Sunday 13 December 2009, 23:16

Pain treatment in cancer patients

How chronic cancer-related pain may be managed

Pain treatment in cancer patients

Chronic cancer-related pain is one of the most challenging problems physicians face today. It is not simply a symptom of the cancer process, but it is a disease in itself and has to be treated like one.


Not only chronic cancer pain causes obvious problems such as suffering, distress, disability and severe decrease of the quality of life; it also starts a complex series of neuropathological events that eventually result in phenomena of hyperalgesia (increased response to a painful stimulus) and allodinia (painful response to a normally innocuous stimulus) and, through the stress-response, it may also contribute to patient morbidity and even mortality.


Cancer pain is difficult to manage and to treat effectively. No definitely drugs with minimal side-effects exist. The prevalence and severity of pain is extremely variable depending on both patient factors (physiopathological state, sensitivity, previous experience of pain) and disease factors (cancer type and its location). That's why cancer patients may suffer different degrees of pain: from mild to severe pain, with a "continuum" of intermediate degrees between these extremes.


There is not a unique universal treatment for all patients affected by cancer pain. Pain treatment has to be titrated against the individual patient's response to achieve the greatest possible pain relief with the fewest side effects. The drugs currently recommended for the treatmentof chronic cancer pain belong to two main classes: analgesic-antipyretic drugs (acetaminophen and nonsteroidal anti-inflammatory drugs, or NSAIDs) and opioid drugs. Additionally, adjuvant medications (eg: antidepressants, anticonvulsivants, corticosteroids) may be used to treat particular types of pain that are otherwise difficult to manage.


The guidelines for the use of the above drugs for the treatment of cacer pain are based on the severity of pain. Mild pain may be treated with acetaminophen or NSAIDs. Mild to moderate pain is often treated with opioid medications, either alone or, more frequently, in combination with analgesic-antipyretic drugs. For moderate to severe pain high doses of opioid analgesics are used, usually given alone. Importantly, the dose and the duration of treatment for all these drugs have always to be titrated individually.


None of the drugs above mentioned is free from side-effects. Some NSAIDs cause gastrointestinal damage (ulcers and bleeding) and renal failure. Acetaminophen may be hepatotoxic, even at therapeutic doses. Opioid analgesics may produce a variety of side-effects, such as gastrointestinal disturbs (constipation, nausea and vomiting), sleepiness and, more seriously, they can cause respiratory depression.


Patient addiction is often cited as one of the main side-effects related to opioid therapy. Actually true addiction (psychological dependence) is rare in patients with persistent pain syndromes; tolerance may develop, but it is a different process from true addiction and it is easily manageable. Tolerance is not a form of psychological dependence. It is the expected response of the patient's body to the prolonged administration of opioid medications: over time the patient needs higher and higher doses to maintain the same level of pain relief. The desidered level of pain may be achieved increasing the amounts by small doses at a time and tolerance may be managed by slowly decreasing the dosage when the drug is no longer needed.


Despite the side effects above mentioned, pain treatment is a must for cancer patients. Fear of side-effects only leads to an ineffective therapy and causes needless suffering for patients. As stated above, chronic cancer pain is a disease in itself and it has to be treated like one.


By Chiara De Carli

Category: Cancer

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