How to Treat Physical Pain? Breast Cancer Guidelines 2020

How to Treat Physical Pain? Breast Cancer Guidelines 2020

Physical pain is a common symptom in cancer patients, and there are many different options available to treat it.

Drug and non-drug treatments can be used for cancer pain. Medications include ibuprofen, Tylenol, drugs originally used to treat depression and seizures, medicine that goes on the skin, and opioids. Non-medication therapy options include surgery, radiation, acupuncture, and physical therapy.

The following sections will explain the definition of cancer pain and provide examples of a few treatment options available.

What is Pain?

According to the International Association for the Study of Pain, pain is defined as an unpleasant sensory and emotional experience, associated with, or resembling that associated with, actual or potential tissue damage. Pain is always subjective – it is unique to the person experiencing those feelings.

Pain can be divided into two general categories, acute pain and chronic pain. You may experience one or both of these pains at the same time. Acute pain is pain that lasts for a short period of time and can be associated with situations like surgery, diagnostic procedures, and short-term illnesses. Chronic pain is pain that lasts for a longer period of time, such as months to years. It comes from changes to your nerve function and nerve transmission. Chronic pain can come from acute pain never being properly treated, and therefore causing these nerve changes in your body, making it harder to control pain when it becomes chronic.

Cancer pain can include both acute and chronic pain. Acute pain may come from cancer treatment or a particular procedure, while chronic pain may come from the cancer itself or even some cancer treatments.

Breakthrough pain is when you have chronic cancer pain and also experience acute pain on top of that. This can sometimes lead to a pain crisis or emergency. Let your doctor know immediately if you are experiencing pain.

The most common cause of cancer-related pain is from the tumor itself. There are other causes of cancer-related pain as well. As someone with cancer, you may experience pain from your particular cancer because the tumor is pressing on parts of your body like your bones, organs, or nerves.

Pain can also be a side effect of chemotherapy, radiation therapy, or surgery. Pain can also come from diagnostic procedures like a biopsy (when a sample of your tumor is taken for testing). You may also experience pain that is unrelated to your cancer, like general pain that everyone gets at times.

Describing Pain

In order to manage your pain, your medical team will want to know whether your pain is mild, moderate, or severe.

This is a common example of a pain scale that you may see at your doctor’s office. On the scale, a 0 means no pain. Mild pain is between 1-3, moderate pain is between 4-6, and severe pain is between 7-10. Your medical team may use several ways to assess your pain and will tailor your pain treatment plan based on your individual assessment.

Your medical team will also want to know other things about your pain. In particular, it is helpful to describe the quality. For example, is the pain sharp? Or dull? Throbbing? Knife-like? The location of the pain in your body is important to describe. Other questions you will be asked include, Does the pain start in one place and move to another? What makes it better? What makes it worse? When did it start?

People who cannot communicate using words still experience pain but will need special considerations when trying to communicate pain. Their doctor may use other methods to assess their pain, like their behavior.

According to the NCCN Palliative Care Guidelines, treating pain has been shown to improve quality of life and perhaps even survival in people with cancer. The following treatments are available to help you treat your pain.

Medication for Cancer-Related Pain

Many types of medication are used in the treatment of pain. In general, your medical team will start with non-opioid medication and then add opioid-type medications if needed.

For acute pain, such as pain after surgery, we try to avoid opioids as much as possible because of the short- and long-term side effects.

Non-Opioid Pain Medications

These medications include medications that increase your pain threshold, decrease inflammation, and treat pain in your joints and nerve endings.

Acetaminophen (Tylenol)

Acetaminophen (brand name, Tylenol), may be used alone for mild pain or with an opioid (see below) for all types of pain. We’ll use the brand name because most people are familiar with the word Tylenol. Tylenol works by increasing your pain threshold.

You can get Tylenol over-the-counter and in higher doses as a prescription. It is available by itself or in combination with other drugs.

Sometimes, Tylenol is combined with opioids in the same pill, such as in the following medications:

  • Norco, Lortab, Vicodin (hydrocodone + Tylenol)
  • Percocet (oxycodone + Tylenol)
  • Tylenol #2, #3, #4 (codeine + Tylenol)
  • Ultracet (tramadol + Tylenol)

If you are given any of the above medications, you should not combine them with over-the-counter Tylenol without speaking with your doctor or pharmacist first.

Tylenol is also in a lot of over-the-counter cough-and-cold medications, so ask before you buy these as well. The maximum dose of Tylenol is 4,000mg in one day. If you are taking multiple products that contain Tylenol, you should still not exceed 4,000mg in one day.

Too much Tylenol can cause severe and even permanent liver damage, so be sure to speak with your medical team for any questions regarding how much medication to take. If you have liver problems, the amount of Tylenol that your body can handle is lower. Work with your medical team to make sure the dose of Tylenol is safe for you.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs may be used alone for mild pain or with an opioid for moderate to severe pain. They reduce pain and fever like Tylenol but also decrease inflammation. Some of the medications in this class are available over-the-counter, and some are prescription-only.

A few examples of NSAIDs are:

  • Ibuprofen (Motrin, Advil)
  • Naproxen (Aleve, Naprosyn)
  • Ketorolac (Toradol)
  • Celecoxib (Celebrex)
  • Diclofenac
  • Meloxicam (Mobic)

If one NSAID does not work, it is possible that another one will.

The short- and long-term side effects of NSAIDs include stomach bleeding, heart problems, kidney problems, and increased blood pressure. Your doctors will closely follow you for these side effects, but let them know if you experience any symptoms at home. One way to tell if you have a stomach bleed is to check if your poop is a black or tarry color or if it has visible blood in it.

Medicines Originally Used to Treat Depression (Antidepressants)

Several medications originally used to treat depression also work for neuropathic (nerve) pain. They can also help treat the aches and pains in the joints that some people have with hormonal treatment for breast cancer.

The way that the medications work to relieve nerve pain has nothing to do with how they work on depression. The following antidepressants may be used at lower doses for nerve pain:

  • Duloxetine (Cymbalta)
  • Venlafaxine (Effexor)
  • Amitriptyline (Elavil)

The medications can take a few weeks to work, so give it some time before you decide that they are not working.

These medications are generally safe, but ask your doctor and pharmacist about common side effects.

When some people start some of these medication, they may develop suicidal thoughts. Let your medical team know right away if you have these thoughts.

If you want to stop taking an antidepressant that you have been taking regularly, you will feel much better if you decrease the dose slowly. Stopping suddenly can lead to uncomfortable side effects like a “fuzzy” feeling, body pain, dizziness, and other uncomfortable feelings. 

If you decide that you want to stop the medication, work with your medical team to make the process of coming off the medication as smooth as possible for you.

Medications That Have Been Used to Treat Seizures

Anti-seizure medications have also been found to help with nerve pain. The most common are gabapentin (Neurontin) and pregabalin (Lyrica). These are generally safe, but a few side effects include sleepiness, leg swelling, and weight gain. Lyrica is a controlled substance, so there are stricter rules with monitoring, prescribing, and dispensing this medication.

These medications may also help with the hot flashes that some people have with hormonal therapy.

Other Medications

Topical pain relievers can be used when your pain is restricted to one area. Lidocaine patches and lidocaine creams are available over-the-counter, but higher strengths are also available as a prescription.

Diclofenac is an NSAID that also comes as a topical gel (Voltaren gel) that is available over-the-counter or as a prescription. Corticosteroids decrease inflammation and can be used for different kinds of cancer pain like diffuse bone pain, nerve compression, and bowel obstruction. Corticosteroids are generally restricted to short-term use.

Although not currently recommended by the NCCN Adult Cancer Pain Guidelines, medical marijuana has been used in chronic pain patients. The District of Columbia and many other states in America legalized the use of medical marijuana. Speak to your medical team for more information on medical marijuana for chronic pain treatment.

Opioids

Opioids are medications commonly used for moderate and severe pain. They work by blocking the pain receptors in your brain. Although there are risks involved with this class of medications, your doctor will monitor your doses to treat your pain safely. Be open and honest with your medical team in order to have the best management of your pain.

Because of the addictive potential of opioids, they are classified as controlled substances and require specific and strict rules for prescribing and dispensing.

Side effects include a decrease in breathing ability, lowered blood pressure and pulse, and sleepiness. Avoid opioids when driving since they can cause sleepiness and drowsiness. Also do not use these medications with alcohol because the combination can severely decrease your breathing ability. Opioids can cause tolerance and physical dependence when taken for an extended period of time. This specified time frame is unique to each individual patient. Opioids can also lead to addiction, so it’s important to only take this medication the way your doctor prescribed it for you. Keep these medications in a safe and secure place, away from children because fatal side effects can occur if they ingest it. The following are examples of opioid medications:

  • Buprenorphine (Subutex)
  • Codeine
  • Fentanyl (Duragesic)
  • Hydrocodone
  • Hydromorphone (Dilaudid)
  • Meperidine (Demerol)
  • Methadone
  • Morphine
  • Oxycodone
  • Oxymorphone
  • Tramadol (Ultram)

Another common side effect of this class of medications is constipation. Since constipation in opioids is common, chronically prescribed opioids are often given with a prescription for constipation. There are a handful of medications that can be used to treat and prevent constipation from an opioid, but the combination of Senna and docusate (Colace) is often used and is available over-the-counter. If you are started on an opioid, it is best if you also have a plan for how to prevent and treat constipation ahead of time. Speak with your medical team if you are experiencing constipation, as well as other side effects, so they can properly treat you.

Opioids can be given in different ways. They are mostly given by mouth as a tablet to swallow, a tablet to dissolve under your tongue, or a film to absorb inside of your cheek. They can also be given as a skin patch or nasal spray. Many opioids may be given in the form of an injection such as through an intravenous (IV) line.

Narcan (brand name for naloxone) is a “rescue” medication that you may be given with your opioid medication. It is used for opioid overdoses, which happen when too much of an opioid is ingested. Oftentimes this is accidental, but it is serious because it can suppress your breathing and lead to a coma or death. Narcan is used to reverse the effects of an opioid in your body and is available as a nasal spray or injection. Some states offer this medication at your pharmacy without a prescription, but you can always ask your doctor for a prescription if you want to keep it at your home in case of an accident.

Some people with cancer-related pain want to wait to take opioids because they want to save it for when their pain is severe. If you are concerned that this might happen, talk with your team about other options. After you start on opioids, you may have to have your dose increased or changed to have the best control of your pain. This is not due to addiction but rather opioid tolerance. Your body has become used to the dose of the medicine and a change is needed. Addiction refers to unhealthy behaviors related to your pain medicine, such as taking more than is prescribed for you, telling stories that aren’t true to get more medicine, or using your pain medicine because of the way it makes you feel rather than for relief of pain.

Non-Drug Treatment of Cancer-Related Pain

Psychosocial Resources

Emotional reactions to pain are normal and evaluated/treated as part of a complete pain assessment. Your medical team may provide you with psychosocial options to help treat your pain. Psychosocial interventions are all interventions where counseling or behavior management is used. These would be used in addition to medication. Below are a few examples of these options:

  • Learning coping skills to provide pain relief
  • Speaking with a skilled, talk therapist to learn skills for pain management
  • Learning coping skills for relief of short-term pain (for example, breathing exercises, distraction techniques)
  • Learning coping skills for relief of long-term pain (for example, relaxation techniques, guided imagery, hypnosis)

Surgery or Interventional Procedures

Some pain can be treated by invasive procedures like surgery or interventional procedures. These methods often use minimally invasive techniques to block the transmission of pain signals to your brain and are generally safe. These procedures are often done by a surgeon, an anesthesiologist who specializes in treating pain, or a specialist in Physical Medicine and Rehabilitative Medicine.

Below are a few examples.

  • Nerve block – injects a local anesthetic into or near a nerve for short-term pain relief.
  • Medication infusion – uses a catheter to inject a pain-relieving drug into your body. A widely known example is an epidural injection, which is when medication is injected into the epidural space near your spinal cord.
  • Neurostimulation – interrupts the pain signals traveling to the brain by modifying the nervous system’s electrical activity. This technique can either be invasive or non-invasive.
  • Ablation therapy – interrupts the pain signals traveling to your brain by destroying or removing a portion of nerve tissue in the area that causes you pain.
  • Surgery – can be done on the cancer itself, or the organs in your body that the cancer is affecting. Surgical intervention can reduce your pain.

Radiation Therapy

If you have pain related to cancer in the bone or other parts of your body, radiation therapy can often treat that pain with just a few short treatments.

Other Ways That You Can Manage Your Pain

All of these options are safe and should be used in addition to your pain medications. Talk to your medical team about these options for treatment.

  • Pacing your activities to conserve your energy
  • Massage
  • Heat or ice
  • Acupuncture or acupressure

Physical Therapy, Occupational Therapy, & Other Rehabilitation Services

Physical therapists, occupational therapists, and Physical Medicine and Rehabilitation physicians can help you with recommendations for the way best to function at home and may also prescribe the following

  • Ultrasonic stimulation
  • Bed, bath, and walking supports
  • among others

Integrative Therapy

Integrative therapy for pain management is combining both mainstream medical care and non-conventional therapy. For cancer pain, the non-conventional options will usually be added on to your medication therapy and are generally safe. A few of these non-conventional options are listed below.

  • Imagery or hypnosis
  • Distraction training
  • Relaxation training
  • Active coping training
  • Tai chi, yoga, mindfulness, or meditation
  • Biofeedback (using techniques to gain control over your pain by using the power of your mind and becoming aware of what’s going on inside your body)
  • Any of the rehabilitation therapy listed in the section above

*Special Considerations: Elderly Patients*

Older patients are more sensitive to side effects from medications, so treating their cancer pain may look a little different from that of younger patients. Medication doses may start lower since they are more sensitive to the side effects listed above for opioids and NSAIDs. There is also a risk of their pain not being treated properly due to not communicating when they have pain, not reporting their pain, or not having effective doses due to concerns about drug side effects.

If you are an older person, talk with your doctor about any pain that you may have, as well as any side effects that you experience. Being open with your medical team about your pain symptoms will improve how fast you recover, improve your physical and mental function, and improve your appetite and sleep.

Final Thoughts…

Untreated pain can cause nerve changes in your body and make it harder to control pain in the future. There are many options to treat your cancer pain, and only a few were mentioned above. Talk to your medical team if you are experiencing pain so that your pain can be treated properly. Be open and honest with your doctor about any side effects that you experience.


References

  1. Swarm RA, Youngwerth JM, Anghelescu DL, et al. National Comprehensive Cancer Network Guidelines: Adult Cancer Pain. Version 1.2020 From the National Comprehensive Cancer Network; April 2020. https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf. Accessed July 10, 2020.
  2. Merskey H, Bogduk N. Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. In: Classification of Chronic Pain, 2e. IASP Press; 1994. https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698#Pain. Accessed July 10, 2020.
  3. Dans M, Kutner JS, Baker JN, et al. National Comprehensive Cancer Network Guidelines: Palliative Care. Version 1.2020 From the National Comprehensive Cancer Network; February 2020. https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf. Accessed July 10, 2020.
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  6. Baumann TJ, Herndon CM, Strickland JM. Chapter 44. Pain Management. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 9e. McGraw-Hill; 2014. https://accesspharmacy-mhmedical-com.ezproxy.findlay.edu/content.aspx?bookid=689&sectionid=45310494. Accessed July 10, 2020.
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