Pain

Are you a health professional?

This page does not replicate the other information in this handbook but provides additional details or context most relevant to professionals.

Right up there with a person’s fear that their cancer will kill them is the fear that it will cause them unbearable pain and suffering. That latter fear is so great as to lead some recently diagnosed patients to consider or even attempt suicide to avert something that may never happen. They don’t know that most people with cancer won’t have severe persistent pain. They don’t know that if they develop such severe pain, there really is good effective pain management provided by experts such as medical oncologists and palliative medicine practitioners. It seems that our first job as healthcare professionals is to learn: What fears, misinformation and misconceptions are on your patients’ minds? What are your own fears, knowledge deficits, and misconceptions about cancer pain management? What are the resources and who are the experts in cancer pain management to whom you can refer your patients?

Many of your patients with cancer are likely interested in knowing if there is anything they can do with lifestyle practices and/or complementary therapies to help with pain control. As we’ve outlined above, many such practices and therapies are helpful alone in relieving mild pain, and/or effective as adjuncts in managing moderate to severe pain, including reducing opioid requirements.

What your patients also respond to intuitively is the sincerity with which you bear witness and attend to their suffering and convey your commitment to care for them even when cancer treatment fails and dying is imminent. This way of being with those you serve is therapeutic in itself and activates a powerful belief in your patients which tends to improve the perceived effectiveness of pain management. If you want to learn more about belief activation, Green and Wright have written an eloquent and compelling paper on the deliberate use of placebo effect tools by both patients and clinicians to catalyze healing. For example, speaking positively and enthusiastically about the treatment you prescribe to begin to build positive patient expectations.¹Green J, Wright H. From bench to bedside: converting placebo research into belief activation. Journal of Alternative and Complementary Medicine. 2017 Aug;23(8):575-580.

Words make a difference, especially when coming from an authority like an oncologist to a patient who is just diagnosed with cancer and is vulnerable. Learning how to appropriately discuss data and probabilities with patients without undermining hope is an important skill for all clinicians. Research on the placebo effect, hypnosis, and informed consent have shown that the messaging and rituals of care can either reduce pain or enhance it, depending on how they are delivered. Learning how to enhance the former (placebo) and minimize the latter (nocebo) is important no matter what the actual treatment being delivered.

Clinical practice guidelines for professionals who are managing pain

More practice guidelines are described in How do integrative experts manage pain? ›

Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline ›

2016 recommendations:

Clinicians should screen for pain at each encounter. 

Recurrent disease, second malignancy, or late-onset treatment effects in any patient who reports new-onset pain should be evaluated, treated, and monitored. 

Clinicians should determine the need for other health professionals to provide comprehensive pain management care in patients with complex needs. 

Systemic nonopioid analgesics and adjuvant analgesics may be prescribed to relieve chronic pain and/or to improve function. 

Clinicians may prescribe a trial of opioids in carefully selected patients with cancer who do not respond to more conservative management and who continue to experience distress or functional impairment.

Risks of adverse effects of opioids should be assessed. 

Clinicians should clearly understand terminology such as tolerance, dependence, abuse, and addiction [substance use disorder] as it relates to the use of opioids and should incorporate universal precautions to minimize abuse, addiction, and adverse consequences.

Use of opioids for adults with pain from cancer or cancer treatment: ASCO guideline ›

This 2023 guideline begins with a strong recommendation that opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Further recommendations address details of opioid use.

This 2018 guideline provides recommendations on these topics: 

This 2022 guideline includes thirty-five recommendations: 19 for the pharmacological management of cancer pain, 6 for the management of opioid-induced adverse effects, and 10 for pharmacological treatment procedures.

2022 recommendations relate to these topics:

2017 recommendations:

Mild pain: Non-opioids, such as paracetamol (acetaminophen) and NSAIDs, must be considered for management of cancer pain in this setting. Combining two NSAIDs does not improve analgesia and increases toxicity.

Moderate pain: Mild opioids are the basis of treatment, in combination or not with drugs described

for mild pain. Low doses of strong opioids together with non-opioid drugs can be weighed as an alternative to mild opioids.

Severe pain: Strong opioids are the cornerstone of analgesia in this setting. Transdermal (TTS) opioids (fentanyl, buprenorphine) are valid alternatives when oral opioids are not suitable and analgesic requirements are stable.

Managing side effects of pain medications: Management includes the following: (1) patient information and prophylactic measures; (2) reduction in opioid dose through the use of a co-adjuvant and/or first step drug; (3) pharmacological strategies, such as antiemetics for nausea, laxatives for constipation, tranquillizers for confusion, psychostimulants for drowsiness; and (4) switching to another opioid or route.

2019 recommendations are organized into three focal areas:

1. Analgesia of cancer pain: Choice of analgesic medicine when initiating pain relief and the choice of opioid for maintenance of pain relief, including optimization of rescue medication, route of administration, and opioid rotation and cessation.
2. Adjuvant medicines for cancer pain: Use of steroids, antidepressants and anticonvulsants as adjuvant medicines.
3. Management of pain related to bone metastases: Use of bisphosphonates and radiotherapy to manage bone metastases.

Other expert recommendations

McPherson ML, Walker KA et al. Safe and appropriate use of methadone in hospice and palliative care: expert consensus white paper. Journal of Pain and Symptom Management. 2019 Mar;57(3):635-645.e4.

Basic principles of managing persistent cancer pain

Oncologists and palliative medicine practitioners usually consider widely accepted management principles in developing a treatment plan for persistent pain.²Paice JA, Portenoy R et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology. 2016 Sep 20;34(27):3325-45; WHO Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. World Health Organization. January 2019. Viewed January 27, 2023.

“Communicating an intent to control pain and stress early on and emphasizing the concern reassures. both the patient and family. This includes active, concerned inquiry about pain, sleep, mental status, energy, and functional capability. Discussion should include family members as well as the patient.”³Chapman CR, Gavrin J. Suffering and its relationship to pain. Journal of Palliative Care. 1993;9(2):5-13.

Persistent cancer pain can be managed, often with relatively simple treatments such as oral analgesics and adjuvant analgesics. The plan should seek to bring the pain under control and keep it under control around the clock. Note that good pain control doesn’t necessarily mean the pain will go away. The goal is to bring it to a level the patient considers manageable. If the pain is frequent or constant, consider using treatments that are long-acting and are taken/administered no more than two or three times a day.

Treat unrelieved pain as an urgent problem. Pain assessment, most especially your patient’s description of pain and its impact on their life, is the place to start. Listen to the story of people’s pain and suffering, knowing that telling the story sometimes profoundly shifts the experience of that pain.

A multi-modal approach, combining nondrug and drug treatments usually works best.

• Base the treatment on the pain’s location, type, intensity, duration, pattern, and other individual factors.
• Start with pain management strategies that are effective for the intensity of pain reported. If the pain is mild, consider non-drug approaches and/or non-opioid drugs such as acetaminophen or NSAIDs. If pain is moderate to severe, an opioid (such as morphine, oxycodone, etc.) is also usually needed. Other drugs such as anticonvulsants like gabapentin, or antidepressants like amitriptyline, may be useful for neuropathic (nerve damage) pain. Other conventional techniques such as physical therapy or treatments such as surgery or radiotherapy may be needed.
• Include treatments to prevent or manage side effects of pain treatment, such as constipation, as well as other symptoms that are related to the pain, such as sleep difficulties or anxiety.
• Consider integrating evidence-based complementary therapies and self-care practices that improve comfort. See What approaches can help you manage pain? › in this handbook for evidence for these therapies)

Have a back-up plan for quick-acting treatments and medications in case of incident pain in which an incident increases or causes pain, such as entering/exiting a car or a painful procedure.

Check in regularly.

Don’t give up. Many more good options can manage pain. 

Refer to an oncology, palliative care, hospice, or other specialist for more complex pain management challenges. “The control of suffering represents a formidable challenge. We advocate a proactive, long-range perspective aimed at (a) preventing brief stress-eliciting events such as pain associated with procedures, (b) treating potentially chronic pain and symptoms aggressively, and (c) promoting the psychosocial well-being of patients at every opportunity.”⁴Chapman CR, Gavrin J. Suffering and its relationship to pain. Journal of Palliative Care. 1993;9(2):5-13.

Commentary

The therapeutic value of a good pain assessment

CancerChoices Senior Clinical Consultant Laura Pole, Oncology Clinical Nurse Specialist:⁵Pole L, O’Toole C et al. Integrative Oncology Patient Navigation Training [Online Course]. Maryland University of Integrative Health. 2022. Viewed September 16, 2023. Fully attending to your patient while assessing their pain can powerfully activate belief. This belief activation actually triggers physiological and psychological changes, thereby altering one’s perception and their experience of pain.⁶Green J, Wright H. From bench to bedside: converting placebo research into belief activation. The Journal of Complementary and Alternative Medicine 2017; 23(8): 575-580; Benedetti F, Thoen W, Blanchard C, Vighetti S, Arduino C. Pain as a reward: changing the meaning of pain from negative to positive co-activates opioid and cannabinoid systems. Pain. 2013 Mar;154(3):361-367. Even if you only have a short amount of time to spend with the patient, refrain from saying or indicating that your time with them will be brief. By putting away all distractions from your paying full attention (computer or phone screens, reading the chart, pagers), communicating with your verbal and body language that you are fully present, sitting close to the person (if you are physically together), and appropriately touching them (holding their hand), the person will perceive that you have spent far more time with them than you actually did. 

I once had a patient referred to me by her pulmonologist who said she had “intractable cancer-related pain” not helped by a fentanyl patch. I prepared a quiet, pleasant space for us to meet, and wore my lab coat with my name badge clearly identifying me as an oncology clinical nurse specialist. She came to this thoughtfully prepared space with her husband, and I gently put my hand on her back and led her to a comfortable chair, with her husband sitting next to her and holding her hand. I sat across from her in a chair, with no desk or table separating us. I told her about what she could expect from this meeting. I asked her to rate her pain on a scale of 0-10, with 10 being the worst possible pain. She looked distressed, anxious and exhausted. She said her pain at the moment was 8, but most of the time it is 10+ and keeps her from sleeping well and from doing most things that she finds enjoyable. I let her tell me the story of her pain (AKA pain assessment) and talked to her about what I was going to recommend to her doctor and what she could expect from her pain management plan. I told her that the first goal would be to control her pain well enough so that she could get a good night’s sleep. I asked her to tell me what she finds helpful in making her more comfortable and suggested she use those measures as well. I gave her choices about pain management measures and incorporated her choices into the final plan. I taught her how to communicate about not only the pain but also her improvements in comfort. I finalized the plan with her physician, which included adjustments to her opioid regimen, and instructed her and her husband on their part in carrying out the plan. For my part, I told her I would be following up with her regularly. This all took about an hour. 

At the end of the session, I asked her to rate her pain, and she gave an astonished look to me and her husband and elatedly said, “I hardly notice it—maybe it’s about a 1.” I called her the next day to ask her what improvements she’d noticed since yesterday, and she said “If I could reach through this phone and hug you, I would, because last night I slept the best I’ve slept in weeks.” This was clearly a case of therapeutic presence, reassurance, and belief activation being a medicine in itself.

Managing pain and other symptoms concurrently

CancerChoices Senior Clinical Consultant Laura Pole, RN, MSN, OCNS: Those of us involved in helping people with cancer manage their pain have long witnessed a connection between cancer-related pain and other symptoms. Studies have also shown this link, as described in this handbook in Why is managing pain important? ›

Usually, what we see is that if people’s pain is poorly managed, especially for a long time, they feel more anxious, depressed, and fatigued. They don’t sleep well. Their physical function declines. They see their quality of life as poor. In turn, these other symptoms and problems worsen people’s perception of their pain.⁷Thielking PD. Cancer pain and anxiety. Current Pain and Headache Reports. 2003 Aug;7(4):249-61. 

This becomes a vicious cycle. It’s imperative to directly treat the pain with effective pain management therapies—with this, the other related symptoms often improve. Though it’s also helpful to manage other symptoms that are linked to the pain, this should be in addition to, not in place of pain treatments.⁸Cleeland CS. The impact of pain on the patient with cancer. Cancer. 1984 Dec 1;54(11 Suppl):2635-41; Thielking PD. Cancer pain and anxiety. Current Pain and Headache Reports. 2003 Aug;7(4):249-61.

A classic 1999 study emphasizes the importance of finding the correct dose and frequency of round-the-clock pain medications.⁹Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999 May;81(1-2):129-34. Healthcare professionals need to frequently check for breakthrough pain and adjust analgesic dosage and frequency accordingly. 

Opioids for cancer pain management: fears about prescribing

CancerChoices Senior Clinical Consultant Laura Pole, RN, MSN, OCNS: Every knowledgeable clinician caring for people with cancer pain knows that opioids are the foundation of treating moderate to severe persistent pain. And most likely, if you prescribe opioids, you’re aware of the increasing scrutiny and restrictions as a backlash of the prescription and illicit drug abuse that has become known as the opioid epidemic. A 2021 study found a dramatic decrease in opioid access among terminally ill cancer patients over a recent 10-year period. The authors link this worsening of end of life pain management to heightened opioid regulations.¹⁰Enzinger AC, Ghosh K et al. US trends in opioid access among patients with poor prognosis cancer near the end-of-life. Journal of Clinical Oncology. 2021 Sep 10;39(26):2948-2958. There is an excellent article in the Journal of Oncology Practice that provides much needed perspective and guidance on balancing public health concerns, patient needs and prescription oversight.¹¹Page R, Blanchard E. Opioids and cancer pain: patients’ needs and access challenges. Journal of Oncology Practice. 2019;15:5:229-231.

Perhaps you’ve seen the incredible suffering that substance use disorder wreaks on those with the disease and their loved ones. Clearly, some people with cancer also have substance use disorder (SUD), and there are effective ways of treating their pain while not exacerbating their problems with substance use. Below, we list resources regarding working with people who are reckoning with two fatal diseases: cancer and SUD. You’ve likely witnessed a person suffering from unmanaged pain, worsened by fears leading to opioids’ either not being prescribed, withheld by family members, or refused by patients. 

You may have concerns about the side effects of opioids. Among those, respiratory depression is one of the most serious. High doses of opioids such as morphine or fentanyl may also cause hyperalgesia. Many opioids are cleared through the kidneys, posing challenges for adjusting doses for elderly patients and those with renal disease. 

The opioid agonist/antagonist buprenorphine, given transdermally, has become a more recent addition to the pain management toolbox and seems to address many of these concerns. However, lack of awareness and prevalent misconceptions keep them underutilized. 

“In clinical practice, buprenorphine produces the same level of analgesia as full μ agonists and exhibits a unique ceiling effect for respiratory depression, but not analgesia. It can be switched or combined with other μ-opioid agonists without compromising analgesia. Buprenorphine has shown a differential profile in terms of gonadal and immunosuppressive effects, cognitive impairment, and hyperalgesia when compared with other specific opioids. TDB has demonstrated good efficacy and tolerability in patients with chronic pain, providing effective analgesia as part of a multifaceted strategy for a wide range of pain indications, including cancer pain, nociceptive pain, and neuropathic pain. It also has the convenience of once weekly or twice-weekly administration, with no specific dose adjustment requirement in elderly patients or those with compromised renal function, and is a valuable alternative for patients who are not suitable for oral opioids.”¹²O’Brien T, Ahn JS et al. Understanding transdermal buprenorphine and a practical guide to its use for chronic cancer and non-cancer pain management. Journal of Opioid Management. 2019 Mar/Apr;15(2):147-158.

Atul Gawande profoundly reminds us that people remember the worst and the last. He says “For human beings, life is meaningful because it is a story. . . and in stories, endings matter” (from Being Mortal). Let us all reckon with our fears that get in the way of us prescribing and administering the treatments necessary to relieve pain on all levels. It is our sacred privilege to relieve suffering so that the end of a person’s life is filled with comfort and compassion—opening the space for the last memory to be filled with love.

Helpful links for professionals

Book chapters

Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.

Mustafa S, Evans S et al. Toll-like receptor 4 in pain: bridging molecules-to-cells-to-systems. Handbook of Experimental Pharmacology. 2022;276:239-273.

Journal articles

Abdel Shaheed C, Hayes C et al. Opioid analgesics for nociceptive cancer pain: a comprehensive review. CA: A Cancer Journal for Clinicians. 2023 Dec 18.

McNally GA, Sica A. Addiction in patients with cancer: challenges and opportunities. Journal of the Advanced Practitioner in Oncology. 2021 Sep;12(7):740-746.

Page R, Blanchard E. Opioids and cancer pain: patients’ needs and access challenges. Journal of Oncology Practice. 2019 May;15(5):229-231.

Paice JA, Mulvey M et al. AAPT diagnostic criteria for chronic cancer pain conditionsu003c/au003e. Journal of Pain. 2017 Mar;18(3):233-246.

Yoon SY, Oh J. Neuropathic cancer pain: prevalence, pathophysiology, and management. Korean Journal of Internal Medicine. 2018 Nov;33(6):1058-1069. 

Scarborough BM, Smith CB. Optimal pain management for patients with cancer in the modern era. CA: A Cancer Journal for Clinicians. 2018 May;68(3):182-196.

Novy DM, Nelson DV et al. Pain, opioid therapy, and survival: a needed discussion. Pain. 2020 Mar;161(3):496-501.

Theobald DE. Cancer pain, fatigue, distress, and insomnia in cancer patients. Clinical Cornerstone. 2004;6 Suppl 1D:S15-21.

Chapman CR, Tuckett RP, Song CW. Pain and stress in a systems perspective: reciprocal neural, endocrine, and immune interactions. Journal of Pain. 2008 Feb;9(2):122-45. 

Eng JW, Kokolus KM, Reed CB, Hylander BL, Ma WW, Repasky EA. A nervous tumor microenvironment: the impact of adrenergic stress on cancer cells, immunosuppression, and immunotherapeutic response. Cancer Immunology, Immunotherapy: CII. 2014 Nov;63(11):1115-28.

Su PP, Zhang L, He L, Zhao N, Guan Z. The role of neuro-immune interactions in chronic pain: implications for clinical practice. Journal of Pain Research. 2022 Aug 4;15:2223-2248.

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