Easing the Pain
Pain is no gain for patients during or after cancer treatment.
By Sue Rochman
Photo © ThinkStock / dina2001
In 2009, Mike Richardson was diagnosed with melanoma, an aggressive skin cancer, following removal of a suspicious-looking mole near his collarbone. He had surgery to remove the area around the mole, and all appeared well. But two years later, a biopsy of a swollen lymph node in his neck confirmed the cancer had returned. To corral the cancer, Mike had surgery to remove that node and others nearby, followed by radiation. That’s when the pain began.
“Mike started having general soreness, and then he started to have some pain, and then that pain began to become extreme,” recalls his wife, Eryn Richardson. “It was unbearable. He couldn’t sit or lay down. He would say ‘everything hurts.’ ” The pain would make the 40-mile drive from their home in Black Diamond, Alberta, Canada, to the Tom Baker Cancer Centre in Calgary seem even longer. Yet when her husband, who died in March 2013, told his oncologist about his discomfort, the physician had little to offer, Richardson says. “Her response was ‘just take some Tylenol or Advil,’ ” she says. “She didn’t seem concerned.”
But to those close to him, it was clear Mike was not doing well. After two months of chemotherapy, the 50-year-old had dropped 50 pounds, and his clothes hung on his 6-foot-plus frame. “He wasn’t the same person,” says Richardson. “He didn’t have a lot of go to him anymore and he didn’t have any drive. And he was frustrated because he didn’t feel his oncologist was taking his pain seriously. His complaints about pain didn’t seem to resonate with her.”
One day, following a routine appointment, a nurse handed Mike a pamphlet about support for cancer patients. Using a phone number on the pamphlet, he scheduled an appointment with a psychologist who had experience with melanoma patients. At the first meeting, the psychologist asked Mike to rate his pain on a scale of one to 10. “When Mike said eight,” says Richardson, “he was flabbergasted.”
The psychologist made an appointment for Mike at the pain clinic at the Tom Baker Cancer Centre for the following day. It took a few more weeks for the specialists there to get Mike on the right dose of the right medications. But after that, his pain was better managed. “He got his appetite back,” says Richardson, “and he began to feel more human.” Still, the Richardsons couldn’t help but wonder: Why had it taken nine months for Mike to get proper pain management?
A Common Problem
Pain and cancer frequently go hand in hand. Studies suggest between 20 and 50 percent of cancer patients are experiencing pain at the time of their diagnosis. If the cancer progresses, the discomfort often does too. About 80 percent of patients with advanced-stage cancer report moderate to severe pain. For some patients, the cancer pain may be complicated by other pain problems unrelated to their cancer. “Pain in cancer patients is not always because the cancer is getting worse,” says David Hui, a palliative care specialist and medical oncologist at the University of Texas M. D. Anderson Cancer Center in Houston. “A patient may have chronic pain syndromes even before their cancer diagnosis, or, after their diagnosis, a patient can develop pain unrelated to the cancer.”
But while pain is common in cancer patients, it’s not always easy to treat. In fact, pain management can be one of the more challenging areas of cancer care. Oncologists with expertise in palliative care and pain management say it is important for patients to know that cancer-related pain can be managed, but that it can take some time and may require seeing one or more pain specialists.
Oncologists are often advised to follow the World Health Organization (WHO) pain ladder and its step-by-step guidelines for managing cancer pain. (See “Follow the Ladder
.”) Studies have found that using the scale can help doctors successfully manage cancer pain in about 70 to 80 percent of patients, says Eric E. Prommer, a hematologist-oncologist who directs the Inpatient Palliative Care Unit at the VA Greater Los Angeles Healthcare System. The program is affiliated with the David Geffen School of Medicine at the University of California, Los Angeles. Prommer’s article, “Pharmacological Management of Cancer-Related Pain,” published in the October 2015 issue of Cancer Control
, reviews the step-by-step
approach for managing chronic pain and the use of increasingly strong opioids and other pain medications based on pain severity.
To a novice, treating pain may seem straightforward. But in fact, pain management is both a science and an art that relies, says Prommer, on confidence gained from experience treating cancer pain and managing any adverse effects. Moreover, physicians also have to know what types of pain don’t respond to the medications recommended on the WHO pain ladder and when different types of treatments are needed. When physicians don’t have this expertise, says Prommer, all too often “pain is undertreated and the medications are underutilized.”
Identifying the Right Dose
The overall goal of managing pain is to use the lowest dose of a drug necessary to control pain and avoid side effects. The first step of the pain ladder recommends acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). If the pain persists or gets worse, the second step is to add one of what are considered “weak” opioids. If the pain becomes more severe, stronger opioids replace weak ones.
Choosing the right pain medication and identifying the right dose can take a while. Part of the problem is that some pain medications take time to build up in the body to effectively manage pain. In addition, some patients stop taking the medications or don’t take them according to the prescribed schedule, leaving them with a bad combination of difficult side effects and no relief.
When Mike first saw the pain doctor, says Richardson, he was told the morphine he would be given was likely to make him tired, affect his appetite, cause nausea and constipation, and keep him from sleeping well—and it did. “It was hard,” she says. “They put him on a really high dose to get the pain managed,” with the intent of then reducing it. But he stuck with the medication, she says, and “within a couple of weeks he felt better, and then when the drugs were at the right level, he could eat and became more active and became more like himself again.”
Prommer says it’s common for palliative care doctors to see patients who have had bad responses while on some pain medications and who believe they can’t take them at all, “when the problem was that they were given too big of a dose. When we use the drugs appropriately, they do well with drugs that had been a problem before.”