Managing pain is one of the most important aspects of your care for pancreatic cancer. Pain is a common symptom: During the course of cancer care, 70 percent of patients experience some form of pain, which can affect their quality of life. Fortunately, pain can be successfully controlled.
Dermot R. Fitzgibbon, MD, and his team at the Seattle Cancer Care Alliance Pain Clinic work with medical oncologists in the Pancreatic Cancer Specialty Clinic (PCSC) to manage patients’ long-term pain with medicines as well as non-drug treatments. The goals of pancreatic cancer pain management are to control any pain you have, minimize any side effects you experience from pain medicines, and enhance your quality of life.
Types of Pain
Cancer patients can experience chronic non-cancer pain, cancer-related pain, or a combination of the two. Chronic non-cancer pain tends not to change much over time. It can usually be managed by one or two doctors. In contrast, cancer pain may be complex and sometimes requires the involvement of many care professionals.
Most of the time, a patient’s oncologist can manage his or her pancreatic cancer pain. “We tend to be more involved in the more complex cases,” Dr. Fitzgibbon says about the Pain Clinic. “Cancer pain care needs to be carefully coordinated. It requires careful follow-up of issues and medications that can complicate a patient’s overall care.”
Comprehensive Pain Assessment
As a PCSC patient, you will be asked about your pain. Your team will ask you detailed questions in order to understand the causes of your pain, select the most appropriate treatments, and evaluate your response to these treatments.
Questions may include:
- Where is your pain located?
- How long has it been bothering you?
- How often does it occur? Is it constant or intermittent?
- What does it feel like (stabbing, shooting, cramping, dull, aching)?
- How intense is the pain on scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable? (If you have trouble using a 0-to-10 pain scale, use this scale instead: Is the pain mild, moderate or severe in intensity?)
- What seems to make the pain worse? What makes it better?
- What medicines or other treatments have you tried for the pain? Were they helpful?
Questions to Ask About Pain Relief
To help ensure that you receive the best pain relief you can get, ask your doctor or nurse these questions about controlling pancreas cancer pain:
- What can be done to relieve my pain?
- What can we do if the medicine does not work?
- Are there non-drug options for pain control?
- Will the pain medicines have side effects?
- What can be done to manage the side effects?
Treatment for Pancreas Cancer Pain with Medicines
“As Needed” and Around-the-Clock Opioids
The main treatment for pancreas cancer pain is opioids (narcotics). These are the strongest pain relievers available, and they are generally very safe if taken as directed.
- If your pain is mild to moderate or intermittent, your doctor may prescribe opioids to take only as needed (not on a regular schedule).
- If your pain is moderate to severe or constant, your doctor will prescribe opioids to take around the clock on a regular schedule.
Taking pain medicines on a regular, around-the-clock basis is a more effective way to treat constant pain, and it may actually decrease the total amount of pain medicine you need to get relief each day.
Short-Acting and Long-Acting Opioids
Opioids come in two main forms: short-acting and long-acting.
- The short-acting form is used for “as needed” management of pain. The medicine takes effect in about 40 minutes, and the effect typically lasts four hours.
- The long-acting form typically takes effect in one hour, and the effect lasts 8 to 12 hours. One form of long-acting opioid is the fentanyl (Duragesic) patch. It takes 12 hours to take effect but lasts for three days. The patch is changed every three days for a constant level of pain relief.
Commonly Used Opioids
These opioids are commonly used for pancreas cancer pain management:
- Morphine (Kadian, MSIR, MS Contin, Oramorph-SR)
- Oxycodone (Roxicodone, OxyIR, OxyContin)
- Hydromorphone (Dilaudid)
- Fentanyl (Duragesic, Actiq)
- Methadone (Dolophine)
Side Effects of Opioids
Side effects of opioid pain medicines may include constipation, sleepiness, balance problems, difficulty urinating, itching, nausea, or vomiting. You should not drive until you know the effects the medicine has on you and whether you can drive safely. Please tell your team if you experience any side effects of your pain medicines.
Non-opioid Medicines for Pain
Other prescription and over-the-counter medicines used to relieve pain include acetaminophen (Tylenol) and non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin, Advil) or naproxen (Aleve). They can be effective for mild to moderate pain. However, they may have interactions with chemotherapy or may not be advised in certain situations. It is very important to check with your doctor, nurse, or pharmacist before taking these medicines.
At times, medicines called “adjuvant analgesics” are also used for pain and symptom management. These are typically anticonvulsant (anti-seizure) or antidepressant medicines. They may help treat nerve pain, improve sleep, or improve mood. Low mood, anxiety, and lack of sleep all worsen quality of life and are important to address.
Non-opioids used for pancreas cancer pain include the following:
- Anticonvulsants: gabapentin (Neurontin), pregabalin (Lyrica)
- Antidepressants: duloxetine (Cymbalta), nortriptyline, desipramine
Advanced Forms of Pain Management for Pancreas Cancer
Pain medicines are usually taken by mouth. For patients who cannot take pills, medicines can be given through an intravenous (IV, by vein) infusion or a subcutaneous (needle under the skin) infusion. In both cases, the medicines can be delivered by a portable pump worn in a backpack, so the patient can walk around while getting the medicine.
Epidural and Intrathecal Routes
Other ways to deliver pain medicine include epidural and intrathecal routes. This involves putting a catheter (tube) into the back so a pump can deliver the medicine through this tube. Because this delivery method can cause leg weakness and problems controlling the bowels and urine, use is usually limited to patients who are in the hospital or bed bound at home.
Celiac Plexus Block
When pain does not respond to other measures, or when pain medicine causes unacceptable side effects, a local anesthetic or alcohol nerve block may be performed.
This procedure provides pain relief by acting directly on the bundle of nerves (celiac plexus) that carries pain signals from the pancreas to the brain. The block can be done in two ways.
- Percutaneous (through the skin) celiac plexus block. This is an invasive procedure that uses either ultrasound or CT guidance to locate the celiac plexus. Needles are placed through the skin, and alcohol is injected on each side of the aorta (large blood vessel) on either side of the celiac axis. This procedure is performed by anesthesia pain specialists in an outpatient setting. The nerve block may last for up to three to four months. It will wear off over time but can be repeated.
- Endoscopic ultrasound-guided celiac plexus nerve block. For this procedure, the doctor uses an endoscope (thin, lighted tube) to look into the stomach, where a needle is placed to inject medicine into the celiac plexus. It appears to be safe and effective but more studies are needed to compare it to other available methods.
A nerve block is performed to reduce pain, reduce the need for high doses of oral opioids, and maintain quality of life. Risks and side effects of a celiac plexus block include diarrhea, leg weakness, and problems controlling bowels or urine.
New Pain Management Techniques
Thorascopic splanchnicectomy is a minimally invasive procedure that cuts specific nerve branches. This technique is done under general anesthesia. Results are promising for significant pain relief, but the duration of pain relief remains unknown.
Other Pain Relief Methods
External-beam radiation therapy is also used to reduce pain. When directed at the tumor, this method may provide fast pain relief.
Non-drug therapies may also be helpful in treating pancreas cancer pain and improving quality of life. These include techniques like relaxation, imagery, distraction, heat and cold therapy, massage, hypnosis, acupuncture, physical therapy, positioning for comfort, coping skills, emotional support, and counseling.