Pain

What approaches can help you manage pain?

We present many approaches to reducing pain and summarize the evidence regarding their effectiveness.

Top practices and therapies for managing pain

Many good conventionalthe cancer care offered by conventionally trained physicians and most hospitals; examples are drugs and physical therapy medicine options are available for managing cancer-related pain. Self-carelifestyle actions and behaviors that may impact cancer outcomes; examples include eating health-promoting foods, limiting alcohol, increasing physical activity, and managing stress practices and complementaryin cancer care, complementary care involves the use of therapies intended to enhance or add to standard conventional treatments; examples include supplements, mind-body approaches such as yoga or psychosocial therapy, and acupuncture therapies can also support pain relief, often with fewer risks and side effects. Often, both conventional and complementary options can be used together.

Therapies and practices we have reviewed

Further therapies

Therapies recommended in clinical practice guidelines but that we haven’t yet reviewed; see guidelines ›

Pain’s connections to other symptoms

Pain may be a symptom of stress or emotional states such as anxiety. If stress, fatigue, anxiety, and/or depression is contributing to your pain, managing these other symptoms will be important in reducing your pain. 

Professionals who provide a comprehensive approach to managing pain have found the most success by integrating approaches that target physical, emotional, mental, and spiritual aspects of pain and suffering. Start by addressing the physical pain directly, then assess and treat other dimensions of pain.²Thielking PD. Cancer pain and anxiety. Current Pain and Headache Reports. 2003 Aug;7(4):249-61. Cleeland CS. The impact of pain on the patient with cancer. Cancer. 1984 Dec 1;54(11 Suppl):2635-41. 

Conventional care

Your oncology team can recommend conventional therapies including over-the-counter and prescription medications to manage pain. Anti-inflammatory drugs—such as steroids or nonsteroidal anti-inflammatory drugs—and other therapies such as cold and heat therapies—can reduce pain from inflammation. Many other types of drugs can address pain, such as acetaminophen, muscle relaxers, antiseizure medications, and opioids. Surgery and radiation therapy are also used to manage cancer-related pain, often by removing or reducing the size of the tumor and relieving the pressure on nerves. 

Radiotherapy can be highly effective in managing cancer-related bone pain. A meta-analysisa statistical analysis that combines the results of two or more research studies; the results of smaller research studies addressing the same or similar questions can be analyzed as though they are one bigger, more powerful study of 27 studies found that almost a third of people treated with radiotherapy experienced total resolution of pain at four weeks.³Chow R, Hoskin P, Hollenberg D, et al. Efficacy of single fraction conventional radiation therapy for painful uncomplicated bone metastases: a systematic review and meta-analysis. Annals of Palliative Medicine. 2017;6:125–142. Physical therapy is also widely used to manage persistent pain.

If you do not find relief from your pain from your primary treating physician’s treatment, consider asking for a referral to a professional trained in managing cancer-related pain. 

• Medical oncologists are usually very knowledgeable about managing cancer pain. 
• Doctors and nurses trained in palliative care are experts in helping people manage symptoms related to chronic illnesses such as cancer. People with cancer receiving palliative care combining symptom control and psychosocial support report less pain in studies (good evidencesignificant effects in one large or several mid-sized and well-designed clinical studies (randomized controlled trials (RCTs) with an appropriate placebo or other strong comparison control or observational studies that control for confounds) (this is the CancerChoices definition; other researchers and studies may define this differently)).

Some medications and treatments can cause pain as a side effect. Check with your doctor or pharmacist to see if any of your prescription medications may contribute to pain and whether adjustments can be made.

Pain medications and cancer survival

The type of pain medication you use may influence cancer survival. Some evidence links opioids to poorer survival. One analysis concluded that the majority of strong opioid analgesics produce immunosuppressionpartial or complete suppression of the immune response that can lead to reduced tolerance to cancer and increased metastatic spread.⁴Budd K. Pain, the immune system, and opioimmunotoxicity. Reviews in Analgesia. 2004;8(1): 1-10.

However, separating out the effects of opioid use from more advanced cancer and tumor-related inflammation is very difficult. “Opioid-use is likely to reflect more aggressive painful disease and is thus a ‘biomarker’ of a poor outcome.”⁸Boland JW, Allgar V et al. The relationship between pain, analgesics and survival in patients with advanced cancer; a secondary data analysis of the international European palliative care cancer symptom study. European Journal of Clinical Pharmacology. 2020 Mar;76(3):393-402. For example, a mid-sized observational study found lower cancer-specific survival among people with cancer with either higher cancer-related pain or opioid use compared to others.⁹Zheng J, He J et al. The impact of pain and opioids use on survival in cancer patients: results from a population-based cohort study and a meta-analysis. Medicine (Baltimore). 2020 Feb;99(9):e19306. The disease process driving the pain and use of opioids may have been the driver of poorer survival, and the pain and use of opioids an indicator of advancing cancer instead of the cause.

More research is needed to determine whether use of opioids among people at various stages of cancer contributes to worse survival. The pain level and its impact on quality of life, the cancer stage and progression, and the effectiveness of various pain-relief options all need to be considered when choosing therapies to manage pain. In some cases living in severe pain is not tolerable, so prioritizing quality of life is not only acceptable but also necessary.

Pain medication and body terrain

For information about connections between body terrain factors and pain control during surgery, see Surgery: An Integrative Approach ›

Pain medications and side effects

Various types of pain medications can not only improve comfort but also relieve side effects and symptoms. However, all medications come with side effects of their own, such as constipation with opioids. We present evidence regarding effects of different types of analgesics on pain but also several other symptoms and side effects. Choosing the right analgesic and delivery method for the type of pain being managed—and discontinuing use as soon as possible—are important. 

What about addiction (substance use disorder)?

Addiction, also known as substance use disordera mental disorder affecting a person’s brain and behavior that leads to an inability to control the use of substances such as legal or illegal drugs, alcohol, or medications, is a concern among both patients and healthcare professionals. We offer some facts to address the many myths often repeated about using chemicals that interact with opioid receptors on nerve cells in the body and brain to reduce the intensity of pain signals and feelings of pain. This class of drugs includes natural, synthetic, or semi-synthetic drugs such as oxycodone, hydrocodone, codeine, morphine, heroin, fentanyl, and many others. for managing pain:

1. Opioid use disorder or drug misuse is not common if you are taking your pain medication as your doctor prescribes and you don’t have a substance use disorder or high risk for substance use disorder. Be open with your doctor if you have or have ever had a substance use disorder so that you can get the right help in managing your pain and reduce the chances of triggering or worsening your substance abuse disorder. Although using opioids on its own doesn’t result in opioid use disorder, some people with cancer may develop this problem. One analysis of five studies found an average of 18% of people with cancer have opioid use problems, with a range of 2% to 35% across studies.²⁹Yusufov M, Braun IM, Pirl WF. A systematic review of substance use and substance use disorders in patients with cancer. General Hospital Psychiatry. 2019 Sep-Oct;60:128-136. 
2. Opioid use disorder and physical dependence are not the same thing. Physical dependence is “adaptation to a drug that produces symptoms of withdrawal when the drug is stopped.”³⁰Opioid Basics: Commonly Used Terms. Centers for Disease Control and Prevention. Viewed July 11, 2022. Dependence is a natural phenomenon that occurs with many different substances, including caffeine, alcohol, corticosteroids, opioids, and other medications. A person can become physically dependent on opioids within a few days, such as when taking them for several days after surgery. If the substance is stopped suddenly, uncomfortable and sometimes dangerous withdrawal symptoms can result. 
3. The risk of opioid-related death is very low in people with cancer taking opioids as prescribed under medical supervision. Most opioid side effects can be prevented or controlled.
4. Raising the dose of an opioid as needed or even switching to another opioid can achieve good pain management with minimal side effects.
5. Pain dampens your thinking abilities. When opioids—often combined with other pain relieving drugs and treatments—effectively control pain, cognitive function usually improves over time. 
6. Unreported, uncontrolled pain can make you weak and lower your quality of life.

Even though substance use disorder is not common overall, some people with cancer misuse opioids by using them without a prescription or for a reason other than as directed by a physician, such as to create euphoria. Misuse also includes using opioids in greater amounts, more often, or longer than prescribed,³¹Opioid Basics: Commonly Used Terms. Centers for Disease Control and Prevention. Viewed July 11, 2022. often because of insufficient pain control.

A study of women undergoing mastectomy with reconstructive surgery as part of cancer treatment studied use of opioids and sedative-hypnotic drugs. These women are at particularly high risk of becoming dependent on opioids following surgery, with about 13% of women who had not used an opioid for the year before surgery becoming a chronic user in the year following surgery. More than 6% of women became chronic users of sedative-hypnotic drugs. The researchers recommend women work closely with the prescribing professional to attempt to minimize risk of dependence.³²The ASCO Post Staff. SABCS 2020: Opioid and sedative-hypnotic use after mastectomy with reconstructive surgery. December 23, 2020. Viewed February 5, 2021; Cogan JC, Raghunathan RR et al. Persistent controlled substance use following mastectomy with reconstruction surgery. Publication Number: GS3-0. 2020 San Antonio Breast Cancer Symposium®. Viewed February 5, 2021.

In response to such reports and perhaps a lack of experience or knowledge, some people—including physicians—have begun avoiding using or prescribing opioid drugs even when indicated. This can lead to unnecessary pain and suffering, as shown in a very large observational study finding a lower proportion of filled prescriptions for opioid drugs and a dramatic rise in the number of emergency department visits for pain among people with poor prognosis cancer in the last month of life in the USA in 2017 compared to 2007.³³Enzinger 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.

If you are not getting good pain management from prescription medications, report this to your physician as soon as possible rather than adjusting the dose or frequency on your own. Misusing opioids, even for what you consider a good reason, may possibly lead to mistrust between you and your doctor and less effective care.

Finally, bear in mind that complete obliteration of physical pain is not usually a realistic objective. A realistic goal is to manage the pain so that it is tolerable and frees you up to achieve your own goals of living well.

Opioids: bottom line

In light of both benefits and risks of opioid use, we recommend they be used when necessary but in the smallest effective amount and, in the case of acute pain, for the shortest period possible. We encourage you to consider non-opioid options such as ibuprofen (Motrin or Advil) or acetaminophen (Tylenol) when available. Unfortunately, not all cancer patients can take NSAIDs safely, and acetaminophen cannot be taken at a dose higher than 3 grams a day. Other nontraditional options for pain control are available and may help to reduce the amount of pain medication needed.

Self-care practices

The evidence supporting the effects for each practice is listed in the full handbooks available through the image links.

• Better measures of physical function and less pain among overweight and obese older adults with knee pain and osteoarthritis participating in a weight-loss diet, sometimes with exercise (modest evidence)
• Less musculoskeletal pain (not specific to cancer) among people eating blueberry, strawberry, and passion fruit peel extract (preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently))
• Less pain and joint stiffness, better measures of sleep quality and quality of life among people with fibromyalgia eating an uncooked vegan diet rich in lactobacteria (preliminary evidence)

Less pain among women recovering after breast cancer surgery participating in 12 months of physical activity (preliminary evidence)

Recommended in a practice guideline for treating pain; see guidelines ›

Combining Eating Well and Moving More: preliminary evidence

Not specific to people with cancer:

• Better measures of physical function and less pain among overweight and obese older adults with knee pain and osteoarthritis participating in a diet and exercise intervention (preliminary evidence)

Complementary therapies

We present complementaryin cancer care, complementary care involves the use of therapies intended to enhance or add to standard conventional treatments; examples include supplements, mind-body approaches such as yoga or psychosocial therapy, and acupuncture therapies supported by evidence for managing pain. Those with the best evidence are presented first.

A therapy may show a stronger effect or have more evidence in some situations than in others. The evidence supporting the effects for each therapy is listed in the full reviews available through the image links.

Strong, good, or modest evidence of benefit

Strong evidenceconsistent, significant effects in several large (or at least one very large) well designed clinical studies or at least two meta-analyses of clinical studies of moderate or better quality (or one large meta-analysis) finding similar results (this is the CancerChoices definition; other researchers and studies may define this differently) indicates a high degree of confidence that the therapy is linked to the outcomes as noted. Good evidencesignificant effects in one large or several mid-sized and well-designed clinical studies (randomized controlled trials (RCTs) with an appropriate placebo or other strong comparison control or observational studies that control for confounds) (this is the CancerChoices definition; other researchers and studies may define this differently) indicates a relatively high degree of confidence that the therapy is linked to the outcomes as noted. Modest evidencesignificant effects in at least three small but well-designed randomized controlled trials (RCTs), or one or more well-designed, mid-sized clinical studies of reasonably good quality (RCTs or observational studies), or several small studies aggregated into a meta-analysis (this is the CancerChoices definition; other researchers and studies may define this differently) means several smaller or at least one large study have found the effect described.

Less pain during bone marrow biopsy among people with cancer treated with acupressure (preliminary evidence)

Recommended in practice guidelines for treating pain; see guidelines ›

Less pain related to aromatase inhibitors among people treated with acupuncture (modest evidence)

Fewer headaches during or after chemotherapy among people with breast cancer treated with acupuncture (preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently))

No evidence of an effectoverall, one or more studies did not demonstrate that a treatment or intervention led to an expected outcome; this does not always mean that there is no effect in clinical practice, but that the studies may have been underpowered (too few participants) or poorly designed. Larger, well-designed studies provide more confidence in making assessments. on pain during chemotherapy, radiotherapy, or hormone therapy among people treated with acupuncture in combined analyses of studies

Recommended in practice guidelines for treating pain; see guidelines ›

Not specific to cancer:

• Lower pain scores among people with pain treated with cannabis or cannabinoids (good evidence)
• Less opioid use among people receiving opioid treatment for chronic pain also treated with medical cannabis for at least 30 days (modest evidence)

Less discomfort during hospitalization among people undergoing brachytherapya type of radiation therapy in which radioactive material sealed in needles, seeds, wires, or catheters is placed directly into or near a tumor; also called implant radiation therapy, internal radiation therapy, and radiation brachytherapy participating in relaxation and guided imagery (preliminary evidence)

Less pain and related distress, and more perceived control over pain during hospitalization, among people treated with analgesica therapy, typically a drug, acting to relieve pain imagery, and comparable to effects with progressive muscle relaxation (preliminary evidence)

Less pain intensity among people with terminal cancer in hospice treated with interactive guided imagery and progressive muscle relaxation (preliminary evidence)

Less pain among hospitalized children treated with imagery (preliminary evidence)

No evidence of an effect on pain from surgery among people with cancer treated with guided imagery, sometimes with other mind-body therapies, in several studies

Recommended in practice guidelines for treating pain; see guidelines ››

Recommended in a practice guideline for treating pain; see guidelines ›

Less pain during chemotherapy among people treated with progressive muscle relaxation, sometimes also with guided imagery (modest evidence)

Less body discomfort during brachytherapya type of radiation therapy in which radioactive material sealed in needles, seeds, wires, or catheters is placed directly into or near a tumor; also called implant radiation therapy, internal radiation therapy, and radiation brachytherapy among people with gynecologic or breast cancer treated with relaxation and guided imagery (preliminary evidence)

Less pain during initial surgery among people with breast cancer using a self-care toolkit of complementary therapies including relaxation (preliminary evidence)

Less aromatase inhibitor-associated joint pain among postmenopausal women with non-metastatic breast cancer treated with relaxation techniques (modest evidence)

Less pain among hospitalized people with cancer treated with relaxation (preliminary evidence)

Less pain among people with terminal cancer in hospice treated with interactive guided imagery and progressive muscle relaxation (preliminary evidence)

No evidence of an effect on pain after conventional resection of colorectal carcinoma among elderly people treated with relaxation in a preliminary study

Recommended in a practice guideline for treating pain; see guidelines ›

No evidence of an effect on pain after brain tumor surgery among people with vitamin D serum levels of 20 ng/dL or lower treated with vitamin D before surgery in a small study

Not specific to people with cancer:

• Fewer requests for pain medication but no evidence of an effect on pain scores overall among people with vitamin D levels below 50 nmol/L treated with vitamin D (good evidence)

Therapies with preliminary or weak evidence of benefit for pain

Preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently) typically indicates that not much research has been published so far, although the outcomes may be meaningful. Weak evidenceone or more case studies, supported by animal evidence OR small treatment effects of limited clinical significance OR studies with no controls OR weak trends of effects (this is the CancerChoices definition; other researchers and studies may define this differently) may mean that the effects are small or that only very preliminary research has been published.

Therapies with no evidence of benefit

Support groups and interventions ›

• No evidence of an effectoverall, one or more studies did not demonstrate that a treatment or intervention led to an expected outcome; this does not always mean that there is no effect in clinical practice, but that the studies may have been underpowered (too few participants) or poorly designed. Larger, well-designed studies provide more confidence in making assessments. on pain among people with cancer participating in interventions including their family caregivers in a combined analysis of studies

Further complementary therapies used to manage pain

These therapies are used to manage pain, but we have not yet reviewed their effectiveness or safety. Those in bold are recommended in at least one clinical practice guideline; see guidelines ›

Resources

Keep reading about pain