This patient summary on pain is adapted from the summary written for health professionals by
This summary is about pain in adults with cancer.
Flexibility is important in managing cancer pain. As patients vary in
To treat pain, it must be measured. The patient and the doctor should measure pain levels at regular intervals after starting
To help the health care provider determine the type and extent of the pain, cancer patients can describe the location and intensity of their pain, any aggravating or relieving factors, and their goals for pain control. The family/caregiver may be asked to report for a patient who has a communication problem involving speech, language, or a thinking
Pain: The patient describes the pain, when it started, how long it lasts, and whether it is worse during certain times of the day or night.
Location: The patient shows exactly where the pain is on his or her body or on a drawing of a body and where the pain goes if it travels.
Pattern: The patient describes if there have been changes in where the pain is, when the pain occurs, and how long it lasts, or if there is new pain.
Intensity or severity: The patient keeps a diary of the degree or severity of pain.
Aggravating and relieving factors: The patient identifies factors that increase or decrease the pain. The patient also identifies
symptomsthat are most troublesome, since they are not always the most serious or severe.
Personal response to pain: Feelings of fear,
confusion, or hopelessness about cancer, its prognosis, and the causes of pain can affect how a patient responds to and describes the pain. For example, a patient who thinks pain is caused by cancer spreading may report more severe pain or more disability from the pain.
Behavioral response to pain: The health care provider and/or caregivers note behaviors that may suggest pain in patients who have communication problems.
Goals for pain control: With the health care provider, the patient decides how much pain he or she can tolerate and how much improvement he or she may achieve. The patient uses a daily pain diary to increase awareness of pain, gain a sense of control of the pain, and receive guidance from health care providers on ways to manage the pain.
The assessment will include an exam of the body to check general signs of health or anything that seems unusual, and to look for signs that the
Assessment of the Outcomes of Pain Management
The results of pain management should be measured by
Management with Drugs
Basic Principles of Cancer Pain Management
For mild to moderate pain, the doctor may prescribe a Step 1 pain
medicationsuch as aspirin, acetaminophen,or a nonsteroidal anti-inflammatory drug(NSAID). Patients should be monitored for side effects, especially those caused by NSAIDs, such as kidney, heart and blood vessel, or stomachand intestinalproblems.
When pain lasts or increases, the doctor may change the
prescriptionto a Step 2 or Step 3 pain medication. Most patients with cancer-related pain will need a Step 2 or Step 3 medication. The doctor may skip Step 1 medications if the patient initially has moderate to severe pain.
At each step, the doctor may prescribe additional
drugsor treatments (for example, radiation therapy).
The patient should take
dosesregularly, "by mouth, by the clock" (at scheduled times), to maintain a constant level of the drug in the body; this will help prevent recurrence of pain. If the patient is unable to swallow, the drugs are given by other routes (for example, by infusionor injection).
The doctor may prescribe additional doses of drug that can be taken as needed for pain that occurs between scheduled doses of drug.
The doctor will adjust the pain medication
regimenfor each patient's individual circumstances and physical condition.
Acetaminophen and NSAIDs
NSAIDs are effective for relief of mild pain. They may be given with
Opioids are very effective for the relief of moderate to severe pain. Many patients with cancer pain, however, become
Types of Opioids
There are several types of opioids.
Guidelines for Giving Opioids
Most patients with cancer pain will need to receive pain medication on a fixed schedule to manage the pain and prevent it from getting worse. The doctor will prescribe a dose of the opioid medication that can be taken as needed along with the regular fixed-schedule opioid to control pain that occurs between the scheduled doses. The amount of time between doses depends on which opioid the doctor prescribes. The correct dose is the amount of opioid that controls pain with the fewest side effects. The goal is to achieve a good balance between pain relief and side effects by gradually adjusting the dose. If opioid tolerance does occur, it can be overcome by increasing the dose or changing to another opioid, especially if higher doses are needed.
Occasionally, doses may need to be decreased or stopped. This may occur when patients become pain free because of cancer treatments such as
Medications for pain may be given in several ways. When the patient has a working stomach and
Side Effects of Opioids
Patients should be watched closely for side effects of opioids. The most common side effects of opioids include
Opioids slow down the muscle contractions and movement in the stomach and intestines resulting in hard
Patients should talk to their doctor about side effects that become too bothersome or severe. Because there are differences between individual patients in the degree to which opioids may cause side effects, severe or continuing problems should be reported to the doctor. The doctor may decrease the dose of the opioid, switch to a different opioid, or switch the way the opioid is given (for example intravenous or injection rather than by mouth) to attempt to decrease the side effects. (Refer to the
Drugs Used with Pain Medications
Other drugs may be given at the same time as the pain medication. This is done to increase the effectiveness of the pain medication, treat
The use of bisphosphonates may cause severe and sometimes disabling pain in the bones,
The use of bisphosphonates is also linked to the risk of
Physical, Integrative, Behavioral, and Psychosocial Interventions
Integrative interventions include
Massage therapy has been studied as part of
Stimulate the release of
endorphins(substances that relieve pain and give a feeling of well-being).
Increase the flow of blood and
Strengthen the effects of pain
Lower pain caused by muscle
Avoid massaging any open
wounds, bruises, or areas with skin breakdown.
Avoid massaging directly over the
Avoid massaging areas with
deep vein thrombosis( blood clotin a vein). Symptomsmay include pain, swelling, warmth, and redness in the affected area.
soft tissuewhen the skin is sensitive following radiation therapy.
(For more information on massage, see Exercise 2 in the following section.)
Acupuncture is an integrative intervention that applies needles, heat, pressure, and other treatments to one or more places on the skin called
Thinking, Behavioral, and Psychosocial Interventions
Thinking, behavioral, and psychosocial interventions are also important in treating pain. These interventions help give patients a sense of control and help them develop
Relaxation and imagery: Simple
relaxation techniquesmay be used for episodes of brief pain (for example, during cancer treatment procedures). Brief, simple techniques are suitable for periods when the patient's ability to concentrate is limited by severe pain, high anxiety, or fatigue. (See Relaxation exercises below.)
Hypnotictechniques may be used to encourage relaxation and may be combined with other thinking/behavior methods. Hypnosis is effective in relieving pain in people who are able to concentrate and use imageryand who are willing to practice the technique.
Redirecting thinking: Focusing attention on
triggersother than pain or negative emotions that come with pain may involve distractions that are internal (for example, counting, praying, or saying things like "I can cope") or external (for example, music, television, talking, listening to someone read, or looking at something specific). Patients can also learn to monitorand evaluate negative thoughts and replace them with more positive thoughts and images.
Patient education: Health care providers can give patients and their families information and instructions about pain and pain management and assure them that most pain can be controlled effectively. Health care providers should also discuss the major
barriersthat interfere with effective pain management.
Psychological support: Short-term psychological
therapyhelps some patients. Patients who develop clinical depressionor adjustment disordermay see a psychiatristfor diagnosis.
Support groups and religious counseling:
Support groupshelp many patients. Religious counselingmay also help by providing spiritualcare and social support.
The following relaxation exercises may be helpful in relieving pain.
Exercise 1. Slow rhythmic breathing for relaxation *
Breathe in slowly and deeply, keeping your
stomachand shoulders relaxed.
As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving your body.
Breathe in and out slowly and regularly at a comfortable rate. Let the breath come all the way down to your stomach, as it completely relaxes.
To help you focus on your breathing and to breathe slowly and rhythmically: Breathe in as you say silently to yourself, "in, two, three." OR Each time you breathe out, say silently to yourself a word such as "peace" or "relax."
Do steps 1 through 4 only once or repeat steps 3 and 4 for up to 20 minutes.
End with a slow deep breath. As you breathe out say to yourself, "I feel alert and relaxed."
Exercise 2. Simple touch, massage, or warmth for relaxation *
Touch and massage are traditional methods of helping others relax. Some examples are:
Brief touch or massage, such as hand holding or briefly touching or rubbing a person's shoulders.
Soaking feet in a basin of warm water or wrapping the feet in a warm, wet towel.
Massage (3 to 10 minutes) of the whole body or just the back, feet, or hands. If the patient is modest or cannot move or turn easily in bed, consider massage of the hands and feet.
Use a warm
lubricant. A small bowl of hand lotion may be warmed in the microwave oven or a bottle of lotion may be warmed in a sink of hot water for about 10 minutes.
Massage for relaxation is usually done with smooth, long, slow strokes. Try several degrees of pressure along with different types of massage, such as kneading and stroking, to determine which is preferred.
Especially for the elderly person, a back rub that effectively produces relaxation may consist of no more than 3 minutes of slow, rhythmic stroking (about 60 strokes per minute) on both sides of the
Exercise 3. Peaceful past experiences *
Something may have happened to you a while ago that brought you peace or comfort. You may be able to draw on that experience to bring you peace or comfort now. Think about these questions:
Can you remember any situation, even when you were a child, when you felt calm, peaceful, secure, hopeful, or comfortable?
Have you ever daydreamed about something peaceful? What were you thinking?
Do you get a dreamy feeling when you listen to music? Do you have any favorite music?
Do you have any favorite poetry that you find uplifting or reassuring?
Have you ever been active religiously? Do you have favorite readings, hymns, or prayers? Even if you haven't heard or thought of them for many years, childhood religious experiences may still be very soothing.
Additional points: Some of the things that may comfort you, such as your favorite music or a prayer, can probably be recorded for you. Then you can listen to the tape whenever you wish. Or, if your memory is strong, you may simply close your eyes and recall the events or words.
Exercise 4. Active listening to recorded music *
Obtain the following:
A cassette player or tape recorder. (Small, battery-operated ones are more convenient.)
Earphones or a headset. (Helps focus the attention better than a speaker a few feet away, and avoids disturbing others.)
A cassette of music you like. (Most people prefer fast, lively music, but some select relaxing music. Other options are comedy routines, sporting events, old radio shows, or stories.)
Mark time to the music; for example, tap out the rhythm with your finger or nod your head. This helps you concentrate on the music rather than on your discomfort.
Keep your eyes open and focus on a fixed spot or object. If you wish to close your eyes, picture something about the music.
Listen to the music at a comfortable volume. If the discomfort increases, try increasing the volume; decrease the volume when the discomfort decreases.
If this is not effective enough, try adding or changing one or more of the following: massage your body in rhythm to the music; try other music; or mark time to the music in more than one manner, such as tapping your foot and finger at the same time.
Additional points: Many patients have found this technique to be helpful. It tends to be very popular, probably because the equipment is usually readily available and is a part of daily life. Other advantages are that it is easy to learn and not physically or mentally demanding. If you are very tired, you may simply listen to the music and omit marking time or focusing on a spot.
*Adapted and reprinted with permission from McCaffery M, Beebe A: Pain: Clinical Manual for Nursing Practice. St. Louis, Mo: CV Mosby: 1989.
Radiofrequency ablation uses a needle
Surgery may be used to remove part or all of a tumor to reduce pain directly, relieve
Invasive Interventions to Relieve Pain
Management of Procedural Pain
Patients usually tolerate procedures better when they know what to expect. Having a relative or friend stay with the patient during the procedure may help reduce anxiety.
Patients and family members should receive written instructions for managing the pain at home. They should receive information regarding whom to contact for questions related to pain management.
Treating Older Patients
Older patients are at risk for under-treatment of pain because their sensitivity to pain may be underestimated, they may be expected to tolerate pain well, and misconceptions may exist about their ability to benefit from
chronicdiseases and sources of pain: Age and complicated medication regimensput older patients at increased risk for interactions between drugsand between drugs and the chronic diseases.
Visual, hearing, movement, and thinking
impairmentsmay require simpler tests and more frequent monitoringto determine the extent of pain in the older patient. Nonsteroidal anti-inflammatory drug(NSAID) side effects, such as stomachand kidney toxicity, thinking problems, constipation, and headaches, are more likely to occur in older patients.
Opioid effectiveness: Older patients may be more sensitive to the pain-relieving and
central nervous systemeffects of opioids resulting in longer periods of pain relief. Patient-controlled analgesiamust be used cautiously in older patients, since drugs are slower to leave the body and older patients are more sensitive to the side effects.
Other methods of
administration, such as rectaladministration, may not be useful in older patients since they may be physically unable to insert the medication.
Pain control after
surgeryrequires frequent direct contact with health care providers to monitor pain management.
Reassessment of pain management and required changes should be made whenever the older patient moves (for example, from hospital to home or
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Changes to This Summary (11/08/2011)
Changes were made to this summary to match those made to the health professional version.
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