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:
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
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:
disruptions in activity, appetite and sleep
helpless and anxious
participating in life to the fullest extent possible
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.
Many people with cancer experience pain. Thirty to 40 percent
of patients in active cancer therapy and 70 to 90 percent
of patients with advanced cancer report pain. Cancer pain can be caused by:
pressing on organs, nerves or bone
such as surgery, chemotherapy or radiation
conditions related to the cancer, such as stiffness from
inactivity, muscle spasms, constipation and bedsores
unrelated to the cancer, such as arthritis or migraine
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:
radiation or chemotherapy to shrink tumors causing pain
therapy or drainage for pain caused by infection
therapies, and social and spiritual support, to influence
the perception of pain
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.
Patients with mild to moderate pain should receive:
nonopioid analgesic, such as acetaminophen or a nonsteroidal
anti-inflammatory drug (NSAID)
drugs if a specific indication exists
Patients with moderate to severe pain (or who have failed
to achieve adequate relief with Step 1) should receive:
opioid conventionally used for moderate pain (usually
codeine, hydrocodone, dihydrocodeine, oxycodone, propoxyphene,
nonopioid analgesic, such as acetaminophen or an NSAID
adjuvant drug in some cases
Patients with severe pain (or who have failed to achieve adequate
relief with Step 2) should receive:
opioid conventionally used for severe pain, such as morphine,
oxycodone, hydromorphone, methadone, levorphanol or fentanyl
nonopioid analgesic in some cases
drugs in some cases
Pain is just as common in AIDS as it is in cancer. Like cancer
pain, AIDS-related pain can be caused by the disease itself
and from therapies. AIDS
patients commonly experience:
due to nerve damage, such as peripheral neuropathy and
pain from gastrointestinal disease
pain from pneumonia
find an appropriate treatment, a doctor should perform a detailed
Treatments that can successfully control pain include:
medications (drugs whose primary purpose is not for pain
but rather for other conditions)
treatments (drugs are applied directly to the skin, as
a patch, gel, or cream)
more information on medications used to treat pain, please
see our General
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.
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 (treatments that do not rely
primarily on medication to achieve their effect) offer a variety
of approaches to pain relief. Most are non-invasive. Simple,
relatively safe non-pharmacological approaches include:
most cases, these techniques should be used in addition to,
not instead of, other approaches to pain relief. More
invasive non-pharmacological treatments include:
Exercising is important because it can:
restore coordination and balance
a sense of well-being
anxiety and stress
the heart healthy
maintain an appropriate weight
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.
Heat therapy can reduce pain, especially the pain of muscle
tension or spasm. Sometimes patients with other types of pain
therapy acts to:
the blood flow to the skin
blood vessels, increasing oxygen and nutrient delivery
to local tissues
joint stiffness by increasing muscle elasticity
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.
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.
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.
Cold therapy, which constricts blood vessels near the skin,
sometimes can relieve the pain of muscle tension or spasm.
Other types of pain also benefit in some cases. It can also
reduce swelling if applied soon after an injury.
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.
Electrical Nerve Stimulation (TENS)
Transcutaneous electrical nerve stimulation (TENS) is a method
of applying a gentle electric current to the skin to relieve
pain. Studies have shown that it can be effective in certain
cases of chronic pain. A
small box-shaped device, which patients can put in their pocket
or hang on their belt, transmits electrical impulses through
wires to electrodes taped to the skin in the painful area.
Patients describe the sensation of TENS as buzzing, tingling
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.
Cognitive behavioral techniques are used to reduce the body's
unproductive responses to stress, helping to relieve pain
or improve the ability to tolerate it. Some
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.
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.
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).
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
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.
biofeedback, electrodes are placed at various points
on the patient's skin to measure:
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.
tension. As a muscle contracts, electrical activity
The stress response is related to blood flow in
the hands or feet, and blood flow determines temperature
Distraction is a pain management technique in which patients
focus their attention on something other than their pain
and negative emotions.
distract themselves, patients can:
to the radio
to friends or family
to stories being read
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
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."
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
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
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
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").
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."
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
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
and Social Support
Psychotherapy and social support can help a patient cope with
leaders are another potential source of support for patients.
Acupuncture is an ancient method for relieving pain and controlling
disease, used in China for thousands of years. It appears
to be effective for some patients with chronic pain. Thin
gold or metal needles, gently twirled for ten to twenty minutes,
can be used to stimulate acupuncture points, which relieve
pain in specific parts of the body (for example, a point on
the leg targets stomach pain). Patients usually feel a tingling,
warm sensation, similar to that of transcutaneous electrical
nerve stimulation. Acupuncture points can also be stimulated
with deep massage (acupressure), electric currents (electroacupuncture),
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
Massage can be a useful addition to a pain management program,
especially for patients who are bedridden. Massage
muscles that are tight or in spasm
Promote a feeling of well-being
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.
patients with pain who fail conservative therapies, simple
to complex interventional therapies such as nerve blocks,
epidural steroid injections, intraspinal drug administration,
or trigger point injections may be helpful. These therapies
are typically provided by anesthesiologists with advanced
training in pain management.
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.
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
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.
steroids, administered through injection, can help to interrupt
the passage of painful impulses through nerves.
Intraspinal drug administration involves the delivery of low
doses of analgesic drugs, such as morphine or clonidine, through
a catheter inserted directly into the spine. This approach
is used often to manage cancer pain.
A trigger point is a painful area in a muscle that can cause localized as well as referred pain. An injection administered to this area may contain a local anesthetic, saline, cortisone, or botulinum toxin. A trigger point injection can relax an area of intense muscle spasm. Sometimes dry needling is also used to treat a trigger point.
Invasive nerve stimulation can provide pain relief for some
patients who have not responded to other therapies. In this
technique, electrodes are implanted in the patient's body
to send a gentle electrical current to nerves in the spinal
column or the brain.
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.
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.
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.
to treat pain (rather than the underlying disease) is only
appropriate in cases where more conservative approaches have
failed and where trained neurosurgeons and follow-up care
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:
the pain only briefly
new pain from nerve damage at the site of the operation
the patient's ability to feel pressure and temperature
in the region, putting him or her at risk for injury