Integrative Cancer Pain Management
By Gwendolyn M Stritter, MD
Uncontrolled pain is one of the most feared consequences of cancer or
its treatment. Therefore, meticulous pain management is essential for the
quality of life of many people living with cancer.
Integrative pain management techniques can improve pain control while
minimizing unwanted side effects.
WHAT IS PAIN?
Pain is "an unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms of such damage."
A pain’s sensory and emotional components are not easily separated
and its subjectivity makes it inherently difficult to measure and research.
Eduardo Bruera, MD, at the University of Texas MD Anderson Cancer
Center expressed it well when he said, "What I call pain is not the same
thing as what Mr. Smith calls pain. For me, pain is clearly afferent
nociceptive
stimulation
by the spinothalamic tract into the somatosensory cortex. Mr. Smith calls
pain something completely different. It's the pain that he has
in the back, his fears, his losses, his worries. All those things are
part of what
Mr. Smith has all the right in the world to call pain. His doctors cannot
run away and steal the word."1
In other words, pain is an individual sensation that is difficult to
specifically define, but "you know it when you feel it."
WHY BE PROACTIVE REGARDING CANCER PAIN MANAGEMENT?
Most physicians are not trained in pain management. Although the
State of California passed a bill in 1997 requiring all physicians
to have a minimum of 12 hours of pain management education, it is not due to go into full effect until 2007.
As a group, oncologists are more pain-management savvy compared to
their peers in other subspecialties. Nevertheless, in my experience
they may
know little about complementary and alternative techniques that
show evidence of effectiveness in the medical literature. They also may
delay seeking
more
aggressive pain-management techniques when the usual pain medications
and combinations do not work well.
Armed with a basic understanding of pain management concepts, patients
with cancer will be better equipped to take advantage of the many pain-relieving modalities currently available.
WHAT CAUSES CANCER PAIN?
Generally, three things will cause pain in people with cancer:
» The Cancer Itself. As a cancer grows, it can press on structures that
cause pain.
» Cancer Treatments. Chemotherapies, such as Cisplatin, Taxol, and Taxotere,
can cause a painful peripheral neuropathy, a condition arising
from malfunctioning pain nerves. Occasionally,
there can be pain after radiation therapy. Surgery, such as that
done to remove all the lymph nodes in the armpit, can also cause
pain and
swelling.
» Coincidental Pain. This type of pain has nothing to do with the cancer
and its treatment. A good example is a pre-existing low back or arthritis pain.
HOW DO YOU MEASURE PAIN?
Pain is a subjective sensation that cannot be measured by a
blood test or scan. It is so closely intertwined with nausea, breathlessness,
depression, fatigue, and anxiety that it is difficult to separate
them.
Most health practitioners use a patient-reported 10-point scale
to document their patient’s pain and their response to
treatments. A zero on this scale means no pain and a 10 is
the worst pain imaginable.
Generally, pain from 1 to 3 is considered mild, from 4 to 6 is
considered moderate, and 7 or above is considered severe.
The goal of a pain management program is to get the pain down
to a 3 or less on this 10-point scale.
WHAT ARE THE DIFFERENT TYPES OF PAIN?
Generally speaking, one can divide pain into five types: myofascial
pain, which primarily originates in muscles; bone pain; visceral
pain, which comes from internal body organs such as the lungs,
liver, and
bowel; neuropathic
pain, which results from malfunctioning nerves; skin and
scar pain; and psychological pain. Many times, pain has more than one cause.
For example, myofascial pain is sustained and even worsened by psychological
stress that tenses up the muscles.
Myofascial pain also deserves special mention because its
cause typically does not show up on X-rays or scans. One
of the most common mistakes a health practitioner can make
is to assume
that someone's pain is psychological because the X-rays
and scans are normal.
Neuropathic pain may also not show up on medical tests,
such as nerve conduction studies. Neuropathic pain is
by far the
most painful of any type of pain condition as its malfunctioning
pain nerves erroneously send strong pain signals to the
brain. This type of pain usually requires several different
pain
treatment modalities for relief.
Cancer can cause any and all of the above types of pain.
HOW CAN YOU TELL WHAT TYPE OF PAIN IS OCCURRING?
Often, just taking a thorough history and physical examination
is enough to find the source of the pain. For cancer
pain specifically, X-rays, CT, MRI, PET, and bone
scans may
also be helpful.
Occasionally, a clear diagnosis of the pain source
is needed but not evident from the above tests.
For conditions
such
as myofascial
pain and neuropathic pain, diagnostic blocks may
be in order.
A diagnostic block consists of an injection of
local anesthetic (e.g. into a muscle trigger point
or around
a nerve); if
the injection
relieves the pain, then the pain source has been
located.
HOW IS CANCER PAIN BEST TREATED?
I first became interested in the integrative treatment
of pain – using
the tools available to both Western and complementary/alternative health practitioners – about 15 years ago when I
learned of acupuncture clinical studies that showed an
intriguing
ability to relieve pain without the adverse
effects associated with most pain mediations. Since then,
I have
found that
using complementary and alternative (non-pharmacologic)
techniques in concert with Western (pharmacologic)
approaches consistently
results in better pain control with lower adverse effects.
There are two concepts I have found to be useful
in the understanding of the integrative treatment of pain. The
first concept is a modification of the well-known
World Health
Organization three-step pain management pyramid:
My modification has two additional steps: non-pharmacologic techniques serve
as the foundation of any complete pain management program and is added
as the first step. Interventional techniques (e.g. nerve blocks), an often
overlooked pain relief technique for severe pain that does
not respond to other interventions, is added to the top of the pyramid:
The second important integrative medicine concept is what I call “Gwen’s
Rule of Tens”:
»
If you make one intervention that decreases your pain by 10%, you have not
affected your pain control very much.
»
If you make ten interventions that each decrease your pain by 10%, you are
much closer to 100% pain control.
»
Therefore, if an intervention has very low side effects, does not interact
with other medications or supplements, and has about 10% activity, consider
adding it to your pain management program.
In other words, many low or no-toxicity
modalities will make for a more successful pain management program than
relying on just one or two.
NON-PHARMACOLOGIC PAIN MANAGEMENT TECHNIQUES
A detailed discussion of all non-pharmacologic modalities is beyond the
scope of this article, however some of my favorites include:
Traditional Chinese Medicine
Many readers will be familiar with the acupuncture and herbs that
are most often associated with Traditional Chinese Medicine
(TCM). TCM has a several thousand-year history of study and practice.
In the past decade, the interest in TCM by Western medicine practitioners
has surged. A recent search of the Western medical literature on studies
including
the words "acupuncture" and "pain" revealed
over 2,500 articles.
Despite the fact that TCM does not easily fit into the scientific
clinical study method, acupuncture has been shown to relieve cancer pain
in
several studies.2, 3 A recent article in Integrative Cancer Therapies
gives an
excellent review of the subject.4 One study bears particular mention
since patients in the acupuncture group had their pain reduced by more that
35%. This study, by Alimi
et al, is especially
impressive because many patients had neuropathic pain, the most difficult
type of pain to treat by Western medicine standards.5
Manual Medical Modalities
Craniosacral osteopathy, a hands-on technique involving gentle manipulation
of the bones of the skull, and chiropractice can be very useful
for musculoskeletal pain. The manipulation and ergonomic counseling that
forms the basis
of this modality are highly beneficial. In addition, craniosacral
osteopaths who
are also proficient in visceral osteopathy can be helpful for those
with visceral pain.
To my knowledge, there are no randomized, controlled clinical trials
that have looked at the effectiveness of osteopathic and chiropractic
techniques
in the cancer pain population. However,
anecdotal evidence has been published.6
Osteopaths, chiropractors, and other health professionals often
use the electro-acuscope, a microamperage transcutaneous electrical
nerve
stimulator
that appears to
strengthen the body’s own (endogenous)
cellular healing pathways. Although not yet tested in randomized
clinical trials, there is some anecdotal evidence of efficacy7
and I believe this technique shows much promise.
Massage therapy is another useful manual technique, which has
demonstrated effectiveness in reducing stress and anxiety
as well as pain.8,
9
Movement Therapies
Yoga and Qi Gong are examples of movement therapies that
have long been known to promote pain relief in people with
benign
health
conditions.10, 11, 12
By extension, it makes sense that these modalities would
also benefit those with cancer pain. Indeed, my clinical
experience
has borne
this out. Although
not yet extensively studied, Pilates, Feldenkrais, and Alexander movement therapies
have been effective in many of my cancer patients.
Relaxation Response
Modalities under this rubric include meditation, guided
imagery, hypnosis, and biofeedback. Its scientific evidence
of effectiveness
is so strong
that many Western cancer centers now routinely offer
these modalities to their
patients.13, 14 No pain management plan is complete without
including at least one modality that incorporates
the relaxation response.
Nutritional Approaches
Most Western medical scientists have not studied diet
and dietary supplements in the context of cancer pain,
but
it makes sense
that any diet that
minimizes the body’s propensity to produce inflammatory
proteins would be useful.
Interestingly, current medical literature finds that
many of the processes that promote inflammation also
promote
carcinogenesis.
An excellent publication by Dr. Jeanne Wallace helps
to elucidate the place of anti-inflammatory supplements
in
the protocols
of people with
cancer.15
She presents data supporting the idea that supplements
such as omega-3 fatty acids (fish oil), curcumin,
boswellia, and
many
others have
a definite place
in an anti-inflammatory, anti-cancer diet.
When formulating a nutritional approach to cancer
and its pain, one must be very careful in selecting
supplements
that are
high quality
and lack
deleterious interactions with prescribed medications
or
other supplements. A practitioner
of traditional Chinese medicine, naturopath, or
integrative medicine physician can be invaluable in helping one
to devise such a regimen.
PHARMACOLOGIC PAIN MANAGEMENT TECHNIQUES
Non-steroidal Anti-inflammatory Medications (NSAIDs)
These are appropriate for mild-to-moderate pain that does not respond to
non-pharmacologic treatments. Anti-inflammatory medications such as Advil,
Motrin, and Naprosyn are most commonly
used. These are especially useful for pain caused by cancer involving the
bones.
Their major side effect is inflammation of the stomach (gastritis
as well as bleeding and nonbleeding ulcers), which can be minimized by
taking antacids and other agents such as sucralfate and misoprostol (Cytotec).
Those
taking blood-thinners or those with bleeding disorders or kidney or liver
problems need to take special care when taking anti-inflammatories.
Recently, clinical trials have shown that NSAIDs such as Motrin, Advil,
Aleve, and Celebrex are associated with a small increased risk of heart
attack.
Therefore, those who have increased
risk (family history, high blood pressure or cholesterol, or diabetes)
must be especially careful.
Acetaminophen (Tylenol) is also included in this group. It neither causes
stomach upset nor does it interact with blood-thinners.
However, it can be toxic to the liver and kidneys when taken for extended
periods or at doses higher than recommended.
Steroidal Anti-inflammatory Medications
Drugs such as prednisone, hydrocortisone (Cortef), methylprednisolone
(Medrol), and dexamethasone (Decadron) are commonly prescribed in this
group. They are especially useful for pain caused by inflammation and
bone metastases.
Their main disadvantage is a long list of serious side effects that
potentially occur in those who take them at higher doses for prolonged
periods. These
adverse effects include infections, fluid retention, suppression of
the adrenal gland, osteoporosis and bone fractures, stomach upset and
ulcers,
diabetes,
and steroid-induced psychosis.
Adjuvant Medications
Adjuvants are used with pain medications to increase their pain-relieving
effects:
»
Antidepressants. It was not long after the introduction of anti-depressants
that their ability to relieve pain was noticed.
This effect is commonly seen at doses lower than those typically
prescribed for depression and are usually seen best in those with
neuropathic
pain. Drugs such as amitriptyline (Elavil) and nortriptyline (Pamelor)
are
commonly
prescribed tricyclic–type antidepressants. Fluoxetine (Prozac) and
Paroxetine (Paxil) are examples of SSRI (selective
serotonin reuptake inhibitors) antidepressants.
Tricyclics can cause drowsiness, dry mouth, fast heart rate, sexual
dysfunction, and urinary retention. They should be used carefully
in those with heart
conditions. SSRIs can cause nausea,
insomnia, sexual dysfunction, and anxiety.
»
Anti-convulsants. These medications are particularly useful for those people
who suffer neuropathic pain; it makes sense that a drug that calms down “brain
nerves” so as to avoid seizures will also calm down pain nerves.
Gabapentin (Neurontin) and topiramate
(Topamax) are good examples and common side effects include drowsiness
and dizziness.
»
Muscle Relaxants & Anxiolytics. Baclofen (Lioresal), carisoprodol
(Soma), and cyclobenzaprine (Flexeril) are commonly
used muscle relaxants and may cause drowsiness.
Anxiolytics are very useful when anxiety maintains or increases a pain
problem. They also have muscle relaxant effects. Lorazepam
(Ativan), diazepam (Valium), and clonazepam (Klonopin)
are examples. They can all cause problems with alertness, physical
coordination, and memory.
»
Bisphosphonates. For cancer patients with bone pain, this group of drugs
can provide surprisingly good pain relief. Used most often in prostate and
breast cancer patients, these drugs will also build up bones; those at risk
for osteoporosis would also benefit from those drugs. They have very few
side effects except for the rare case of osteonecrosis of the jaw, a condition
where a portion the jawbone will break down.
Opioid Medications
Codeine is a mild opioid best used in combination with NSAIDs for
mild or occasional moderate pain. Morphine (e.g. MS Contin, Roxanol),
methadone,
hydromorphone (Dilaudid), and oxycodone
(found in Percocet and Oxycontin) are very good opioids for moderate
to severe pain.
Severe pain is best managed by combining different types of opioids.
First, a long-acting opioid (MS Contin, Oxycontin, methadone) is
taken around
the clock. If pain “breaks through” the long-acting
opioid, a short-acting opioid (Roxanol, oxycodone,
hydromorphone) is taken as needed.
Skillfully combining a long-acting and short-acting opioid can
prevent people with cancer from being on the “pain roller coaster” where periods
of too little medication (severe pain) alternate
with periods of too much (drowsiness, nausea). No matter what kind
of opioid medication one is taking, a proactive bowel program is
in order
to prevent
constipation, the most common opioid side effect. Other side effects
include drowsiness, nausea, lack of appetite and, at high doses,
muscle twitching.
Many people taking opioids are concerned about becoming addicted to them.
Addiction is both a physical and psychological condition where a person uses
his or her drug of choice to satisfy emotional cravings. The incidence of
addiction in people with cancer pain has been found to be very low (7 out
of 24,000 cancer patients).16
Addiction is often confused with dependence. Dependence is a physical (not
psychological) condition found in people who take daily opioid medications
for prolonged periods. This results in an uncomfortable withdrawal syndrome
(restlessness, insomnia,
yawning, sweating, muscle cramps, nausea, and vomiting) should the opioid
be stopped abruptly. Slow weaning of the opioids
minimizes withdrawal symptoms.
Interventional Pain Management
Moderate to severe pain sometimes does not respond adequately to the combination
of non-pharmacologic interventions, opioids, and adjuvant medications
or, occasionally, the prescribed medications
cause severe side effects. In these cases, interventional pain management
is in order. Although these techniques are great for pain control, the
potential for complications is also greater, which is why they are not
used in patients
with milder pain.
Anesthesia techniques, such as permanent nerve blocks, and spinal cord
stimulation can be very useful. Surgical techniques also have a place,
particularly in
the case of cancer involvement in the spine where one can restore the
integrity of a collapsed vertebra
(vertebroplasty). Radiation therapy can treat cancers localized to a
single bone. Finally, radiopharmaceuticals (intravenous forms of low-dose
radiation
that hones in on bone) such as strontium-89 (Metastron) and samarium
(Quadramet) can treat bone pain caused by bone metastases to more than
one bone.
Of note, CyberKnife, a state-of-the-art radiation therapy technique,
can be useful for painful bone metastases in the spinal area that are
not amenable
to standard surgical approaches.
Cancer–directed Therapies
When pain is caused by an expanding tumor, then therapies that shrink
or eradicate the tumor are appropriate. Such therapies include chemotherapy,
radiation, and surgery as indicated.
SUMMARY
Integrative pain management provides the best pain relief with
the minimum of side effects. Use of multiple non-pharmacologic techniques
affords additive and possibly even synergistic effects so that small
individual gains in pain relief can be multiplied significantly;
they form the foundation
of any complete pain management program.
Pain medications, when used appropriately, can successfully relieve
severe pain not relieved by non-pharmacologic means. In those cases
where other
interventions are not successful, interventional
pain management techniques are indispensable.
Gwendolyn Stritter, MD, is a board-certified anesthesiologist and pain
specialist and a member of the American Society for Clinical Oncology,
the American Association for Cancer Research, and the American Pain Society.
Her practice is based in Portola Valley, California. Dr. Stritter would
like to thank Carl Stritter and Ann Baldwin for reviewing this manuscript. She
can be reached through her website: www.strittermed.org
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What Are Common Pain Managment Mistakes?
The most common mistake is that long-acting and short-acting opioids are
not used in tandem for moderate to severe
pain. Relying primarily on short-acting pain medications results in a "pain
roller coaster." Simply adding a long-acting opioid around the
clock can result in better pain control while using the same, or even less,
pain
medication.
The next most common mistake is that health professionals
do not move quickly enough into interventional pain management when it
is needed. I have often seen patients wonder at the delay in referral to
pain
management
specialists when the referral resulted in less pain and increased alertness.
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Resources for People with Cancer Pain
Cancer-pain.org discusses both Western and CAM approaches to cancer pain:
www.cancer-pain.org/treatments/alternative.html
Beth Israel’s website has a more detailed look at CAM pain management
techniques:
www.stoppain.org/pain_medicine/content/
treatments/complementary.asp
The Natural Medicines Comprehensive Database, available
by subscription, has detailed descriptions of herbs and supplements:
www.naturaldatabase.com
The American College of Physicians discusses pain and
management from a Western point of view:
www.acponline.org/public/h_care/3-pain.htm
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.................................................................................................................... References:
1. Oncology. May 2004;49.
2. European Journal of Surgical Oncology. 1985;11:389–394.
3. J Traditional Chinese Medicine. 1998;18(1):31-38.
4. Integrative Cancer Therapies. Jun 2005;4(2):131-4.
5. J of Clinical Oncology. 2003;21:4120–6.
6. J of Manipulative and Physiological Therapeutics. 2001 Jan; 24(1):52-7.
7. International Journal of Radiation Oncology, Biology
and Physics. Sep 2002;
54(1): 23-34.
8. Cancer Control: J of the Moffitt Cancer Center. Jul 2005;12(3):158-64.
9. J of Pain and Symptom Management. Sep 2004;28(3):244-9.
10. Pain. May 2005;115(1-2):107-17.
12. Physical Medicine and Rehabilitation Clinics of North
America. Nov 2004;15(4):783-98.
13. J Alternative and Complementary Medicine. Jun 2004;10(3):456-62
14. Supportive Care in Cancer. May 2004;12(5):293-301.
15. CA: A Cancer Journal for Clinicians. 2005;55:109-116
16. Integrative Cancer Therapies. 2002;1(1): 7-37.
17. Friedman, DP et al. J Pain Symptom Manage. Feb 1990;5(1 Suppl):S2-5.
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