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The Pain Doctor

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Understanding and Managing Cancer Pain

Pain is the most common complaint in medicine. In cancer practice, it often heralds the presence of a tumor. Any new complaint of pain in a known cancer patient should be considered a recurrence until ruled out. Cancer patients frequently associate worsening of pain as a sign of a deteriorating condition, while its lessening may indicate a resolving, or an improving condition. Large sums of money are earmarked for research to develop innovations in cancer therapy, yet precious little time and resources are devoted to the study and treatment of this singular, most common complaint. At present, less than 1% of National Cancer Institute grants are used to fund pain-related research. Despite this lack of funding, advances have been made in improving the cancer patients’ battle with pain.
While obviously influenced by the underlying cancer responsible for the discomfort, pain per se is associated with significant personality changes and dramatically affects quality of life. Cancer patients commonly require combinations of medications to achieve pain relief and are expected to self medicate appropriately as needed. This is becoming more common and is appropriate when one understands the multitude of chemical receptors that are involved in the development of pain. Drugs such as antiepileptics and antidepressants are commonly used as supplemental pain therapy in some types of pain. But these medications do not just serve as pain relieving adjuncts. Denial, depression and anxiety are not uncommon [nor should they be surprising] findings in the cancer patient. These need to be addressed medically and behaviorally as the entire patient needs treatment in order to achieve the best possible result.

Opioids (e.g., morphine and related compounds) continue to remain the mainstay of cancer pain management. There are a multitude of different preparations as well as a variety of routes in which they may be administered. Patient prescriptions need to be individualized and a specific program tailored to each patient’s specific needs and tolerance. While oral medications are by far the most popular, other routes are increasingly being used. Transdermal, oral transmucosal and spinal delivery of opioids are frequently included in the treatment armamentarium. Other, less commonly used routes include the rectal, inhaled, subcutaneous and intravenous routes, which have their indications and may be of benefit in selected patients.

Interventional Techniques to relieve pain are becoming more prevalent. Dr. Ricardo Plancarte’s group from the Cancer Institute of Mexico City has long renowned as pioneers in interventional approaches to cancer pain relief. The use of chemical neurolysis (i.e., alcohol or phenol to destroy nerves) has a long history of use in the cancer patient. Dr. Plancarte’s group has developed new techniques (e.g., superior hypogastric plexus neurolysis [pelvic pain], ganglion impar block [perineal pain], thoracic transdiscal splachnic [upper abdominal pain] nerve blocks) to treat pain more effectively, with fewer side effects. As long as patients are selected appropriately and there is understanding of the risks and possible post-procedural sequelae, it is an attractive option for analgesia in the cancer patient. Spinal catheters and implanted pumps are also options available for pain control using a fraction of the amount of medications that need to be administered by the oral route. A myriad of catheters and pumps exist, progressively more sophisticated that improve pain relief, functionality and may affect longevity. Each has their accompanying indications and drawbacks which need to be taken into consideration but are largely appropriate options to any cancer patient.

Bony metastases are common therapeutic dilemmas faced by many cancer patients. Multidisciplinary approaches into their management are essential in order to obtain optimal control. Stabilization and prevention of a spinal catastrophe are as important, if not more so, than pain control and need to be addressed quickly, in order that maximum neurological function may be preserved.

Barriers to effective pain relief exist. Some of these originate at the treating physician level, where the knowledge base may not be sufficient to adequately treat complex pain problems. Other barriers exist at the patient or caregiver level, where they may be reluctant to take opioid medication for fear of addiction or loss of faculties. Another great impediment to effective, widespread pain relief is real or perceived regulatory scrutiny. Examples of these are recent actions by the DEA supporting regulations, such as triplicate prescriptions. In these, a copy of each controlled substance prescription goes to the physician and the other two to the pharmacist, who keeps one and forwards the other to the respective State Department of Health. There has been no comprehensive evaluation of these programs for efficacy, yet millions of dollars are spent each year to operate them. While enormous strides have been made in the last 2 decades in improving pain management, the prescribing physicians and patients should take the lead role in contacting their legislators and encouraging them to enact legislation aimed at combating obstacles towards adequate pain relief by early pain diagnosis, appropriate referrals, and strident opposition to questionable regulatory scrutiny. Legislators nationwide are finally realizing the importance of pain relief, especially in cancer patients. Recent studies have added to the perception that improved pain control with greater functionality is associated with greater longevity in cancer patients, largely by minimizing the use of larger doses of opioids, which may affect vitality.

Cancer appears to be flourishing in our Society. Its diagnosis is made earlier and more consistently, making curative intervention, or at the very least a longer life, more commonplace. Cancer and its therapeutic strategies, such as surgery and radiation, may induce pain syndromes. In the final stages of life, most cancer patients have come to terms with their mortality. Their main concern may not be unrealistic expectations of survival, but rather a very clear request that their remaining days not be ones in pain. It is a request that demands our full and undivided attention.

“We must all die. But that I can save him from days of torture, that is what I feel is my great and ever new privilege. Pain is a more terrible lord to mankind than death itself”
Albert Schweitzer, M.D.

Rafael Miguel, M.D.
Professor of Anesthesiology
Program Director, Pain Medicine
Department of Anesthesiology
University of South Florida

Interventional Pain Program
H. Lee Moffitt Cancer Center
Tampa, Florida

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