Understanding and Preventing Post Surgery Pain for Mesothelioma Patients: An Outline

I. PAIN AND ITS EFFECTS

• Many cancer patients feel that pain is a sign of weakness. They underestimate the importance of pain relief as part of their treatment regimens and as part of their lives.
• This attitude toward pain relief is counterproductive and actually does compromise the quality of their cancer treatment.
• Pain management is an integral part of the healing process.
• Pain has physical, emotional and psychological components.
• If it goes untreated, pain can destroy relationships with loved ones
• Pain can destroy the will to live.
• Pain can lead to the following:
  • Depression
  • Loss of appetite
  • Irritability
  • Withdrawal from social interaction
  • Anger
  • Loss of sleep
  • Inability to cope
• A great majority of cancer-related fatigue is caused by trying to stave away the pain.
• Pain may be worsened by fear of death, suffering, deformity, financial disability or isolation.
• Cancer-related pain may be relieved in 90 to 99% of cases. Of these cases, 85 to 95% may be treated through something as simple and effective as oral administration of pain relievers.

II. WHAT CAN BE DONE

• Three types of pain:
  • Somatic: Results from a tumor pressing against a bone or an organ.
  • Neuropathic: Results from a tumor touching and adversely stimulating nerves throughout the body.
  • Breakthrough: Temporary, moderate to severe flare in pain that occurs even though you may be taking medications regularly.
• Managing the pain requires honesty and communication.
• Possible treaters include the oncologist, a neurologist/neurosurgeon and an anesthesiologist, as well as nurses, or any one of those combinations.
• Keep a journal.
• The journal should contain:
  • Instructions regarding which medications to take
  • Instructions regarding dosage amounts
  • Questions regarding instructions
• Devise an individualized pain treatment regimen with your treating team.
• Treat breakthrough pain immediately. Do not wait for it to build up.
• Do not let anyone rush your visits
• Remember these five principles of treating cancer-related pain:
  1. By the mouth: Most medication can be orally administered.
  2. By the clock: Take medication at regularly scheduled intervals.
  3. By the ladder: Start with the least medication needed first -- analgesics, NSAIDs and adjuvants, followed by weak narcotics followed by stronger narcotics.
  4. For the individual: It is your treatment regimen. Ensure that it works for you.
  5. Attention to detail: Make certain that you and your treating team know everything you need to know about your pain management therapy to ensure that you get the most benefit and endure no unwanted complications.

III. TYPES OF PAIN MEDICATION

There are several types of pain medication available to patients with cancer-related pain:

• NSAIDs : Non Steroidal anti-inflammatory medications. These counter low levels of pain. They have an efficacy threshold; beyond a certain level of pain, they cannot work. They include:
  • Acetaminophen
  • Aspirin
  • Ibuprofen and others.
• Opioids : They can be oral (pill or liquid), patch, suppository, or injection. There are two types:
  1. Partial agonist: Stronger than an NSAID, but also has an efficacy threshold.
     Example: buprenorphine
  2. Full agonist: Does not have an efficacy threshold. Generally prescribed in doses to be taken every four hours or increments of four hours (ie: every 8 hours, every 12 hours). Additionally, these can be increased in dosage safely.
     Examples: morphine, hydromorphone, codeine, oxycodone, hydrocodone, methadone, levorphanol, fentanyl.
• Adjuvants: This refers to other medications such as steroids and antidepressants that assist in pain relief. For example, antidepressants in this case, are used to relieve the burning and tingling resulting from radiation and chemotherapy.
• Relaxation/meditation and distraction: These do not involve medication. The first consists of breathing exercises and visualization. The second involves different activities to distract the mind from the pain. Other methods include imagery, skin stimulation and exercise.

In certain cases, when all other forms of medicinal administration have failed, a nerve block or nerve cordotomy or other surgical procedure might be in order.

IV. ADMINISTRATION

• Pain medication is primarily administered orally in the form of tablets or liquid. It is also delivered by the following methods:
  • Skin patch (transdermal)
  • Suppository pill
  • Patient controlled analgesia (PCA)
  • Parenteral route:
    • Intramuscular (IM) injections
    • Subcutaneously (under the skin or sub Q)
    • Intravenously (IV)
    • Intraspinally
    • Intraventricularly
  • A patient's response to various opioids taken orally (or whatever the first preferred administration method was) be observed before switching method of administration.

V. MYTHS

Fact : Patients' prescriptions are safely decreased as deemed necessary by their treating physicians.

Fact : Dosage can be safely increased to continue to manage pain.

Fact : The body adjusts to the increase in morphine in the bloodstream, and respiration will continue unabated.

Fact : Opioids are prescribed for patients in pain to help them function and heal more effectively.

• Morphine usage leads to addiction.
• My body will develop a tolerance to the medication; it will then lose its potency.
• Morphine and other opioids will induce respiratory failure.
• Opioids are for patients declining or near death.

VI. ACTUAL SIDE EFFECTS AND WARNINGS

• Certain situations require emergency assistance. They include:
  • Failure of breakthrough pain remedies.
  • Inability to get up or walk because of pain.
  • Inability to sleep because of pain.
  • Crying and getting upset about feeling pain.
  • Unwillingness to move or muscles that are very tense when moving.
  • Patients' ability to move or not is a very good indicator of their actual pain, despite their claims of health.
• Drug reactions and overdosage are not common. However, if they do occur, they must be reported immediately. Symptoms can include:
  • Disturbing hallucinations
  • Ringing or buzzing in ears
  • Severe trembling, uncontrolled muscle movements, seizures
  • Numbness or tingling in lower legs or feet
  • Unprecedented incontinence
  • Constipation
  • Uncontrollable nausea or vomiting
  • Hives, rashes, swollen face

Sources consulted for this article included the following online reports: "The Pain Control Program" by Wendy Robbins, MD, and Robert W. Allen, MD; "Pain Management" by Texas Cancer Online; "Finding and Getting the Most from Cancer Pain Treatment" by Lycos Health with WebMd; and "Cancer Pain" from a collaborative effort of the American College of Physicians/American Society of Internal Medicine online.