Pain Syndromes In Cancer

"He grieves more than necessary who grieves before it is necessary."
The word Cancer is synonymous with Pain and Death—most people think of cancer as a very painful diease. This is not wholly true since cancer in its early stages is not painful. Any pain associated with it then maybe because of the treatment and is no different from the treatment of any other disease—it is controllable and temporary. It'sonly in advanced cancers that pain becomes a problem.

What is pain?

Pain is what patient says hurts—it is an unpleasant sensation which manifess physically health, fear of the illness, ethnic stoicism, tolerance, times of the day, associated events, etc. Total pain would include suffering which is physical, emotional, psychological and spiritual and for proper control of pain the total pain must be tackled. Physical pain can be broadly classified into visceral pain and neuropathic pain.
To understand each it is easier if the physiology of pain is understood—there are peripherial nerve endings present in the surface of the skin bodyetc. Which are stimulated by physical, chemical or thermal tissue injury. There is an electrical impulse generated in the nerve ending which is transmitted to the nerve endings in the spinal cord and there are conducted unto the brain-from where the perception of pain takes place.
Nerve endings in the skin muscle bone are more specific and conduction of the sensation of pain is much faster to the brain. The berve endings in the viscera or organs are most spread out withnthe same nerve also coming getting ending from part of the skin. The Physical pain sensation is therefore of different characters and can be broadly classified into Somatic, Visceral and Neuropathic. Somatic pain – connected with the muscles and the bone of the body. The pain is intense,sharp,piercing and localised and changes with movement or postural change.The pain maybe be due to release of prostagladins at the site of injury or due the presence of osteolclasts which destroy your bone where a tumour maybe infiltrating.
Visceral pain—concerned with any of the organs or viscerae—the character of the pain is dull, deep, sqeezing, colicky aching or nagging maybe constant or spasmodic and not related to change of posture. The area cannot be delineated accurately. There maybe referred pain to the area on the surface of the body which is supplied by the same nerve. The pain maybe due to distention of the organ, obstruction, compression or infiltration by a tumour.
Neuropathis pain— due to chemical , physical, or thermal injury to a nerve—the pain here is shooting, spasmodic,spontaneous, burning and shock-like.
Each of the pains above are modulated by associated features, which may form the characteristics of emotional/psychosocial and spiritual pain. Each of the pain needs to managed individually. The threshold for pain maybe lowered by discomfort, anxiety, fear, insommia, depression, isolation, loneliness, fatigue, boredom, anger, low self-esteem, frustration, etc.
This treshold maybe raised by elevation of mood , moral support of carers, companionship, sympathy, distraction, creative activity, analgestics, relief of discomfort, good self esteem, relaxation, adequate sleep and rest.
In advanced cancer where pain is a major problem in nearly 75% patients,there maybe a combination of all types of pain and here for proper management which is possible there must be a proper assessment of the pain.
Today almost all patients can have a pain free life inspite of their cancer. Unfortunately there are barriers to the management of the pain which are…..

Inadequate assessment of pain
Reluctance of the Patient to report pain
Reluctance to take medication
Reluctance of the physician to prescribe medication
Inadequate dosing
Misgivings about opioids
Ignorance of non physical pain

Inadequate assessment of pain
• Requires a trust between the physician an the patient
• Good communication
• Good history taking—site, duration, intensity, character of pain, impact on daily life
• Requires repeated assessment at intervals

Reluctance of the Patient to report pain---This may be related to the patient's own views of pain being a part of the diease –Stotocism, Guilt
Reluctance to take medication---Aversion to even more medicines. Acceptance of pain as a part of deserved suffeing –guilt.
Economics
Reluctance of the physician to prescribe medication---Sadly many physicians do not regard pain as a manageable sympton or the importance of reducing pain.
Inadequate dosing---Ignorance coupled with the patient's acceptance and reluctance to complain
Misgivings about opioids---Addiction, hallucinations etc which really relevant in advanced mallignancies.
Ignorance of non physical pain---Emotional suffering , etc which really influences all of the above and which is difficult to assess unless there is a good communication. Psychological evaluation is necessary.

Pain in cancer is of many origins and this multiple.Pain needs to be priorised.Treatment needs to be individualised for each patient.Management then depends on the resources available—with the methods starting from the simpliest to the more complicated.

ORIGIN OF THE PAIN

• Due to the cancer—tumour compression or infiltration into the bone or nerves etc.
• Due to the treatment—surgery, radiotherapy,drugs extravasation, muscle cramps due to hypocalceamia.
• Due to associated illness—diabetic neuropathy,cardiac ischeamia etc

Management of pain in cancer requires

• Assessment—establish trust
• Identifying the cause, the site
• Explanation
• Modification of the cause by --
*Treating the cause
*Raising the threshold of pain in the patient
*Alternating the pain pathways

Treating the cause
Therapy of the cancer—causing tumour shrinkage or removal by surgery radiotherapy or chemotherapy

Elevation of the pain threshold
By drugs
By nondrug method

Alternative of the pain pathways
By drugs
By surgical procedures
By change of lifestyles—avoiding pain-precipitating activities

Drugs—analgesics used on the basis of the WHO StepLadder approach is the most widely accepted and safest. The pain is classified according to its intensity as Mild, Moderate and Severe. The end aim is to achieve the maximum relief of pain with the minimum side effects. To achieve the right analgesic must be given in the right dose at the right time.

Step1— Mild pain maybe controlled by NSAID(non steroid anti-inflammatory drugs) anf non-opioids.In this class would come –Aspirins,paracetamols,diclofenac.
Step2— Moderate pain would require a combination of NSAIDs and a weak opioid eg Codeine,Tramadol.
Step3— Severe pain would require stronger opioids—eg morphine, fentanyl

At each step there maybe a neccessity of adding medication which will minimize the side effects such as gastritis, constipation, nausea etc.
No Drugs – these would include relaxation techniques like Yoga, Visualisation, Meditation or Accupressure, Reiki, hypnosis, etc.

Alteration of pain pathways
By disruption of the nerve transmission of the pain sensation to the brain.Drugs—local anesthetics, anti convulsants, psychotropic drugs (antidepressants) Neuro-surgical procedures—nerve blocks by injection of alcohol, phenol, cryosurgery, thermocoagulation, cordotomy.

The first aim should be to give the patient a good pain free sleep. This would perhaps go a long way in improving the management.

There is no justification for allowing a patient of Cancer to suffer with pain today.

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