Pain management program

The Pain Management is a key component of palliative care and is of vital importance to the quality of life. Seventy to ninety percent of advanced cancer patients require pain relief. Pain management can take many forms. In addition to conventional pain medications, radiotherapy and chemotherapy can relieve pain by shrinking tumors. Some people benefit from relaxation techniques and others from non-traditional approaches. Pain can result from the disease, its diagnostic procedures and/or its treatments. At KHCC, we have an Adult Pain Management Clinic and a Pediatric Pain Management Clinic. All the above services are coordinated and controlled by the pain management committee that include members in the following areas: anesthesiology, palliative, pediatrics, psychology, nursing and pharmacy.

Adult Pain Management Clinic

This clinic was established as part of the Department of Anesthesiology to offer consultations on the management of chronic and acute pain in cancer patients. The clinic successfully introduced an unimodal pain assessment tool that became an integral part of routine patient assessment. A protocol for acute pain management was introduced in the triage room to outline guidelines for pain management in emergency situations. The clinic runs three days a week. Moreover, pain management consultations are available around the clock. The services are based on a pain nurse-anesthesia supervised concept.

Facts about Cancer Pain

Having cancer does not always mean having pain: many kinds of cancer do not cause pain until they are in late or advanced stages. With good communication with the treating team, pain can be rapidly controlled in most situations

You have a right to pain relief, and you should insist on it: cancer pain can almost always be relieved. There are different ways and methods available to control cancer pain.

No one doctor can know everything about all medical problems: if you are in pain and your doctor suggests no other options, ask to see a pain specialist or have your doctor consult with a pain specialist.

Communication is very important: not everyone feels or tolerates pain in the same way. There is no need to be "stoic" or "brave"; if you have pain, even when others don’t, you should voice your concerns. The pain management team is there to help.
Controlling your cancer pain is part of the overall treatment of cancer.
People who take cancer pain medications rarely become addicted to them: fear of addiction to pain medication is a common misconception. Only rarely do patients with cancer ever become addicted to pain medications. Moreover, when taking pain medication, your doctor should guide you on proper usage during and after treatment.
Most people do not get high or lose control when they take pain medications: only occasionally do people feel dizzy or confused when they take pain medications.
Your body does not become immune to pain medicine: Pain should be treated early. Tolerance to pain medications is not common and can be managed by adding other medications and/or altering dosage.

Causes of Cancer pain
Pain can be caused by pressure from tumors on the body’s organs. The most agonizing pain is caused by tumors spreading to the bones as the outer layer of the bone is very sensitive to pain. Some procedures, including needle sticks, used to diagnose cancer may also be painful. With proper management, treatment related pain can be prevented; in most cases patients should feel little or no pain when when undergoing these procedures. Phantom pain is a unique type of pain that is felt when a limb is amputated or a breast is removed. This can be managed, but usually takes some time to completely get under control. Spinal cord compression may also cause pain; this is usually neck or back pain that gets worse with movement. In many cases, surgery or radiation may be necessary to alleviate pain along with standard medical treatment.

Treatment of Cancer Pain
The ultimate goal of pain treatment is getting pain under control so it won’t interfere with your daily activities or your sleep. Patients should not be preoccupied with pain sensations and should take the required amounts of medication(s) to control the pain. It is also very important to know the cause of the pain, to work on eliminating it. Commonly, nurses and doctors will ask you to score your pain on a scale of 0 to 10. Zero being no pain and ten being the worst pain that you can imagine. You will also need to tell the team the site and a description of your pain, how frequent you take your pain medications and how long you feel relief after taking them.
For mild pain: usually doctors start with simple pain medications called NSAIDs like Aspirin or Ibuprofen. Paracetamol (Panadol® or Tylenol ®) is also commonly prescribed.
For moderate to severe pain: Tramadol (Tramal) or paracetamol with codeine can be the first option, as they have the least side effects.
For severe pain: as pain gets worse, opioids (e.g. Morphine) are usually started. These medications have great ability to control the worst kinds of pain with acceptable side effects. They can be given by mouth or by injection. An opioid called fentanyl can be given through a skin patch that can effectively control pain for a few days. Sometimes, extra doses of pain medicine need to be given intravenously for breakthrough pain, specifically early on until a patient’s requirements are accurately known. Some patients may benefit from continuous intravenous infusions of pain medications through a simple pump or a PCA (patient-controlled analgesia) which enables patients to control their needed amount of infused pain medication by pushing a button.

Side effects of pain medications are usually mild and include drowsiness, nausea and itching; however, these symptoms usually improve over time. More serious side effects are noticed at very high doses and may include dizziness, urine retention and dificulty breathing. These symptoms should prompt an immediate consultation of your doctor to change the medication or adjust the dose.

Non-drug treatment of pain
Relaxation

Relaxation relieves pain or keeps it from getting worse by reducing tension in the muscles. It can help you fall asleep, give you more energy, make you less tired, reduce your anxiety, and help other pain relief methods work better. Some people, for instance, find that taking pain medicine or using a cold or hot pack works faster and better when they relax at the same time.

How to Use Relaxation
Relaxation may be done sitting up or lying down. Choose a quiet place whenever possible. Close your eyes. Do not cross your arms and legs because that may cut off circulation and cause numbness or tingling. If you are lying down, be sure you are comfortable. Put a small pillow under your neck and under your knees or use a low stool to support your lower legs.

Visual concentration and rhythmic massage:

• Open your eyes and stare at an object, or close your eyes and think of a peaceful, calm scene.

• With the palm of your hand, massage the area near the site of your pain in a circular, firm manner. Avoid direct contact with red, raw, or swollen areas. You may wish to ask a family member or friend to assist you.

Inhale/tense, exhale/relax:

• Breathe in deeply, while simultaneously tensing your muscles or a group of muscles. For example, you can squeeze your eyes shut, frown, clench your teeth, make a fist, stiffen your arms and legs, or draw up your arms and legs as tightly as you can.

• Hold your breath and keep your muscles tense for a second or two.

• Let go! Breathe out and let your body go limp.

Slow rhythmic breathing:

• Stare at an object or close your eyes and concentrate on your breathing or on a peaceful scene.

• Take a slow, deep breath and, as you breathe in, tense your muscles (such as your arms).

• As you breathe out, relax your muscles and feel the tension draining.

• Now remain relaxed and begin breathing slowly and comfortably, concentrating on your breathing, taking about 9 to 12 breaths a minute. Do not breathe too deeply.

• To maintain a slow, even rhythm as you breathe out, you can say silently to yourself, "In, one, two; out, one, two." It may be helpful at first if someone counts out loud for you. If you ever feel out of breath, take a deep breath and then, continue the slow breathing. Each time you breathe out, feel yourself relaxing and going limp. If some muscles, such as your shoulder muscles, are not relaxed, tense them as you breathe in and relax them as you breathe out. Do this only once or twice for each specific muscle group.

• Continue slow, rhythmic breathing for a few seconds up to 10 minutes, depending on your need.

• To end your slow rhythmic breathing, count silently and slowly from one to three. Open your eyes. Say silently to yourself, "I feel alert and relaxed." Begin moving about slowly.
  

As with any of the techniques described, you should use what works best for you. Heat often relieves sore muscles; cold lessens pain sensations by numbing the painful area. Many people with prolonged pain use only heat and have never tried cold. Some people find that cold relieves pain faster, and relief may last longer. Also, you can alternate heat and cold for added relief in some cases.

For cold, try gel packs that are sealed in plastic and remain soft and flexible even at freezing temperatures. Gel packs are available at drugstores and medical supplies stores. They can be reused and stored in the freezer. You may want to wrap the pack in a towel to make it more comfortable before applying to skin. An ice pack, ice cubes wrapped in a towel or water frozen in a paper cup are alternatives that may also work.

To use heat for pain relief, a heating pad that generates its own moisture is convenient. You can also try gel packs heated in hot water, hot water bottles, a hot, moist towel, a regular heating pad, a hot bath or shower, or a hot tub to apply heat. For aching joints, such as elbows and knees, wrap the joint in a lightweight plastic wrap. Tape the plastic to itself to retain body heat and moisture.