Cancer
Pain
I think every doctor has several patients that are etched
into his memory. One
such patient was Dr. G. He
was a doctor, the same age that I was, and he had cancer. Cancer pain is different from other pains.
Few other diseases grab young, healthy people, and so quickly
force them to face their own mortality.
Even fewer diseases so consume patient and family in a (possibly
prolonged) battle to survive, and evoke such fear of not just death,
but a painful death.
The
Myth about Cancer Pain
The fact is most cancer patients never suffer with significant
pain. There is a myth
that cancer means pain. This
is usually not the case, but unfortunately, Dr. G. was not so lucky--he
was struggling with ongoing pain.
Since cancer occurs in so many different forms and areas
of the body, there is no such thing as typical cancer pain. The pain can be nociceptive—related
to tissue damage; or can be neuropathic—related to compression
or infiltration of nerves.
(See our previous update for more information about nociceptive and neuropathic
pain.) Frequently,
the pain is a combination of both.
There may be constant pain, and there may be bouts of brief,
intense pain. Sometimes the latter is associated with
certain movements or activities.
Dr. G. experienced constant burning and gnawing pain in the
upper abdomen, and he also suffered with 10-30 minutes of intense
pain after eating. This
was contributing to his dangerous weight loss and lack of energy.
Dr. G. told me that he knew he was dying. He was struggling to fight off depression
and hopelessness. He
said, “I’m more afraid of this pain than of dying.” Unfortunately, I’ve heard this from
many patients. As we
discussed his problems, it became clear that when Dr. G. experienced
any increase of his pain, he would become extremely anxious and
would focus all his attention on the pain.
He would have thoughts of tumors growing and infiltrating
or even rupturing his organs. He and I both realized that this anxiety
was making his pain worse.
The pain was also contributing to nausea and shortness of
breath. If we could decrease Dr. G.’s pain
we would be helping to decrease his anxiety, depression, weight
loss, lack of energy, nausea, and shortness of breath.
There
is No Single Treatment for Cancer Pain
We ended up providing Dr. G. with a variety of treatments.
Nerve blocks helped reduce the constant pain, but were not
very helpful with the episodic pain. A trial of a spinal morphine infusion
also failed to control the episodic pain.
Fortunately, we found that sub-lingual and buccal (under
the tongue and in the cheek) opioids were very effective in providing
rapid relief when the episodic pain occurred.
After several months, the pain intensity increased and
we switched to a home PCA (patient controlled analgesia) pump, which
Dr. G. found to be very effective.
Every time he pressed a button, the PCA pump delivered a
dose of medication into an intravenous line.
Additional relief was obtained by using oral medications
for the components of neuropathic pain.
In Dr. G.’s case we used gabapentin.
At times, I also prescribed Ritalin to help increase Dr.
G.’s energy, and to help counteract the sedation from his
other medications.
Another important part of the treatment was psychological.
A pain psychologist worked with Dr. G., to help him diminish
the anxiety that came with and exacerbated the pain.
In my own visits, I made an effort to be open to discuss
any problems that were troubling him.
Usually, the discussions were about his symptoms, and I tried
to convey the impression that there was something that we could
do about almost any symptom. Occasionally, Dr. G. didn’t want
to talk about his body, but instead would talk about his family,
what he wanted to do with his remaining time, and the legacy that
he wanted to leave. He was a religious man, and sometimes
we would talk about faith in God even when God’s plan is not
clear. I remember these discussions better than
our medical discussions—they felt like Dr. G.’s gifts
to me.
He knew that his legacy would be the impact he made on
the many people who loved him—foremost his family and friends,
but also his patients and students.
Until the end, he focused his attention on others, not himself,
and greatly influenced all of them.
After nearly a year and a half, Dr. G. lost his battle
with cancer. It was
not a pain-free battle, but pain did become a minor enemy rather
than the focus of the battle.
A year later, I ran into Dr. G.’s brother, who thanked
me for having helped his brother to maintain quality time with his
family and children. He
assured me that in the end, his brother died peacefully.
Until next time...Steven Richeimer, M.D.
Thank
you for subscribing to Pain Updates. You may view the archived Updates
at www.helpforpain.com, or click directly
to:
Your
colleagues may add themselves to the list, or you may remove yourself
from the mailing list by sending me a note to mailto:richeime@usc.edu, or by contacting me
through www.helpforpain.com.
