Cancer Center, we combine psychological approaches to pain management with the medical treatment of pain. Psychological treatments can be effective in reducing pain and helping patients have a better quality of life. As part of psychological support, we strive to help patients develop better ways of coping with pain.
What can help?
Our clinic uses cognitive behavior therapy, a form of therapy that is time-limited and has been shown by some studies to be effective in reducing pain or learning to cope more effectively with pain. This therapy focuses on identifying distressing, unhelpful thoughts and finding new, more useful ways of thinking about problems or situations. It also uses specific techniques to help reduce how much pain a patient feels. Some of these techniques are listed below.
- Distraction: This technique turns a person’s attention away from the pain and focuses it on something else, which can help to decrease pain and muscle tension. This technique can easily be used by patients who are fatigued, because it doesn’t require a lot of energy. Examples of distraction include reading, watching television, craft projects, listening to music, or other focused activities such as working on crossword puzzles or other mental games.
- Hypnosis: This is a relaxed state of highly focused concentration that allows a person to try different ideas or images to control pain. Some patients find that learning how to hypnotize themselves can help to reduce their experience of pain.
- Relaxation and imagery: These techniques offer ways of relaxing muscles and refocusing attention. They are useful in relieving pain and reducing distress related to cancer treatment. Often these techniques can be practiced at home or during treatment with cassette tapes. One technique is called progressive muscle relaxation, and involves learning to sequentially relax the major muscle groups. Another technique is guided imagery, in which you visualize yourself in pleasant, relaxing scenarios. There are a number of excellent audio tapes that provide instruction in these techniques, or the psychologists at VICC can make tapes for you and assist you in learning these techniques.
- Activity scheduling. Patients keep track of their activity levels and how these relate to their experience of pain. Patients also plan and engage in enjoyable events. Often patients find that during pleasant activities, their experience of pain is reduced. Patients may also note that specific times of day are associated with increased pain, and may find that planning how to cope with these times is helpful.
- Addressing problems with anxiety and depression. Participation in cognitive behavioral therapy and/or using medication to treat problems with anxiety and depression may lower the amount of physical pain that a patient feels.
In addition, some patients have found other complementary therapies to be helpful in managing pain. These include acupuncture, yoga, exercise (including energy exercises such as tai chi or chi gong), prayer and attention to spirituality, and meditation.