Pain Patterns and Cancer Pain Treatments

It is estimated that 70 percent of patients with cancer have cancer-related pain that will need treatment during the course of their illness. Distinguishing between acute pain and chronic pain syndromes is important for proper selection of pharmacologic and nonmedicinal treatment.

Evaluation should include location, severity and quality of pain, a determination of its impact on sleep, and the ability to perform usual daily routines. Acute or chronic pain may be the result of interventions, treatments, or intercurrent medical problems.

Treatment guidelines for the management of acute pain recently have been published by the Agency of Health Care Policy and Research, which builds on the World Health Organization analgesic ladder, which matches the intensity of pain to the treatment recommended.

The first line of treatment is the nonopioidal anti-inflammatory. Should these fail to control the pain, then an opioid like propoxyphene, codeine, ocycodone, morphine, fentanyl, and methodone should be added.

Dosing depends on the severity of symptoms. The prescribed route of administration depends on whether the patient can consume medication by mouth and whether the severity of the pain can be adequately controlled using oral medication, as well as on the ease of administration.

Adjuvant pain medication may be added, if needed, for better control and includes the addition of antidepressants, benzodiazepines, psychostimulants, corticosteroids, and clonidine.

Never blocks, epidural injections, and surgical ablation also may be useful in treating acute cancer pain. Modalities of heat, cold, electricity, and nontraditional therapy like acupuncture all have been shown to be helpful in relieving acute pain in patients with cancer diagnoses.

The likelihood of cancer pain being chronic is high. The World Health Organization has strongly urged use of pain management strategies that are designed to totally relieve symptoms, and the efficacy of the analgesic ladder described above has become demonstrated to be effective.

Detailed and systematic assessment of pain must be performed both initially and at regular intervals. Chronic pain in this population is either visceral such as poorly localized, cramping, or deep aching, somatic such as well localized to discreet anatomic areas, often sharp or stabbing, or neuropathic like burning, tingling, throbbing in the peripheral or central nervous system.

There are 4 key principles to effective pharmacologic pain management. These include choosing a medication, selecting a route for administration, picking the proper dosage, and recognizing and mitigating side effects or toxicities.

In general, dosing should be advanced to the level at which pain is controlled or at which toxicities preclude higher dosing. Adjuvant pain control should be provided for those patients in whom control is inadequate.

Typically, these diverse medications are used in treating somatic pain. Neuropathic pain and musculoskeletal pain are responsive to this approach.

Among the nonpharmacologic approaches are somatic and sympathetic nerve blocks. Intraspinal opioids also have been used successfully. Ablative procedures such as cordotomy, dorsal column stimulators, and local stimulators such as tanscutaneous electrical nerve stimulation or TENS also have been used effectively.

For more information on chronic pain in cancer patients, please visit the authors website PainsWeb.com