Long Island Neurosurgical & Spinal Associates (LINSA)

Pain Alleviation

Most cancer pain comes from the cancer tissue itself as it presses on or invades bones, nerves, organs, and other structures. The nature of the pain varies considerably, from a dull throbbing to a sharp burning sensation. The intensity varies as well, from a slight ache now and then to intolerable, excruciating pain in the advanced disease stages. Some cancer pain may be a side effect of the cancer treatment itself, caused by tissue necrosis and swelling from chemotherapy or radiotherapy.

What are common treatments for cancer pain ?

Physicians have a variety of options in treating cancer pain. The type of cancer, the rate and pattern of progression, and the needs of the patient are all taken into consideration by the physician in advising a specific treatment.

• Oral medication - Non-steroidal anti-inflammatory medication (NSAIDs), cortisone steroids or narcotic medication, such as morphine. Morphine is an inhibitory neurotransmitter that works in the spinal cord to interrupt pain messages before they reach the brain.

• Injections/Intravenous Infusions - With injections - 'shots' into the veins (intravenous), muscles (intramuscular), or under the skin (hypodermic) - the drug is absorbed more quickly into the blood system. A smaller dose may provide better pain relief with fewer side effects. Most of the patients who still have pain or serious side effects with oral medications find these injections an effective alternative. Terminal cancer patients may benefit from continuous intra-venous infusions by way of intra-venous morphine pumps. Eventually the side effects of these measures may outweigh their benefits.

• Intrathecal drug infusion - This technique involves implanting a drug pump with a catheter to deliver morphine into the spinal fluid space around the spinal cord (closer to the pain receptors than epidural injections). To provide the same pain relief, intrathecal morphine requires a much lower dosage than oral, intra-muscular, intra-venous or an epidural injections and consequently has much less systemic side effects.

• Destructive neurosurgical procedures - Examples of these procedures include: a cordotomy (surgical division of a tract of the spinal cord); rhizotomy (cutting a nerve close to the spinal cord); thalamotomy (electrocoagulation, or burning, of areas of the thalamus in the brain), or chemical destruction (alcohol nerve blocks, intrathecal phenol) of nervous structures. These procedures often bring about sensory or motor dysfunction, and relief is often only temporary since the pain usually switches to a different pathway or redevelops later.

What is the normal sequence for treatments for cancer pain ?

Patients with cancer pain often begin treatment with a mild pain reliever like ibuprofen or a weak narcotic such as codeine. As the cancer progresses, and these treatments no longer control the pain, many patients take stronger narcotics such as morphine, methadone, and dilaudid.Some patients eventually go beyond the point where oral medications can help them. The side effects are hard to tolerate, and sometimes oral drugs just do not stop the pain. The physician might then try injections into the muscles or the bloodstream -- a treatment that usually requires less drug. About 10 to 15 percent of all patients with significant intractable cancer pain require the more involved treatments, such as epidural injections or a drug pump. In cases where the patient Is expected to live more than three months, and responds to a trial dose of intraspinal morphine, it may be more cost effective to implant a drug pump. The need to go to the hospital for frequent injections is reduced because the programmable pump is refilled every two to three months, and dosage changes may be easily accomplished by reprogramming the pump. The automatic, precise drug delivery with an implanted pump is generally more effective, in particular for pain in parts of the body below the chest (though recent research suggests it is may also be a viable treatment for head and neck cancer pain). Implanting a drug pump requires minor surgery, however, and the patient needs to be carefully screened by a physician to determine if this therapy is an appropriate treatment. Destructive neurosurgical operations are often the last resort for some cancer pain patients. Unfortunately, many of these operations have a history of complications, and cutting the nerves does not always relieve the pain. These procedures are also irreversible, unlike the other methods listed above.

Will these treatments provide complete relief ?

Despite all measures, it is unrealistic to expect total eradication of a patient's pain. Therefor, the goal is to achieve a pain reduction of 70% or more, which means the patient is functional, able to live with the residual pain and capable of performing the basic, everyday activities (walking, eating, sleeping, etc.). Patients might not be as active as they were before having cancer, but they may not be bedridden either. Of the more progressive measures, drug pumps may provide improved pain relief about 80% of the time, while neurosurgical procedures are less likely to be effective and may produce more complications.

Since many of the medications are narcotics, won't patients become addicted to the drug ?

Cancer pain patients rarely become psychologically addicted to drugs. Chronic use of narcotic medications may cause a physical dependence on a drug, and withdrawal symptoms may occur if the drug is suddenly discontinued. However, if the medication is no longer needed, and/or the dosage is tapered off slowly, withdrawal symptoms can be avoided.

How much tolerance do patients develop to a drug ?

Fortunately, tolerance to narcotic drugs such as morphine is relatively low among most patients treated for cancer pain. Some patients, however, do develop high tolerances and require larger and larger doses of the drug to obtain adequate pain relief.