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9 Articles in Volume 17, Issue #3
Anxiety and Pain
Central Pain in Rheumatoid Arthritis
Imagine Dragons’ Dan Reynolds Educates People About Ankylosing Spondylitis
Letters to the Editor: Ehlers-Danlos Syndrome, Arachnoiditis
Managing Cancer-Related Pain: A Look at Alternative Approaches
Pain Management in the Elderly: Focus on Safe Prescribing
Painful Genetic Diseases
Responding to Women's Pain Early and Effectively
The 5 Most Misunderstood Terms in Pain Medicine

Managing Cancer-Related Pain: A Look at Alternative Approaches

Nonpharmacologic cancer-pain management has advanced beyond palliative care, showing significant evidence of benefit and potential for pain relief and improved quality of life.

Pain continues to be the most important undertreated symptom in end-stage cancer patients, with 50% to 90% of patients experiencing cancer-related pain.1,2 Cancer pain can be multifaceted, involving somatic, visceral, and neuropathic components. The ability to effectively assess a patient’s pain and know different ways of providing pain relief are essential not only for healthcare providers but for all those involved in the care of cancer patients. Unfortunately, cancer pain management tends to focus solely on biomedical issues, with the primary emphasis on medications.

Nonpharmacologic cancer-pain management has advanced to enhance quality of life.

Despite the fact that nonpharmacologic therapies have significant evidence of benefit and potential for pain relief and quality-of-life improvements, they still are not widely incorporated into palliative-care models for cancer patients. Cancer affects millions of individuals and their families. The aim of this article is to increase awareness of different ways to cope with cancer-related pain, whether this is through medication or complementary interventions. Ultimately, the goal is to help cancer patients feel like they once again have a life worth living.

Pain-Relief Ladder

As noted, pharmacologic management is considered the first line of treatment for cancer-related pain. In 1986, the World Health Organization (WHO) established guidelines for pain relief in cancer patients; these guidelines remain the standard of care to this day.3 Understanding the fundamentals expected of healthcare providers in treating cancer pain is essential before alternative treatment approaches are explored. WHO outlined a 3-step ladder, involving a progression from nonopioids (eg, aspirin and nonsteroidal anti-inflammatory drugs) to “weak” opioids, and from adjuvant therapies to strong opioids (eg, morphine) until the patient is theoretically pain free (Figure 1).3,4

A patient’s medical management is based on the current severity of pain in relation to the stage of disease. These drugs are usually administered every 3 to 6 hours instead of on an “as needed” basis. Consequently, if a patient reports inadequate pain relief, a provider can determine if the dosing and associated intervals are appropriate. Similarly, the intensity and frequency of pain can be correlated with the WHO ladder to see if the patient is being undertreated. The WHO recommendations are clear and have been implemented with quantifiable success in different clinical settings.5-7

When practiced appropriately, the WHO guidelines provide a good foundation for pain relief. Ideal medical management of pain also involves tracking patient progress, assessing and reassessing the patient’s pain, and monitoring side effects of different therapeutic modalities. If patients are experiencing neuropathic pain, an existing medication schedule can be supplemented with antidepressants (eg, tricyclic antidepressants), anticonvulsants (eg, gabapentin, pregabalin), and topical agents (eg, lidocaine patch). Medication side effects, fear of addiction, and the development of tolerance can weigh down on patients and make them noncompliant or averse to the pharmacologic pain management. The search then begins for nonpharmacologic ways to cope with pain.

Palliative Treatment

If the cancer is potentially curable, surgery, radiation, and/or systemic therapy can be used to durably alleviate cancer pain. A subset of patients with limited metastases have long-term survival following definitive treatment. More commonly, patients with distant metastases require supportive care and palliative treatment.  

Radiation therapy can be safely performed in 1 to 10 treatments, is 65% to 70% effective at relieving pain, and reduces the need for opioid medications and the subsequent risk of pathologic fractures.8 Painful metastases may respond to radiation, chemotherapy, hormonal therapy, and/or regional nerve blocks. Interestingly, pain is not necessarily associated with lower survival odds in patients with advanced cancer.9

Individuals with poor performance status, extensive disease, and inadequate nutrition generally have a worse prognosis and may be better candidates for supportive therapy alone. For this poor-prognosis cohort, potential side effects of treatment may outweigh any palliative benefit.  

Relaxation Techniques And Psychosocial Support

Interventions geared toward relaxation in cancer patients can also be used to reduce reactivity to pain. The relaxation techniques discussed here involve the use of deep breathing and imagery. On a basic level, consciously pairing muscle tension with inhalation and muscle relaxation with exhalation assists a patient in using breathing to control pain. More specifically, deep breathing is thought to help the patient concentrate better, soothe the nervous system, and balance the mind-body connection—this is especially true when used during activities like yoga, meditation, and tai chi.10

Jon Kabat-Zinn, PhD, established the mindfulness-based stress reduction (MBSR) meditation technique that has been studied for its effect on psychological stress and pain in cancer patients. MBSR is an 8-week, structured program that includes sitting meditation, silent body scanning, and simple yoga postures.11 A recent study by CA Lengacher, RN, PhD, and colleagues of breast-cancer survivors revealed improvements in physical functioning, pain, and emotional well-being in patients who regularly practiced the MBSR technique.12

Imagery in the context of cancer is defined as having patients use positive visualizations to substitute for the feeling of pain. Imagery and relaxation training have been found to decrease the intensity of cancer-related pain, possibly through an interruption in the pain/muscle tension/anxiety cycle.13,14 Sloman and colleagues studied the use of imagery and relaxation training in intermediate- to advanced-stage cancer patients and, in addition to the above, they noted a decreased need for non-opioid analgesics in managing pain.15

The actual practice of using imagery involves asking a patient in a relaxed state to think of an image representing pain and then have the patient purposely change this image into a more positive one. This can be done by cognitively molding or replacing the painful, negative image with a peaceful, happy, or calm mental experience. By using such imagery training, the patient focuses less on pain itself when it happens. Furthermore, the ability to use this technique at will gives patients a sense of power over their pain.16 Relaxation techniques can even be used in combination with structured behavioral interventions like stimulus conditioning to extinguish the feelings of anxiety and fear in patients.17 Healthcare providers must understand that patients’ emotions contribute to the total pain experience, and this explains why relaxation techniques provide pain relief. By using relaxation techniques as a form of distraction and/or as a means of controlling mental activity, patients lessen the sensation of pain and reduce its associated distress.

Exercise

A scientific framework exists behind the use of exercise for pain relief in cancer patients, for which both physiological and psychological benefits have been reported. The main objective in using exercise to relieve cancer-related pain is to resolve the physical inactivity that often accompanies the diagnosis. The limitations of a cancer patient’s physical abilities may lead to a loss of function that further intensifies the way in which the patient experiences pain. With immobility comes muscle wasting and weakness, changes in affect, decreased self-reliance, and reduced coping skills.18

It is important for a patient with a confirmed diagnosis of cancer, however, to undergo necessary health and fitness assessments before being prescribed an exercise regimen. This includes a review of recent EKGs, imaging studies, cardiovascular exams, feeding habits, current medications, and baseline laboratory results. Detailed exercise programs for cancer patients have been developed; they are designed to improve cardiorespiratory endurance (eg, walking, jogging, cycling, swimming), muscular strength (eg, free weights and resistance-geared devices), body composition (eg, aerobic exercise), flexibility (eg, stretching), and neuromuscular tension/stress (eg, movement to music).19

Generating temporary muscle tension through exercise prevents muscle atrophy and increases muscle mass. On a similar note, techniques from osteopathic manipulative medicine (OMM), such as soft-tissue mobilization, myofascial release, connective-tissue stretches, and joint articulation can be used to manage pain.20 Exercise and OMM treat pain in muscles, nerves, joints, and bones, but attention must always be given to a patient’s comfort level throughout the period of activity. The mode, frequency, intensity, and duration of the exercises should be adjusted over time based on the health status, needs, and goals of the individual patient.

A patient can begin exercise therapy under the supervision of many practitioners, including cancer-pain specialists, personal trainers, physical therapists, nurses, and primary-care providers. By better understanding the type and stage of cancer, the current treatment being received, and the patient’s capabilities, a customized, consistent program of physical activity can be established to help reduce pain symptoms. Exercise results in increased endurance, improved functional capacity, enhanced well-being and body image, and decreased emotional distress caused by anxiety, depression and fatigue; all of these factors effectively contribute to the reduction in pain.21-23 As an added benefit, physical activity has been shown to reduce the risk of development of certain malignancies, prevent recurrence, and even increase survival in the oncologic population.24 The habit of exercise makes cancer-related pain more bearable by helping patients improve their strength and concept of self-efficacy.

Conclusion

The fight against cancer-related pain should be a multidisciplinary team approach. Physicians, counselors, therapists, mental-health professionals, trainers, families, and of course, patients themselves, should work together to create an ideal pain-
management plan. Cancer patients with uncontrolled pain have a greater risk of suicide, which highlights the importance of timely intervention.25 The more a patient is educated about his or her cancer diagnosis and the options for relieving any associated pain, the more likely it is that feelings of helplessness will be diminished and a sense of control over his or her health will be increased.

Last updated on: April 17, 2017
Continue Reading:
Central Pain in Rheumatoid Arthritis

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