Pain Management
Medical statistics suggest that during the course of oncology care, 70 percent of patients will experience some form of pain which can affect their quality of life.
Dr. Dermot Fitzgibbon and his team at the SCCA Pain Clinic work with Pancreas Cancer Specialty Clinic medical oncologists to manage a patient’s long-term pain care needs.
Most pancreatic cancer pain can be managed by the oncologist. “We tend to be more involved in the more complex cases,” Fitzgibbon says.
Cancer patients can experience chronic noncancer pain, tumor-related pain, or a combination of the two. Chronic non-cancer pain remains relatively stable over time and can usually be managed by one or two doctors. In contrast, cancer pain may be complex, and require the involvement of many different care professionals.
“Cancer pain care needs to be carefully coordinated,” Fitzgibbon says. and requires careful follow-up of issues and medications that can complicate a patient’s overall care.”
The pain of pancreas cancer can be managed with medications as well as non-drug treatments, so that you don’t have to endure excessive pain.
Questions to Ask About Pancreas Cancer Pain
Questions to ask your doctor or nurse 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-medicine options for pain control?
- Will the pain medicines have side effects?
- What can be done to manage the side effects?
Managing Pancreas Cancer Pain
Managing pancreas cancer pain is one of the most important aspects of a patient’s care. Pain is a common symptom that can be successfully controlled. The goals of pancreatic cancer pain management are to control pain, minimize pain medication side effects and enhance quality of life. The team will ask detailed questions about the pain in in order to understand the causes of the pain, select the most appropriate treatments, and evaluate the patient's response to these treatments.
Comprehensive Pain Assessment
As a Pancreas Cancer Specialty Clinic (PCSC) patient, you will be asked about your pain. Questions may include:
- Where is your pain located?
- How long has it been bothering you?
- ow often does it occur? (Is it constant or intermittent?)
- hat does it feel like? (stabbing, shooting, cramping, dull, aching)
- How intense is the pain?
a. On scale from 0 to 10, how severe is the pain? With 0 being no pain and 10 is the worst pain imaginable?
b. Note: 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?
Treatment for Pancreas Cancer Pain with Medicines
The primary treatment for pancreas cancer pain are opioids (narcotics). These are the strongest pain relievers available, and are generally very safe if taken as directed. If pain is mild-moderate or intermittent, opioids may be prescribed on an “as needed” basis. If the pain is constant or moderate-severe, it will be prescribed on a timed, regular basis, rather than on an "as needed" basis. Taking pain medications on a regular, around-the-clock basis, is a more effective way to treat constant pain and may actually decrease the total daily amount of pain medication required. Opioids come in two main forms: short-acting and long-acting. The short-acting drug is used for “as needed” management of pain. The medicine takes effect in about 40 minutes, and typically lasts 4 hours. The long-acting medicine typically takes effect in 1 hour, and lasts anywhere 8-12 hours. One form of long-acting opioid is the fentanyl (Duragesic®) patch. It takes 12 hours to take effect, but lasts for 3 days. The patch is changed every 3 days for a constant level of pain relief.
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-moderate pain. However, they may have interactions with chemotherapy, or may not be advised in certain situations. Therefore, 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 which are used to 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.
Opioids commonly used for pancreas cancer pain management
- Morphine (Kadian®, MSIR®, MS Contin®, Oramorph-SR®)
- Oxycodone (Roxicodone®, OxyIR®, OxyContin®)
- Hydromorphone (Dilaudid®)
- Fentanyl (Duragesic®, Actiq®) -- Patch applied to the skin for 3 days
- Methadone (Dolophine®) -- Note: Methadone is an excellent pain reliever, and is frequently used in cancer pain management.
Non-Opioids used for pancreas cancer pain
- Anticonvulsants: gabapentin (Neurontin®), pregabalin (Lyrica®)
- Antidepressants: duloxetine (Cymbalta®), nortriptyline, desipramine
Side Effects
Side effects of pain medicines may include constipation, sleepiness, balance problems, difficulty urinating, itching, nausea or vomiting. You should not drive until the effect of the medicine is well known. Please contact your team should you experience any of these side effects.
Advanced Forms of Pain Management for Pancreas Cancer
Intravenous Infusion
Pain medications are usually taken by mouth. For patients who cannot take pills, medicines can be given through an intravenous (IV) infusion or a subcutaneous (needle under the skin) infusion. . Both of these can be given by a portable pump worn in a backpack, so the patient can walk around while getting the pain medicine.
Epidural and Intrathecal Routes
Other ways to deliver pain medicine include epidural and intrathecal routes. This involves putting a catheter into the back delivering the medicine with a pump. 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 medication lead to unacceptable side effects, a local anesthetic or alcohol nerve block may be performed.
This procedure provides pain relief by acting directly on the nerves that carry pain signals from the pancreas to the brain. This bundle of nerves is referred to as the “celiac plexus”, The block can be done via two approaches: percutaneous (through the skin) or endoscopic (through a tube down the throat).
Percutaneous Celiac Plexus Block: This is an invasive procedure that uses either ultrasound or CT guidance to locate the celiac nerve plexus. Needles are placed through the skin and alcohol is injected on each side of the aorta 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 3 to 4 months as the nerves were "numbed." The block will wear off over time, but can be repeated.
Endoscopic ultrasound-guided celiac plexus nerve block uses a endoscope to look into the stomach where a needle is placed to inject the celiac plexus nerves. It appears to be safe and effective but more studies are needed to compare it to other available methods.
This 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, potential leg weakness or 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 and 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/Holistic pain relief methods
- Non-drug therapies may also be helpful in treating pancreas cancer pain and improving quality of life. Techniques like relaxation, imagery, distraction, heat and cold therapy, massage, hypnosis, acupuncture, physical therapy, position for comfort, learning coping skills, as well as emotional support and counseling.
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