Debilitating pain is often associated with advanced cancer, leading to fears that a miserable life lies ahead. You can be reassured that this need not be the case and there are many sources of help and drugs to keep you comfortable, pain-free and able to enjoy a good quality of life.
It does, therefore, seem perverse that many people with advanced cancer delay reporting their symptoms, or are unwilling to take their analgesics. The reasons for this include not wishing to become addicted to strong pain-killers; using pain as a gauge to the cancer progressing or side effects such as drowsiness interfering with day to day life. With a proper assessment of your pain and how it affects you individually, a step-wise approach starting with mild analgesics through to the stronger morphine-based drugs can achieve good pain control which in turn can lead to improved sleep, energy levels and appetite.
Pain is caused by cancerous growths pressing on bones, nerves or organs in the body and may differ in type and severity. Individuals may variously describe pain as aching, throbbing, burning, shooting, sharp or tingling. It may be acute, coming on quickly and lasting only for a short time – post-operative pain for example. More often with advanced cancer, the pain becomes chronic, due to nerve changes and may be persistent. Chronic pain can be more difficult to treat so it is important that your Oncology team and GP are able to build up a picture about the type and cause of your pain, as drugs and other treatments work in different ways.
N.B. Spinal cord compression, though uncommon, is a medical emergency and requires immediate attention. Symptoms are: severe pain in your back that doesn’t go away; numbness or difficulty using your arms or legs; pins and needles or electric shock sensations; problems controlling your bladder or bowels.
New or increased pain does not necessarily mean your cancer is getting worse, but you should always report it to your medical team as you may require an adjustment of your pain medication along with further investigations. Keeping a pain diary noting where the pain is, what it feels like, how often it occurs and how it is interfering with your sleep and daily life can be useful to work with a doctor or specialist nurse to find the best analgesia for you. Remember that not all pain is caused by your cancer as other health issues for example arthritis, may also cause pain and discomfort.
Macmillan Cancer Support have developed a useful pain diary which can be found on their website.
Your Oncology team and Specialist Nurse can advise you on drugs for pain control, but often this can be better managed in the community by your GP, Macmillan Nurse or Hospice Doctor. They can also assess you in your home environment and refer you to Occupational Therapists who may suggest some aids to make life easier (e.g. handrails, bath seats) and to Physiotherapists who can advise on safe exercise. If pain becomes difficult to manage then there are Pain Specialists, usually specialist anaesthetists, and Palliative Care teams who may offer more advanced management such as nerve blocks, epidural and intrathecal analgesia, and patient controlled infusions (syringe drivers).
Treatments for pain include medication, radiotherapy, chemotherapy and non-invasive measures.
There are many drugs to help control pain caused by cancer, ranging from mild anti-inflammatories to strong opioids. Drugs are available in different strengths and forms – tablets, liquids, patches, injections and infusions. The aim is to gain maximum pain control using the minimum dosage required, in order to reduce unwanted side effects. Building up the correct components for optimum pain control takes time and effort, trial and error and remembering that pain is not a constant thing but will vary day-to-day itself.
Opiates, opioids and narcotics are terms often used interchangeably, although there are some differences. Opiates are naturally derived from the opium poppy plant and include morphine and codeine. Opioids refer to synthetic drugs (examples include fentanyl, methadone and tramadol) or semi-synthetically produced drugs (for example heroin, oxycodone and hydrocodone). Narcotic describes a pain-relieving, sleep inducing drug. The most commonly used term which covers both natural and synthetic drugs is opioid. All are Class A drugs/ Controlled Drugs with laws to prevent their illegal and non-medicinal use.
Analgesics may be “layered” in order to gain good control:
Opioids are tolerated differently by people and individuals find a huge variation in each type of opioid, so some specialists will use opioid rotation in order to keep the daily dose to a minimum in an attempt to reduce unwanted side-effects. Tolerance can be a problem with opioids leading to a steep increase in dosage and this is when it may be necessary to look to other agents to manage the pain. Pain can also be affected by emotional, social ,environmental and deeply personal factors in addition to the physical and mechanical nature of the problem.
There is a popular misconception that people who take opioids regularly to manage their pain will become addicted and for that reason, may be undertreated and needlessly suffer.
Addiction is associated with a psychological desire to get “high” or euphoric. The stigma attached to legal and medically prescribed narcotics comes from their association with illegal recreational drugs such as heroin and cocaine. Experts report that it is rare for people to become addicted to opioids when taken for pain caused by cancer.
Addiction is different from physical dependence on a drug. Your body can get used to a drug and you may require a higher dosage to get the same effect. This does not happen to everyone but may mean that you will need to adjust the dose of your medication under the guidance of your doctors or specialist nurse. Withdrawal symptoms may occur if you suddenly stop your drugs
Side effects vary between individuals and some people may be more affected than others. Very often, your body will adjust to a new drug after a few doses. Do discuss any side effects with your doctor or specialist nurse as most side effects can be effectively controlled. Listed below are the more common side effects:
You may like to consider your home and environment and what effects these may have on your pain control. Comfortable seating, pillows, mattresses, bathing aids and no undue reaching or pulling can all relieve pressure on your body. An Occupational Therapist can carry out a full assessment in your home, and can often supply the equipment free of charge. Sensible exercise combined with intervals of rest can make a big difference to your pain management.
Constant pain can be isolating and debilitating, so classes such as art therapy or other activities may help distract you and keep you engaged with the outside world. A duvet day or a good film may be necessary occasionally, but days filled slumped on the sofa with daytime TV is probably not so helpful.
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