Symptom Management

Pain

Many serious diseases, such as cancer and AIDS, cause pain. Pain can be intermittent or constant, and can vary in severity from mild to severe. It can have many different qualities, such as burning, shooting, aching, piercing or pinching. Many factors influence the perception of pain, including mood, activity level, stress, and the availability of pain-relieving therapies. Pain can be caused by:

	The activation of pain receptors by something that injures pain-sensitive tissues (nociceptive pain). Tissue damage from a mass (like a tumor) or from inflammation, for example, can cause this type of pain
	Nerve damage (neuropathic pain) from a virus, chemotherapy, trauma or a disease such as multiple sclerosis

Treating pain is important. Unrelieved pain can cause patients to:

	Experience depression
	Experience disruptions in activity, appetite and sleep
	Feel helpless and anxious
	Give up hope
	Reject treatment programs
	Stop participating in life to the fullest extent possible

Pain usually can be controlled. There are many treatment options. To offer the best approaches for pain, doctors must recognize that pain is different in every person. All patients who experience pain deserve a detailed evaluation of the pain, the effect of the pain, and the diseases that may be causing the pain.

Pain in Cancer Patients

Tumors pressing on organs, nerves or bone

	Treatment such as surgery, chemotherapy or radiation
	Other conditions related to the cancer, such as stiffness from inactivity, muscle spasms, constipation and bedsores
	Conditions unrelated to the cancer, such as arthritis or migraine

In most cases, cancer pain can be controlled through relatively simple means. Doctors usually use medications, which are prescribed according to a plan that was first described by the World Health Organization and is called the Analgesic Ladder approach to cancer pain management. Other ways to alleviate cancer pain include:

Surgery, radiation or chemotherapy to shrink tumors causing pain

	Antibiotic therapy or drainage for pain caused by infection
	Psychological therapies, and social and spiritual support, to influence the perception of pain
	Other pain treatments

Beth Israel Medical Center, a major cancer care provider in New York City, has hundreds of cancer specialists in its network including top-rated surgeons, medical oncologists, physicians, radiation oncologists, radiologists, and oncology nurses. The Medical Center also features the Beth Israel Cancer Center, a patient-friendly facility that offers a complete range of services for cancer patients and their families.

World Health Organization's Analgesic Ladder Approach for Relief of Cancer Pain

	A nonopioid analgesic, such as acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID)
	Adjuvant drugs if a specific indication exists

	An opioid conventionally used for moderate pain (usually codeine, hydrocodone, dihydrocodeine, oxycodone, propoxyphene, or tramadol)
	A nonopioid analgesic, such as acetaminophen or an NSAID
	An adjuvant drug in some cases

	An opioid conventionally used for severe pain, such as morphine, oxycodone, hydromorphone, methadone, levorphanol or fentanyl
	A nonopioid analgesic in some cases
	Adjuvant drugs in some cases

Pain in AIDS Patients

	Pain due to nerve damage, such as peripheral neuropathy and postherpetic neuralgia
	Headaches from meningitis
	Abdominal pain from gastrointestinal disease
	Chest pain from pneumonia
	Muscle pains

To find an appropriate treatment, a doctor should perform a detailed assessment.

Treatment of Pain

Pharmacological Therapies (Medication)

	Non-opioid pain relievers
	Opioids
	Adjuvant medications (drugs whose primary purpose is not for pain but rather for other conditions)
	Topical treatments (drugs are applied directly to the skin, as a patch, gel, or cream)

For more information on medications used to treat pain, please see our General Treatments section. Because the effects of a medication can vary widely from person to person, treatment of pain needs to be tailored to fit each individual. Some patients may need to try many different kinds of treatments before they find the right balance between pain relief and side effects.

Patients should be sure their doctors are aware of all medications they are taking, even for conditions unrelated to their pain or over-the-counter drugs such as aspirin. Many medications should not be taken together because they increase or decrease each other's effects or produce new adverse reactions. Of course, the doctor should also be informed if the patient is pregnant or breast-feeding.

Non-Pharmacological Treatments

In most cases, these techniques should be used in addition to, not instead of, other approaches to pain relief. More invasive non-pharmacological treatments include:

Physiatric Approaches

	Strengthen weak muscles
	Mobilize stiff joints
	Help restore coordination and balance
	Promote a sense of well-being
	Decrease anxiety and stress
	Keep the heart healthy
	Help maintain an appropriate weight

A physical therapist, exercise physiologist or certified athletic trainer can help patients get started safely and learn exercises designed specifically to target problem areas. Even bedridden patients can benefit from range-of-motion exercises.

	Increase the blood flow to the skin
	Dilate blood vessels, increasing oxygen and nutrient delivery to local tissues
	Decrease joint stiffness by increasing muscle elasticity

Heat should be applied for 20 minutes. Patients can use hot packs, hot water bottles, hot and moist compresses, electric heating pads, or chemical and gel packs carefully wrapped to avoid burns. Patients can also submerge themselves or the painful part in warm water.

Heat therapy is not recommended on tissue that has received radiation treatment. Pregnant women should avoid using hot tubs or any method that subjects the developing baby to prolonged heat.

Deep heat delivered to underlying tissue by short wave diathermy, microwave diathermy or ultrasound is also sometimes used to relieve pain. Deep heat should be used with caution by patients with active cancer and should not be applied directly over a cancer site.

Ice packs, towels soaked in ice water or commercially-prepared chemical gel packs should be applied for 15 minutes. Cold sources should be sealed to prevent dripping, flexible to conform to the body, and adequately wrapped to prevent irritation or damage to the skin.

Non-Invasive Stimulatory Approaches

The patient should experiment with the placement of the electrodes and the timing, intensity, amplitude and frequency of the electrical current to find the most effective setting. Pain relief usually lasts beyond the period when current is applied. TENS can become less effective at relieving pain over time. TENS is usually safe and well tolerated. However, it is not recommended on inflamed, infected or otherwise unhealthy skin, over a pregnant uterus (except for obstetric pain relief), or in the presence of a cardiac pacemaker.

Psychoeducational Approaches

	Deep breathing. In this simple technique, the patient focuses his or her attention on breathing deeply. This may shift attention away from the source of pain.
	Progressive muscle relaxation. In this technique, developed in the 1930s, patients contract, then relax, muscles throughout the body, group by group. Progressive muscle relaxation can help patients learn about the tension in their body and the contrast between tense and relaxed muscles.
	Imagery. In this technique, patients focus on pleasant thoughts, for example waves gently hitting a sandy beach. One variation is to think of an image that represents the pain (such as a hot, blazing concrete sidewalk), then imagine it changing into an image representing a pain-free state (a pretty, snow-covered forest).
	Meditation. In this technique, practiced routinely in Asia, the individual aims to empty his or her mind of thoughts, focusing instead on the sensation of breathing and the rhythms of his or her body.
	Biofeedback Therapy. Biofeedback is a method in which people learn to reduce their body's unproductive responses to stress, and thus decrease their sensitivity to pain. Children are particularly quick to learn from biofeedback. In biofeedback, electrodes are placed at various points on the patient's skin to measure:
	Muscle tension. As a muscle contracts, electrical activity increases Temperature. The stress response is related to blood flow in the hands or feet, and blood flow determines temperature Heart beat Sweating Patients watch the monitor and listen to the tones measuring their stress indicators. They use these as a guide in learning to release tension throughout their body.
	Distraction. Distraction is a pain management technique in which patients focus their attention on something other than their pain and negative emotions.
	To distract themselves, patients can:
	Sing Count Listen to music Watch TV Listen to the radio Talk to friends or family Read Listen to stories being read
	Reframing. Reframing is a pain and stress management technique that teaches patients to monitor negative thoughts and images and replace them with positive ones. Patients can learn to have a more positive outlook by recognizing some counterproductive thought patterns, such as: Blaming, in which the individual avoids taking responsibility. Thoughts such as "It's my boss's fault I have this headache" can be replaced with "I'm going to focus on what I can do to feel better." "Should" or "must" statements, which imply that someone has failed to live up to an arbitrary standard. Statements such as "I should have been more careful" can be counteracted with "I do not have to be perfect" or "I made the best decision I could have at the time." Polarized thinking, in which everything is black or white, with no shades of gray. Statements such as "I'm still in pain, so this program is useless" can be counteracted with "I wish I could be free of pain, but I have made some progress. Sometimes small improvements add up." Catastrophizing, in which the person imagines the worst possible scenario then acts as if it will surely come true. Statements such as "This pain must mean I am going downhill" can be counteracted with "I am jumping to conclusions" or "I'll find a way to cope with whatever happens." Control fallacy, in which the person sees him or herself as completely controlled by others (or controlling everything). Thoughts such as "My spouse doesn't think I need to see a counselor, so I can't go" can be counteracted with "I am not a helpless victim" (or thoughts such as "My family will fall apart without me" can be counteracted with "Members of my family are not helpless"). Emotional reasoning, in which the individual believes that what he or she feels must be true. Statements such as "I'm so frightened the pain will never stop, I know it never will" can be counteracted with "I'm scared, but that does not give me an accurate view of the situation" or "When I calm down, I will think about what this means." Filtering, in which people focus on one thing (such as pain) to the exclusion of any other experience or point of view. Statements such as "I can't take it"" can be replaced with "I have coped before and can cope again." Entitlement fallacy, in which individuals believe they have the right to what they want. Statements such as "Life is so unfair" or "I have been cheated" can be counteracted with "No one promised me a rose garden. I will focus on finding ways to make things better."

Psychotherapy and Social Support
Psychotherapy and social support can help a patient cope with pain.

	Psychotherapy may be useful for anyone whose pain is difficult to manage, who has developed clinical depression or anxiety or who has a history of psychiatric illness.
	Among the goals of psychotherapy are the following: Emphasize the patient's past strengths Support the patient's use of previously successful coping strategies Teach new coping skills Establish a bond to decrease a patient's sense of isolation Foster a sense of self-worth
	Psychological Approaches
	Group Approaches: Peer groups, in which a patient meets with others with the same condition, can help by Providing support Showing the patient how others have coped effectively Helping the patient maintain a social identity Providing access to information and material aid

Spiritual leaders are another potential source of support for patients.

Complementary/Alternative Approaches

The risk of side effects is low. Side effects can include post-needling pain, bleeding, bruising, dizziness, fainting, and local skin reactions. Rarely, organ damage can occur with deep needling techniques. Infection because of inadequately sterilized needles is a hazard; disposable needles are recommended. Acupuncture is not recommended for patients with serious blood clotting problems. Acupuncture should be used with caution by pregnant women.

	Stimulate blood flow
	Relax muscles that are tight or in spasm
	Promote a feeling of well-being

Muscles can be stroked, kneaded or rubbed in a circular motion. A lotion can reduce friction on the skin. Massage is not recommended in cases of swollen tissue. It should be used in addition to, and not instead of, exercise by patients who can walk.

Anesthesiologic Approaches

Nerve Blocks and Epidural Steroid Injections
Nerve blocks can relieve pain by inhibiting the impulses that travel along specific nerves in the body. To achieve a block, the doctor usually injects a local anesthetic along the course of a nerve or nerves. Although this is called a "temporary" block, in the best outcome, pain relief lasts for a long time. In very selected cases, the doctor can inject a solution that damages the nerve and produces a more permanent block.

Sympathetic nerve blocks inhibit the nerves of the sympathetic nervous system, which are responsible for increasing heart rate, constricting blood vessels and raising blood pressure in response to stress. Sympathetic nerve blocks can be useful in treating some pains due to nerve damage, such as some types of complex regional pain syndrome (also called reflex sympathetic dystrophy or causalgia).

Blocks of somatic nerves can be targeted to any area of the body. In some cases, nerve blocks fail to provide pain relief, or provide only a brief respite.

Epidural steroids, administered through injection, can help to interrupt the passage of painful impulses through nerves.

Invasive Stimulatory Approaches

Spinal cord stimulation has been used for chronic back and/or leg pain following lumbar surgery, pain due to nerve damage (complex regional pain syndrome and postherpetic neuralgia) and intractable angina. Few controlled studies of this method exist.

Deep brain stimulation may help as many as half of patients with central pain, a challenging condition that can develop as a result of damage to the central nervous system from stroke.

Disadvantages of this therapy include its high cost, risks of an invasive treatment (such as infection), and difficulty predicting before a trial which patients will benefit.

Surgical Approaches

A surgeon can cut a nerve close to the spinal cord (rhizotomy) or bundles of nerves in the spinal cord (cordotomy) to interrupt the pathways that send pain signals to the brain. In the best possible outcome, surgery relieves pain and the need for most or all pain medication. However, surgery carries the risk of:

	Stopping the pain only briefly
	Creating new pain from nerve damage at the site of the operation
	Limiting the patient's ability to feel pressure and temperature in the region, putting him or her at risk for injury