A Patient's Guide to Managing Hormone-Refractory Prostate Cancer  

Chapter 17.  Managing Pain

Be prepared

The time to take pain management seriously is before you experience serious pain as a result of prostate cancer. When you do have serious pain--as a result of the disease or as a result of a treatment side effect--nothing else will matter. No matter what stage of the disease you are dealing with, read this section, and know that its message will be available should you need it.

You will hear, from medical professionals, that there is no need to suffer pain from cancer. That may be true…theoretically. However, I know of no one with metastatic cancer who has not experienced severe pain for some reason, pain that by its severity became the foremost issue in their battle. Eventually, a resolution was found; in the meantime there was considerable suffering. This chapter is intended to help you reduce that suffering to a minimum by giving you the knowledge and a strategy for working with your doctor to relieve the pain and restore your quality of life.

Assessment of pain is subjective; therefore, what constitutes adequate relief is also subjective. You want to control the pain to a level that permits you to enjoy a good quality of life.

You may have to be persistent with your caregivers, but you should insist on treatment for any level of pain that interferes with your ability to enjoy life.

It is important to control pain. Serious pain invariably leads to depression, which becomes a threat to life.

This paper does not cover every treatment for pain, but it should be enough that you can use the information to initiate meaningful discussions with your doctors.

Drug dependency is a controllable issue

The risk of addiction should not keep you from getting adequate pain relief. For most of us, the problem of pain is more severe than the problem of dependency. Dependency, for most of us, is a non-issue, unless you are already an alcoholic or an addict.

I became physically dependent on morphine during a single week, but found myself eager to stop because of the unpleasantness of feeling drugged. I stopped over a few days with some discomfort, but no difficulty. If you have become dependent, you should stop gradually to minimize the discomfort and prevent the serious risks associated with stopping “cold turkey.” Your normal condition is that your quality of life is better when you don’t have to take pain relievers.

Dosing

In starting a pain management regimen, your purpose is to keep the pain under control, to the extent that you can enjoy your normal activities. It takes 2 to 3 days for an opioid pain drug to build to an effective level in your blood stream and suppress the pain on a continuing basis. Do not stop taking the opioid medicines when you no longer feel the pain. First discuss that with the doctor. If you do stop, you may find yourself back in pain, at the beginning of the process, and have to spend several days in pain rebuilding the drug level in your blood.

Constipation and Diarrhea with Opioids

When you use opioids, you are likely to experience constipation at the outset and during the usage. Be prepared with suppositories and laxatives. Metamucil may help.

When you discontinue an opioid, especially morphine, you may experience diarrhea. Be prepared for it with Imodium or other over-the-counter remedy. Do not let diarrhea go on without treatment because it can dehydrate your system dangerously.

Whose help do you need?

Your primary contact for pain management is your oncologist, who is experienced in dealing with pain associated with cancer. If you are unable to find an acceptable solution, you may wish to consult a pain specialist (frequently an anesthesiologist with special training), usually available at larger hospitals.

Try to determine the source of the pain

Eliminating the source is always better than treating the symptom. If you can determine the source, it may be easy to eliminate the pain. However, with prostate cancer, the source is often in the bone, a difficult area to treat. In some cases, nerves are involved in persistent pain, and the source may be at a location different from the perceived pain. In still other cases, the source may be unknown, and you can only treat the symptom.

Gastrointestinal pain may require a different approach than use of the normal pain relief drugs. For example, acid reflux can cause severe pain up and down the chest; sometimes it will respond to Pepto-Bismol or other acid control medication. An ulcer may need different treatment. Pain may even be caused by one of the drugs you are taking.

You are always better off if you can eliminate the pain at its source.

Determine the level of pain

Pain is a subjective issue; the headache that is “killing” one person may be ignored by the next. However, the only opinion that counts is that of the person with the pain. The pain level is a continuum; the numeric levels listed below are designated as an aid to communication. The level will need to be communicated to the doctor in order that the appropriate treatment can be used.

Most medical practitioners are used to dealing with a scale of 1 to 10 in severity. A level of 1 is a pain that is trivial; a level of 10 is the worst pain you’ve ever experienced. For example, many people have indicated that kidney stones cause level 10 pain. Hitting your thumb with a hammer is a brief introduction to level 10 pain. For that instant, nothing else matters. What the doctor needs to know is your estimate of the severity of your pain.

Level Description
0 No pain.

1-2 Annoying, but bearable, such as a common headache; you may seek a remedy or you may ignore the pain.

3-4 Sufficiently painful to cause you to seek a remedy.

5-6 Interferes with your ability to focus on normal
activities; stronger relief is needed.

7-8 Dealing with the pain has become your first priority;
You are prevented from doing normal activities. This is near to unbearable.

9-10 The worst pain you have ever experienced. The pain is unbearable.

Recently, Federal law has required that all hospitals include in their review of your health status whether you are currently experiencing pain and what the level is.

Treating level 1-2 pain

Take Tylenol, Ibuprofen or Advil according to the directions. If you are being treated with chemotherapy, you may want to avoid aspirin because it thins the blood by reducing platelet function and compounds the suppressing action of the chemotherapy.

Treating level 3-4 pain

From this point all drugs require a prescription. First, try Tylenol with codeine if you are fairly tolerant of the pain. If you cannot comfortably tolerate the pain, try Vicodin.

If those do not control the pain, try Oxycontin next. (This name means “oxy” for oxycodone—an opioid--and “contin” for continuous-release dose.) The typical starting dose is one 10-mg tablet every 12 hours. This drug has an effective time in the body of 12 hours, so it should be dosed on that schedule. If more is needed, that larger dose should also be taken every 12 hours, rather than more frequently.

If the pain is not controlled, then the Oxycontin dose may be ramped up. Over a long period, with pain that is nearly under control, the dose might be ramped up by an additional 10 mg per dose every month. If the pain is more severe, the ramping schedule can be shortened to every 2-3 days.

If the Oxycontin is not sufficient to control the pain, then MScontin (morphine) can be started at 15 mg every 12 hours. Again, maintain the 12-hour schedule when ramping up.

Treating level 5-6 pain

Continue with Oxycontin or MScontin, ramping up as necessary to control the pain.

At this time, consideration should also be given to hospitalization if you are ramping up with morphine. High doses can lead to respiratory failure, so emergency care may need to be at hand. This is a decision for the doctor.

Ramping up should be done no faster than necessary in order to give the brain time to assimilate the drug. If the ramping up is done too quickly, the individual will temporarily experience the notorious and unpleasant side effects of opioids: lethargy, loss of mental alertness, confusion, loss of emotional control, etc.

Treating level 7-8 pain

Hospitalization is required. To achieve the necessary higher doses of morphine, intravenous dosing is needed. It will be necessary to have emergency care at hand during administration of the higher doses.

Once the effective dose has been established by ramping up the IV, the dose can be converted to pills for home use. An IV dose of 1 mg of morphine is equivalent to 3 mg in a pill taken orally.

Treating level 9-10 pain

This pain requires continued ramping up of morphine doses from the previous level.

Fentanyl (an opioid) can be administered via a patch (Duragesic) or by a drip when the patient cannot tolerate Oxycontin or morphine. Patches are used when nausea and vomiting are a problem. A fentanyl portable pump can also be worn, like a “fanny-pack,” for continuous administration.

Breakthrough pain

If you are taking prescription drugs for chronic pain, you should also discuss with the doctor what drug can be supplied in case you experience temporary “breakthrough pain.” You should be prepared--ahead of time--in case the regular dose effect is overwhelmed by the pain. Do not wait to discuss this until the pain spikes—unless you are in the hospital, where help is always at hand.

Some examples of prescription drugs for breakthrough pain include Percocet and Endocet.

If you are fighting pain at levels 7 to 10 and still have breakthrough pain, there is a high-powered version of fentanyl with the brand name Actiq. It comes in the form of a “lollipop” that can be sucked; the medicine is absorbed by the mucous membranes of your mouth and in the GI tract. Because of the strength of this drug, you must already be accustomed to an opioid drug to avoid overdosing.



Nerve pain is more difficult to treat

Neurological pain can be a difficult problem to control. Identifying the source may be the first problem.

For example, tumors growing in the spine can block the channel for the spinal nerves (stenosis) and lead to painful compression. Strangely, though, this pain may show up in a leg rather than at the point of compression. The answer to this type of pain may be surgery to remove the compression. The problem also entails the risk of permanent nerve damage.

Chemotherapy often results in “peripheral neuropathy,” (PN) or pain and numbness at the extremities. We have been able to mitigate some of the effects of PN by dosing glutamine amino acid, which helps in the repair of damaged cells. The dose is 10 grams t.i.d. plus 50 mg magnesium and 50 mg vitamin B-6 daily. Avoid taking with hot foods. (Discuss this with your onco before starting.)

Another treatment for nerve pain is Neurontin. If the other pain-relievers are ineffective, this may be an alternative.

Radiation and radioisotope injections for bone pain

External-beam radiation can sometimes be used (in a technique called “spot welding”) to alleviate localized pain due to cancer in the bones. However, the treatment is localized and may not be useful if there are many bone metastases.

Strontium-89 (Metastron) and samarium-151 (Quadramet) can be injected in a generalized treatment of bone pain. From our experience, we prefer Quadramet. These radioisotopes seek the bone, especially areas with bone lesions, i.e., tumors. Radiation is an effective and quick tool for eliminating pain, although the injected radioisotopes can cause an initial pain flare before the original pain subsides. Relief with these radioisotopes can last for as long as a year.

There is a price to pay for the use of radiation. It also damages bone marrow, especially when used in the pelvic area, where large concentrations of bone marrow exist. A reduction in bone marrow will limit the amount of chemotherapy that can be administered because chemotherapy also affects the bone marrow and suppresses the immune system.

Radiation cannot be repeated indefinitely because of the damage to the bone marrow, which is the source of white blood cells for the immune system and red blood cells for oxygen transport. Radiation also damages other healthy tissue in the body and may result in severe side effects, such as diarrhea and bleeding.

Chemotherapy for pain management

Chemotherapy can relieve bone pain by suppressing the cancer—the source of the pain. It is not unusual to experience quick pain relief on starting an effective chemotherapy. (See the sections on chemotherapy.) Any strategies, including hormone therapy, that inhibit the cancer may also relieve pain.

Bisphosphonates for bone pain

The bisphosphonate drugs (Zometa, Aredia, Fosamax) have also been shown to relieve pain by suppressing bone metastases. Anyone with HRPCa should be using one of these drugs. (See Chapter 13. Protect bone integrity.)


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