Pain Relief: The L.A. Pain Clinic Guideby Sota Omoigui

CANCER PAIN

There are many causes of cancer pain. Pain may arise from the tumor pressing on bone, nerves, muscles or body organs. Such pain may be a constant ache or gnawing feeling. Sometimes pain results from obstruction of body organs such as the stomach or kidneys. This kind of pain may be felt as a deep squeeze or pressure. When the cancer spreads into the nerves, it may result in a shooting electrical shock type of pain. The blood supply to part of the body can sometimes be obstructed by a tumor resulting in pain, swelling, redness and occasionally tissue death. Pain can also result from fracture of weak bones or from herpes zoster infections especially in patients receiving chemotherapy. In one out of four persons, cancer treatment with surgery, chemotherapy or radiation therapy may result in pain due to nerve injury or tissue scarring. Persons with cancer are unfortunately still entitled to pain from non cancer causes such as headaches, muscle strains, and arthritis e.t.c.
You may take aspirin or other over-the-counter pain relievers such as Tylenol. These medications decrease the production of prostaglandins that cause pain. Do not wait until the pain becomes severe to take your medicine. Pain is easier to control when it is mild than when it is severe. You should take your pain medicine regularly and as your doctors and nurses tell you. This may mean taking it on a regular schedule and around the clock. Take the medicines with food to prevent stomach upset. A hot shower coupled with daily exercises such as yoga or water exercises can relieve soreness due to stiff unused muscles. Do not overdo any exercises or activities. Pace yourself throughout the day so you do not get too tired. Learn to relax. Books and audiotapes teaching relaxation techniques are available at many bookstores. Maintaining a healthy diet with adequate protein and calcium is important. Limit your alcohol intake. It may worsen stomach upset from aspirin, Advil and other arthritis drugs.
The various treatments depend on the severity and cause of the pain. When pain is slight, you may take pain relievers, such as Tylenol or Motrin. Apply wet or dry heat to painful muscles and joints or rub over the counter ointments, rubs and sprays such as Eucalypta Mint or Ben Gay. Take herbal supplements such as Quercetin, Rutin, Curcumin, Red Wine tablets, Cinnamon and Ground Clove Extracts. These contain polyphenols which are the best anti-inflammatory agents that nature has provided to us. A new ointment called Zostrix (Capsaicin) may help by decreasing the amount of substance P, which sends pain signals to the brain. Zostrix is the burning ingredient in red-hot chili peppers. The ointment itself may give you a funny burning sensation that lasts the initial couple of days. Wear rubber gloves when you apply it and keep it out of your eyes. With more severe pain, you will require stronger pain relievers such as Hydrocodone or Oxycodone. These are short acting and should be taken every four to six hours as prescribed by your doctor. These medications may be combined with other medications such as anti inflammatory drugs like Motrin, antidepressant drugs like Elavil or Lexapro. St. John’s Wort, a herbal antidepressant is just as effective. These other medications may significantly increase the pain relief. The antidepressant medication may also help in improving your moods. If your pain returns before the next dose of pain medications is due, you will need a long acting strong pain medications to provide background pain relief while still using the short acting pain medications for any breakthrough pain. In such case your physician may prescribe long acting morphine or methadone tablets to be taken one to two times daily and short acting Vicodin ES or Percocet to be taken every four to six hours as needed. The long acting pain medications need to be taken regularly even when you feel you do not have a lot of pain. A new long acting painkiller your doctor may want to use is a skin patch called Duragesic. This is a very strong pain killer (stronger than morphine) that you wear as a patch over your chest or back. It releases medication slowly through the skin and should be replaced every two to three days. Your short-acting pain medications may be used in-between. Medications used in special situations include intravenous (IV) or intramuscular (IM) injections of strong pain medications such as Morphine or Demerol. Other drugs that help control nerve inflammation and cancer pain include a subcutaneous injection of the biologic drug Kineret as well as an intravenous (IV) or intramuscular (IM) injection of cortisone, plus an IV infusion of the anti-seizure drug Depacon combined with IV infusion of magnesium sulfate and IV mini bolus doses of Ketamine. These are often used in specialist clinics such as the L.A. Pain Clinic, Hawthorne, California, a hospital or nursing home. There are new machines for hospital and home use called PCA (Patient Controlled Analgesia) pumps. These machines have a user button which when pressed injects a small amount of the pain killer medication through the IV tubing. After an injection, the PCA pump will not deliver medication for a programmed (lockout) period of time e.g. 10 minutes even if the button is pressed. After the lockout time, the PCA pump will deliver medication with the next press of the button. The PCA pump reduces pain medication side effects by allowing you to give yourself frequent small doses rather than occasional big doses. Other medications used in special situations include low dose steroids for pain due to spread of cancer into the bone. Steroids reduce the swelling and inflammation of the bone. Medications such as calcitonin (given by injection or nasal spray) and bisphosphonate drugs such as intravenous zoledronic acid (Zometa) stop the breakdown of bone and relieve the pain. Another bisphosphonate drug called Clodronate may also decrease the spread of cancer to the bones. Local anesthetics used alone or combined with opioids or clonidine may be injected directly into the back using a small tube called an epidural or intrathecal catheter. This may provide long lasting pain relief because the medication acts right at the site of the pain receptors in the spinal cord. With use of strong pain medications such as morphine, codeine, stool softeners such as Colace are helpful in preventing an otherwise inevitable occurrence of severe constipation. Cytotec is a drug used to treat ulcers but which can be used to prevent constipation from opioids because it increases the movement of the intestines. A high fiber diet and lots of fruits and fruit juices is essential. Anticonvulsant medications e.g. Trileptal, Topamax or Neurontin help treat neuropathic pain that is due to irritation of the nerves from the tumor. Take the medications regularly. Some of these medications may decrease the production of blood cells so your physician may have to check your blood every few weeks. Occasionally some of these medications may produce a skin rash. Other medications that are used in treating nerve pain include antidepressants like Lexapro, St. John’s Wort and strong pain relievers like Vicodin or Oxycontin. Dextromethorphan is a morphine like drug that is used in cough medications to reduce coughing. It does not produce any pain relief by itself. However it prevents development of tolerance to the pain relieving effects of opioids. When used in combination with opioids dextromethorphan may enable a decrease of up to 50% in the amount of opioid required, thus enabling pain relief with fewer side effects e.g. drowsiness. Dextromethorphan may be prepared in a pure form by a compounding pharmacist. Commercially it is often combined with other ingredients such as antihistamines in cough syrups. In addition to medications, nerve block with local anesthetic, steroids or glycerol may provide good long-term relief. A side effect of these procedures may be prolonged numbness in the area of pain. Before any procedure your doctor should explain the risks and benefits to you. When pain is caused by tumor pressing on the nerves, bone or tissue, removing as much of the tumor with surgery may relieve the pain. Surgery may sometimes be required to remove painful nerves. The tumor size may also be reduced with chemotherapy or radiation therapy. Acupuncture and electrical stimulation therapies are sometimes helpful by increasing the body’s production of natural pain killing hormones. Alternative cancer therapies include shark cartilage tablets (sharks do not get cancer), special diets, macrobiotics, megavitamin therapies, herbal and detoxification treatments. Gather as much information as you can and be wary of treatments that sound too good to be true. Mind body therapies help in pain control by promoting relaxation, hope, control and optimism. These include relaxation training, controlled breathing, meditation, repetitive prayer, visualization, and imagery/distraction techniques, yoga and music therapy. Your doctor may also help you learn to relax by using biofeedback, behavioral modification or hypnosis. Join support groups. These are helpful as they enable you talk to others who have the same problems. You will be able to share your feelings and practice stress reduction and pain control techniques. If you are depressed you may need antidepressant medication and counseling.

Call your Doctor: If you experience constipation or any side effects from your medications. Inform your doctor that you have a right to obtain adequate pain relief.

National Organization: The American Cancer Society (www.cancer.org Ph: 800 227-2345). The National Cancer Institute, Cancer Information Service (www.cancer.gov 1 800 4 CANCER). You may request educational booklets and information on diet, nutrition, emotional support, symptom control and dying at home.