Pain

“Pain is as diverse as man. One suffers as one can.” Victor Hugo

Pain is a subjective experience. There are many different physical and emotional factors that can make the experience of pain worse. Previous experiences of pain can make things worse in the present. How we interpret the reason for and the meaning of pain is very important also.

Pain occurs in more than 50% of patients with advanced cancer (page 167, Therapeutic Guidelines, Palliative care, 2005). It may also be a problem for patients who suffer from diseases of nerve and muscle (like motor neurone disease, or diabetes). Pain may be easily seen–like the pain associated with a large ulcer–but even in this case there is often more than one “type” of pain involved. Pain can also be difficult to pin point or may just be a general feeling of discomfort.

Not all cancers cause pain. It is quite common for pancreatic cancer to have very few symptoms for example. Pain may be only indirectly due to a secondary effect of the cancer–for example the blockage of the gut by a tumor, or the ulceration of a skin cancer, or the thinning and fracturing of bone from tumor invasion. This might sound terribly frightening but it is good to know that reasonable levels of pain control can be achieved for nearly everyone. It is also helpful to know that most people can tolerate some pain and not be too bothered by it. Understanding this means that you don’t have to have an unrealistic aim of never having any pain.

Different types of pain

Nociceptive Pain (including bone and muscle pain)

This is the usual pain type of “every day pain.” This type of pain occurs when special pain receptors in the skin or deep tissue are irritated by various “noxious” substances which injured body tissues release.

Nerve pain (called neuropathic pain)

This results from irritation or damage to nerve endings. Think of someone who has “sciatica” or shingles (which affects nerve endings). The words, “burning, shooting, creeping and electric-shock-like,” suggest that nerve pain may be involved. Not all medications are good at treating nerve pain. Opiates (like morphine or endone for example) can help but sometimes other medications need to be “added on” to help reduce nerve pain. Apart from medications, you could think about TENS (see the complementary therapy page) or about cold packs/ heat packs, or massage. Many doctors are able to provide information on techniques which block the nerve signals to the brain. Some of these techniques might involve injections into nerve group, or “radio frequency ablation” which destroys the troublesome nerve endings. These procedures usually require a short admission to hospital and the involvement of a pain specialist or anaesthetist.

Breakthrough Pain

You will become familiar with this term which palliative care nurses and doctors use a lot. Pain medication is usually given regularly (often morning and night, or morning, lunch and dinner). Breakthrough pain occurs between the regular doses of an analgesic (pain-relief) medication. The pain has broken through the regular pain releif. A few breakthrough doses of pain medication is normal, but if your loved one is needing more than 4 or 5 doses of extra (breakthrough) medication in a 24 hour period, then it might be time to talk to your doctor about increading the regular dose.

Activity pain (Incident pain)

This is pain which comes on and can be predicted with a particular activity. It commonly occurs in patients who have cancer which has spread to the bone. For example, many people find that the simple activity of using the toilet or shower can cause them lots of pain. If this is the cas ehten it is very sensible to use a dose of prescribed pain relief (like ordine, morphine, endone, oxynorm etc) and possibly a muscle relaxant (like diazepam/ valium) half an hour before the painful activity. If the procedure of changing a wound dressing causes your loved one pain then you need to think about using pain relief before the dressings.

Pain Management

Medications

These include regular paracetamol (this workes together with other stronger pain medications), possibly anti-inflammatories (like ketorolac, neurofen etc) and opiates (short acting or slow release morphine for example). Other medications that play an important role include medications which help reduce nerve pain (including methadone, amitriptyline, gabapentin and pregabalin/ lyrica). Dexamethasone is a steroid that is helpful in reducing the pain associated with swelling around a tumor. There are other medications like this including prednisolone and hydracortisone. Muscle spasm (like cramping/ spasms of the bowel caused by constipation or a blocked bowel) can cause severe pain. This can be releived a bit by using an anti-spasmodic which works on the gut smooth muscle. Other muscles (like muscles attached to the skeleton) can also spasm and there are a number of medications which can help releive this, for example diazepam (valium) and baclofen.

Other options

We often think of radiotherapy as a curative treatment but it has a big place in the management of pain caused by the spread of tumor into bone. The Therapuetic Guidelines for Palliative care (version 3, page 224) says that a single dose of radiotherapy can ease bone pain in up to 80% of people, and can completely relieve pain in half of people treated. This releif usually lasts for 3 to 4 months. It is important to note that after the radiotherapy has been delivered it may take up to 2 or 3 weeks before you notice any response. If the response is good the the amount of pain releif often has to be reduced accordingly. Radiotherapy can be repeated, especially if the first response lasted longer than 3 months.

Palliative chemotherapy is an option for patients who suffer from severe pain related head and neck, pancreatic, breast, and lung cancer.

There are many helpful things you can do at home to help relieve pain including:

  • Having some of your loved one’s favourite music playing
  • Playing an interesting audio book to help them think about something else
  • Massage with essential oils (use olive or canola or sunflower oil as an inexpensive base)
  • Elevating swollen and aching legs (to reduce pain and tightness from swelling try raising the legs above the level of the heart so the fluid can drain)
  • Practicing relaxation exercises (you might be able to get a trained psychologist or palliative care social worker to come and teach you and your loved one specific relaxation therapies)
  • Heat or cold packs applied alternately to the painful area
  • Getting a special “hospital bed” with an air matress to avoid pressure sores
  • Hiring a TENS machine from your chemist or hospital. This is the use of electric current to stimulate nerves so that the nerve receives a distracting sensation which blocks the transmission of the pain signal. This is usually a small battery operated device which is attached to the skin for specified periods of time.
  • Sometimes pain can be spiritual as much as physical and inviting a trusted chaplain or local minister to come and share with your loved one can often help.

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