Libyan Journal of Medical Sciences

COMMENTARY
Year
: 2020  |  Volume : 4  |  Issue : 1  |  Page : 5--7

Defeating cancer pain while fighting without pain: A brief guide


Edoardo Arcuri1, Patrizia Ginobbi2, Walter Tirelli2,  
1 Intensive Care and Resuscitation Department, Pain Unit, The “Regina Elena” National Cancer Institute, Rome, Italy
2 Health and Research Foundation, Rome, Italy

Correspondence Address:
Prof. Edoardo Arcuri
Pain Unit, The “Regina Elena” National Cancer Institute, Rome
Italy




How to cite this article:
Arcuri E, Ginobbi P, Tirelli W. Defeating cancer pain while fighting without pain: A brief guide.Libyan J Med Sci 2020;4:5-7


How to cite this URL:
Arcuri E, Ginobbi P, Tirelli W. Defeating cancer pain while fighting without pain: A brief guide. Libyan J Med Sci [serial online] 2020 [cited 2020 May 29 ];4:5-7
Available from: http://www.ljmsonline.com/text.asp?2020/4/1/5/280563


Full Text



 Introduction



Cancer-related pain is one of the cancer symptoms that may arise from a tumor compressing or infiltrating nearby body parts; from treatments and diagnostic procedures; or from the skin, nerve, and other changes caused by a hormone imbalance or immune response. The incidence of pain in cancer is 60%–80% in millions of cancer patients creating great difficulty both for patients, their families, and caregivers. Cancer pain is, therefore, a formidable universal social, ethical, economic, and scientific problem so that somebody retains almost impossible, extremely hard, or yet senseless the challenge of antineoplastic therapies.

The aim of this commentary is to bring to light our initiative on the preparation of the guide (vade mecum) which will help patients, families, and caregivers to recognize the true face and the hundred masks of pain. The emerging strategy of this effort is adherent to most recent international guidelines of palliative care and tailored both on the patient social issues as the home care setting, overall in countries or areas at lower medicalization. In this perspective, the rationale of therapies, especially pharmacological, is just mentioned to make it easier for simplicity. The result of the aim is – as well as the specific notions – to introduce among patients and caregivers team a feeling of trust and empathy that is the care of the right not to suffer. The title of the guide is “Tumor associated pain: A guide to help patients, doctors and caregivers to fight pain jointly,” and herein in this report, we describe it as following:

 Pain and Tumors



Informing patients about its strategies to control the pain which is often associated with their disease is of primary importance from the therapeutic point of view. Indeed, this will free patients from the frequently associated anxiety, and it will be conducive to a two-way constructive relationship with the therapy team. This pamphlet is meant to help patients to build up this relationship by understanding that pain can be controlled to the point of being eliminated, thus enabling them to face pain fearlessly and actively.

Where, how, and why pain occurs?

Pain which originates from affected parts of the body is funneled through the nerves to the brain being the outcome feeling by the patient of discomfort of variable intensity and invariably distress and anxiety. If pain is somehow helpful to alert that therapies should start for an underline disease, its persistence (chronic pain) is useless since it represents a second illness. Thus, its relief resulting in an improved quality of life gives patients strength, hope to recover, and confidence in the adopted therapies.

The side effects of pain

Long-lasting pain produces discomfort and anxiety. This often prevents movements, thus making patients inactive and dependent on somebody's help. Frequently, chronic pain is associated with insomnia, fatigue, irritability, and depression. As a result, the patient may live with resentment (why it happened to me?) and with a diminishing will to fight the disease to the point of refusing medical advice and even the help and support from friends and the family. Treating pain and its worsening, therefore, helps to prevent all or a significant part of the above ailments.

When to start pain therapy?

Under this heading, numbers of questions have been included and will help in answering (with yes or no) the survey with the patients, as follows:

Is the pain present in most parts of the day?Patient tries to resist the pain as long as possible?Pain-controlling drugs are used only for unbearable pain?Is the pain accompanied with depression?Is the pain associated with insomnia?

Even if only one of the above questions answer is “yes,” patents' therapy should be started.

Pain therapy and its rules: A strategy like in a battlefield

Frequently, pain-bearing patients believe that its treatment is something difficult and mysterious, as pain itself nothing is more erroneous. Pain therapy is the intensity calibrated and timely use of all means available to fight pain.[1] Therefore, the delivery of a correct pain therapy relays on:

Knowledge of the available therapiesUse of the easiest usable therapy at lowest dosage needed to control pain and to avoid their side effectsChoice of timing and dosages to be able to treat all types of pain (acute or chronic) in a patient-tailored way, andMonitoring of the pain intensity to continuously validate the efficacy of the treatment.

Means to deliver a pain therapy

Pain-controlling drugs are the primary and largely available and deliverable resourcesThe methods to block the nerve conductivity should be used only in specialized centers.

The pain-controlling drugs

As a rule, drug therapy is initiated with pills containing aspirin-derived substances, namely nonsteroidal anti-inflammatory drugs (NSAIDs) which are capable of controlling pain within 30–40 min, for a 4–5 h time. Since they may produce gastrointestinal pain and bleeding even if given by injection, they are administered together with drugs which protect the stomach such as proton-pump inhibitors (PPIs)In the event of persisting pain, opium-deriving drugs (opioids) will be given starting from the less potent medication (codeine and tramadol) and moving if needed to the more efficacious (oxycodone, morphine, fentanyl, and methadone). At the beginning of the treatment, it is advisable to use the combination of a weak opioid and paracetamol. No alcohol should be consumed when on opioid treatmentCorticosteroids, a group of steroid hormones produced by our own body in the adrenal cortex or synthetically, are often associated with the above drugs to reduce anxiety, insomnia, depression, and the “burning pain”In case pills cannot be taken because of impaired swallowing, fentanyl-containing patches can be applied for a pain relief lasting 2–3 days. Acute pain attacks can be rapidly treated with fentanyl nasal sprays or sublingual pillsThe main guideline is recommended to restrict aggressive therapies in cases of resistant pain.[2]

What dosage and when?

Since pain treatment may require the use of more than one drug, the following should be considered:

Medications should preferably be taken by the mouth, though the relief from pain starts slowly and its duration is prolongedIntramuscular injections should not be used for prolonged therapiesDrugs should be taken in established hoursThe best therapy is the one that anticipates the onset of painWhen dealing with acute recurrent pain during the day, it is advisable to use fast-acting drugs by the sublingual route.

To be remembered

A frequent failure of the pain therapy derives from the use of suboptimal dosage of the medications and not from the opposite. Further, the drug should be used before the onset of pain and not waiting for its worsening.

How to prevent or reduce the adverse effects of the pain-controlling drugs?

Stomachache and heartburning

They often arise during uptake of NSAIDs and steroids and are frequently relieved by stomach-protecting drugs such as PPIs.

Nausea and vomiting

They occur frequently accompanying the uptake of opium-derived drugs, radiotherapy, and chemotherapy and occur in patients with impaired liver functions. Appropriate remedies are available.

Loss of appetite

Pain-controlling drugs may decrease the appetite by lowering the taste of food, in addition to the effect of the disease itself on the appetite. In this case, it is advisable to eat small servings repeatedly during the day.

Constipation

To overcome this adverse effect, anti-constipation compounds are frequently present in pain-controlling drugs, especially in the opioids. A diet rich in vegetables seasoned with olive oil may be of help. An abundant daily uptake of water may reduce constipation and increase the disposal of drugs from the body. The use of laxatives and rectal enema should be resorted to only in case of constipation lasting 2–3 days.

Sleepiness

This may occur during the day when taking opioids. In older patients with some degree of memory decline, this may result in woolliness. The moderate use of coffee may be of help.

Insomnia and grumpiness

During prolonged therapies for chronic pain which are accompanied by insomnia, some drugs such as steroids may induce grumpiness. The patient believes that their condition is misunderstood, thus refusing advice and attentions from family members, relatives, and friends. Since sharing pain may contribute to its forbearing, patients should be helped to accept any manifestation of affection, concern, and care.

Frequent questions from patients

Aren't so many pain-controlling pills dangerous?

No. Since pain therapy may require the combination of pain controlling drugs and medications to overcome their associated adverse effects, it is not uncommon that a number of pills, drops, and syrups even 4–5 times are daily taken. Patients should be encouraged to keep a daily record of the various medications to help the caring team to change the schedule of treatment according to the pain duration and severity.

Can the use of opioid drugs induce dependence?

Opioids when properly used according to the established doses and schedules do not induce dependence. On the contrary, prolonged treatments can produce a loss of efficacy of the drug so-called “tolerance” and decrease of their associated untoward adverse effects (shortness of breathing, constipation, nausea, etc.). In this case, therapy should be rescheduled.

Is it possible to interrupt the use of pain-controlling drugs?

Yes. Pain therapy can be suspended provided that it does not occur abruptly but in few days and only when pain is significantly decreased or disappeared.[3]

Bones pain

Pain that arises in bones, especially in the spine, may be very intense to the point that even simple movements cannot be done. The treatment of this pain which makes feel the patient helpless requires the combined effort of different specialists (oncologist, radiotherapist, orthopedist, physiotherapist, and neurosurgeon).

The main available therapies are as follows:

Periodic administration of drugs that prevent bone loss and help the production of new boneRadiotherapy which is by curing the diseased bone may relieve painOrthopedic supports that by limiting movements may ease pain.

Neuropathic pain

When the disease and/or its treatment damage the nerves, a characteristic type of pain develops. Patients complain of burning, electric shocks, prick feelings, and numbness. These sensations are often referred as arising from surgically removed diseased tissues (breast, intestine, and limbs). This pain called “phantom pain” is often insensitive to standard pain-controlling therapy but may be diminished by antiepileptic drugs and eased by antidepressants.

Tumor-associated depression

The disease and the associated pain, especially if long lasting, may induce depression and anxiety. Patients should be encouraged to discuss the status of their mood helping them to understand that “talking of their pain” is not a sign of weakness. Discussing their physiologic distress will help them to cure the “pain of the soul” and to start adequate treatment before worsening of the symptoms.

Blocking the pain

In case the above-described treatments failed, it will be necessary to block or decrease the transmission of the pain through nerves to the brain. This therapy which should be discussed with the doctor will require the direct injection of pain-controlling drugs into the nervous structures, as it is done in women during labor.

Hospital-based pain therapy centers

In these referral centers, a continuous management of pain is taken care by a team of specialists (anesthetists, neurologists, radiotherapists, oncologists, psychologists, etc.). The pain will therefore be carefully monitored in terms of intensity, duration, and response to applied therapies which could then be varied accordingly with a personalized strategy.

Psychological support

It should when possible accompany patients and families to fight the discomfort of pain and the side effects of the disease and therapies.

Alternative therapies

A number of therapeutic/supportive interventions (acupuncture, dietary regimens, herbs, homeopathy, Qi gong lessons, and meditation training, etc.) outside current official guidelines are advertised by uncensored sources offering relief for the tumor-associated pain. They are very often offered with unproven efficacy according to strict scientific assessment and may be harmful and of unjustified high costs. Sometimes, the patients are also encouraged to abandoning the standard therapies with the result of disease and/or pain worsening. It is advisable that none of these alternative therapies should be undergone without consulting the treating physician or team. Furthermore, music, art, dance, and any activity that “distracts” patients from their difficulties during standard therapies may improve their quality of life.[4]

 Conclusion



Being pain of no benefit to patients during or following cancer treatment, it should be treated since its appearance. Thus, patients should be encouraged not to be afraid to discuss their pain. Available therapies which have been developed through basic and clinical research will be able to diminish or block pain when customized to the patients' clinical situation, their family, and the living environment. We hope that this guide may help patients and the managing team to establish a professional alliance to maximize the therapeutic beneficial outcomes freeing the highest number of patients from pain.[5]

Acknowledgments

This work has been supported by Mediterranean Task force for Cancer Control: MTCC (www.mtcc-prevention.net) and the “Federico Calabresi Foundation.” Rome. Italy. The authors are grateful to Carol El-Jabari, Suhiela Kar'ean Hijazi and Walaa Sabih, MD: http://www.pfsjerusalem.org for advice and the translation of the leaflet into Arabic.

The printable text of the leaflet is available also in Arabic. The word version to be used for translation in any other language can be obtained from Professor Pier Giorgio Natali, Secretary General MTCC, by inquiring to natalipg2002@yahoo.it

References

1Pain Control. Available from: http://www.cancer.gov. [Last accessed on 2020 Feb 12].
2Rochman S. Easing the Pain. Cancer Today Spring; 2016. Available from: https://www.cancertodaymag.org/Pages/Spring2016/Easing-the-Pain-Management.aspx. [Last accessed on 2020 Feb 12].
3Taking Care of Your Health: Islam and Chronic Pain Information Leaflet for Muslim Patients Therapy Services and Maulana Mohammed Arshad – Muslim Chaplain and Imam; 2014. Available from: https://ppa.csp.org.uk/system/files/islam_and_chronic_pain.pdf. [Last accessed on 2020 Feb 12].
4PDQ® Cancer Information Summaries: Integrative, Alternative, and Complementary Therapies. Available from: https://www.cancer.gov/publications/pdq/information-summaries/cam. [Last accessed on 2020 Feb 12].
5The International Association for the Study of Pain (IASP)“2019 Global Year Against Pain in the Most Vulnerable”, An International Campaign by the Pain Community to Boost Awareness and Education that Results in Better Pain Relief. Available from: https://www.iasp-pain.org/. [Last accessed on 2020 Feb 12].