The Sol Goldman Pancreatic Cancer Research Center

How is pain managed?

Pain in Pancreatic Cancer Can Be Controlled

The management of pain for patients with pancreatic cancer is one of the most important aspects of their care. Pain is a common symptom that can be successfully controlled. The best management of pain is aggressive therapy with constant assessment. The patient with pancreatic cancer who is experiencing pain can maintain his/her quality of life.

A patient's report concerning his/her pain should always be the primary source of information that health care providers use to assess and control pain successfully. The goals of pancreatic cancer pain management are to control pain, prevent or minimize side effects and to enhance quality of life. The goals of the health care provider are to understand the causes of the pain, perform a comprehensive assessment, select the most appropriate drug/medication and nondrug interventions, and evaluate the patient's response to these treatments.

Comprehensive Pain Assessment: assessment of pain intensity

  • Onset: When did it start? How often does it occur?
  • Location: Where is it?
  • Quality: What does it feel like? (stabbing, shooting, cramping, dull, aching)
  • Intensity: What is the intensity of the current pain?
  • Numerical rating scale: On a scale of 0 to 10, with 0 being no pain and 10 the worst pain imaginable, the patient needs to select a number between 0 and 10 that best describes how intense the pain feels.
  • When is it most intense? When is it better?
  • Verbal descriptor scale: The patient needs to indicate if he or she is in pain. If so, is the pain mild, moderate, or severe?

Aggravating and relieving factors: What makes the pain better or worse?

  • Previous treatment: What treatments were used in the past and how successful were they?
  • Relief with current treatment: Is relief of pain complete, almost complete, partial, very little, none?
  • Side effects of current treatment: Is the patient experiencing any side effects to current treatment?
  • Assess other factors that influence the management of pain.

Effect of pain on patient and family members/significant others.

  • Meaning of pain to patient and family/significant others.
  • Usual coping strategies for pain and other stressors.
  • Mood states.
  • Effect of pain on sleep and fatigue.
  • Concern about addiction and side effects of medication.
  • Concern about costs of treatment.

Treatments

The use of opioids (or narcotics, the strongest pain relievers available) is the main way to treat pain from pancreatic cancer. Other types of medicines used to relieve pain that are not opioids are: acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs). At times, medicines called adjuvant analgesics are also used. These are medicines used for purposes other than the treatment of pain but help in relieving pain in some situations.

Types of Opioids Recommended for Pain of Pancreatic Cancer*

  • codeine
  • hydrocodone (Vicodin®, Vicoprofen®)
  • hydromorphone (Dilaudid®)
  • levorphanol (Levo-Dromoran®)
  • morphine (Kadian®, MSIR®, MS Contin®, Oramorph-SR®)
  • oxycodone (Roxicodone®, OxyIR®, OxyContin®, Percodan®)
  • fentanyl (Duragesic®, Actiq®)
  • methadone (Dolophine®)
  • tramadol (Ultram®)
  • MSIR=morphine sulfate immediate release
  • MS Contin=morphine sulfate sustained release
  • Oramorph-SR=morphine sulfate sustained release
  • Roxicodone=oxycodone immediate release
  • OxyIR=oxycodone immediate release
  • OxyContin=oxycodone sustained release
  • Percodan=oxycodone and immediate release
*Opioids are available only by prescription

Non-Opioids Recommended for Pain of Pancreatic Cancer

NSAIDS Antidepressants Anticonvulsants
Aspirin amitriptyline carbamazepine
Bufferin® Elavil® Tegretol®
Ecotrin® Pamelor® phenytoin
Trilisate® desipramine Dilantin®
Dolobid® Norpramin® valproate
Ibuprofen® doxepin Depakote®
Motrin® Sinequan® clonazepam
Advil® imipramine Klonopin®
Ansaid® Tofranil® gabapentin
Orudis® venlafaxine Neurontin®
Aleve® Effexor® lamotrigine
Anaprox® citalopram Lamictal®
Daypro® Celexa®  
Lodine®    
Voltaren®    
Arthrotec®    
Celebrex®    
Bextra®    
Vioxx®    
acetaminophen ®    
Tylenol® (classified as a non-opioid)    
Some NSAIDs, as well as acetaminophen, are available without prescription. All other medications require a prescription.

A successful method for treating patients with significant pain is to use opioids on a timed, regular basis, rather than on an "as needed" basis. The pain medication is taken round-the-clock. Pain medications taken round-the-clock are more effective and may decrease the total daily amount of pain medication required.

Routes for Pain Medication Oral

Pain caused by pancreatic cancer is best treated with long-acting oral (taken by mouth) opioid analgesics in appropriate doses, with the most common drug used being long-acting morphine sulfate. Morphine is widely available, comes in various formulations, and has well-characterized pharmacologic properties. In patients who cannot take oral medications, topical opioids worn as a continuous-release patch placed on the skin can be highly effective such as Duragesic (Fentanyl) patches. Opioids can even be given rectally in the form of a suppository.

Even when a patient is placed on long-acting, regular timed medication there may still be episodes of pain between doses. This is referred to as "breakthrough pain". A short acting or immediate-release opioid is usually prescribed to be taken at these times. Accurate notation as to the time, amount of opioid for breakthrough pain, and related activity or circumstances is necessary to help the health care professional assist in the successful management of the pain. An assessment of the need for more long-acting opioid and a change in the amount of long-acting opioid can be calculated appropriately when there is good communication between the patient and the collaborating health care professional for the pain management.

Subcutaneous and Intravenous (IV)

Subcutaneous continuous infusions of opioids can be provided for rapid pain relief without use of an intravenous (IV) access. Continuous intravenous infusion of opioids for pain management is an alternative to subcutaneous infusion and requires an IV access. Both modes of therapy can provide patient-controlled analgesia (PCA). The PCA technique allows for rapid, individual administration of pain medication by means of a programmable portable pump. The patient is able to receive a continuous infusion of pain medication and has the ability to give himself a bolus (smaller amount of pain medication) for breakthrough pain. This provides the patient a sense of control in administering pain medication. Skilled nursing and pharmacy support are necessary. The infusion pump may be expensive to rent and there may be recurring charges for disposable supplies required for medication infusion.

Epidural and Intrathecal

Epidural and intrathecal routes are useful for pain that has not responded to less invasive measures. Local anesthetics may be added to spinal opioids and may produce additive analgesia. Special care is given to the site where the catheter enters the skin since an infection at the site can cause meningitis or an epidural abscess. Itching and the inability to pass urine (urinary retention) are more common than with other means of opioid administration. These modes of pain medicine administration require special physician and nursing expertise and need careful monitoring. The infusion pump may be expensive to rent and there may also be recurring charges for disposable supplies required for medication infusion.

Special Pain Management Team

Poorly controlled pain is often the result of inadequate analgesic dosing and may require the expertise of pain management specialists. Pain management specialists may be part of a pain team, pain and symptom management team, palliative care team or an anesthesia pain service.

Celiac Plexus Block

For pain from pancreatic cancer that does not respond to other measures or when taking oral or topical medication leads to unacceptable side effects, an alcohol nerve block may be performed. This procedure provides pain relief by acting directly on the nerves which carry painful stimuli from the diseased pancreas to the brain. This nerve group is referred to as the celiac plexus. A local anesthetic is injected into the nerve root of the celiac plexus. This is an invasive procedure that uses either ultrasound or CT scan guidance to locate the celiac nerve plexus. Needles are placed through the skin (percutaneous) 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. This nerve block may last for up to 3 to 4 months as the nerves were "numbed" and the block tends to wear off over time. A percutaneous alcohol nerve block can be performed to reduce pain and to reduce the need for high doses of oral opioids. Nerve blocks can be done as an outpatient procedure. Percutaneous nerve blocks may be repeated in a patient with a previous block that has worn off. The patient may also take any pain medication as needed but the hope is that the patient will not require as high a dose of opioids to provide pain relief and maintain quality of life.

Newer Alternatives

Newer alternatives are available. Thorascopic splanchnicectomy is a minimally invasive procedure that cuts specific nerve branches. This technique is done under general anesthesia. Results appear promising for significant pain relief but the duration of pain relief remains unknown. Another technique is the endoscopic ultrasound-guided celiac plexus nerve block. This approach uses a endoscope to look into the stomach and then place a needle through the stomach to inject the celiac plexus nerves. It appears to be safe and effective but more studies are needed to compare to other available methods.

Pain Management Procedure During Surgery

Pain may also be treated at the time a patient has surgery for pancreatic cancer. If a patient is unable to have surgery for cure, and has exploration with or without palliative bowel bypass procedure(s), an alcohol nerve block may be performed. The surgeon injects alcohol directly on both sides of the nerve root that runs behind the pancreas, the celiac plexus. This helps to numb the nerves usually 3 to 4 months, helping to minimize pain related to tumor growth.

Additional Methods of Pain Treatment Radiation Therapy

Another modality to assist with pain management is external beam radiation therapy. The radiation beam is directed at the tumor and may provide fast onset of pain relief.

Non-Drug Pain Treatment

Non-drug therapies may also be helpful in treating the pain from pancreatic cancer and improving the patient's ability to perform normal activities. These therapies include relaxation, imagery, distraction, heat and cold therapy, massage, hypnosis, physical therapy, learning to position for comfort, learning coping skills, and emotional support and counseling. These therapies can be used in conjunction with pain medications. More than one non-drug pain therapy can be used at any one time.

Patient and family or significant other education is an important part of helping all involved in the care of the patient. Patient education can promote self-care in pain treatment and the management of side effects.

Questions to Ask Your Doctor about Pain Control

  1. What can be done to relieve my pain?
  2. What can we do if the medicine does not work?
  3. What other options do I have for pain control?
  4. Will the pain medicines have side effects?
  5. What can be done to manage the side effects?
  6. Will the treatment limit my activities (i.e., working, driving, etc.)?

It is important to remember that each patient is unique and any treatment plan developed will be developed for each person's specific pain. The type and amount of pain medication may need to be adjusted and fine-tuned to each patient's need. The management of pain in the patient with pancreatic cancer requires constant vigilance and a commitment by all members of the team to manage and control pain. If a patient does not feel the doctors or other members of the health care team are not responsive to his or her pain management, then seek another doctor or pain management team that will. A patient must feel comfortable with not only the pain management plan but also with those health care individuals involved in the plan. The pain of pancreatic cancer can be managed and must not be ignored.

There can be side effects of the various pain medications and other pain management therapies. Constipation is usual after analgesic drugs. Diarrhea is common after procedures directed toward the celiac plexus. Nausea and vomiting can be the effect of the pain but also the side effect of oral analgesics, and further decrease the already impaired appetite of the patient, increasing the rate of weight loss, fatigue, and depressed mood.

There are numerous pharmacologic agents such as opioids and other analgesics along with nonpharmacologic agents that are available such that no patient with pancreatic cancer should have to endure pain.

The Blaustein Pain Treatment Center at Johns Hopkins

The Blaustein Pain Treatment Center's team of pain medicine specialists provides some of the world’s most advanced treatment options in a supportive, compassionate environment. Our doctors care for thousands of patients on an inpatient and outpatient basis each year. They have helped patients return to independence and comfort, and have restored their quality of life.
Learn About the Blaustein Pain Treatment Center

Source of Information about Pain Management for Patients

An excellent resource for patients with cancer pain is "Cancer Pain - Treatment Guidelines for Patients" January 2001. This information is provided by the American Cancer Society (ACS) in partnership with the National Comprehensive Cancer Network ® (NCCN®). For the most up-to-date version of the guidelines, consult the web sites of the ACS (www.cancer.org) or NCCN (www.nccn.org) or call the NCCN at 1-888-909-NCCN or the ACS at 1-800-ACS-2345 for the most recent information.

References

  1. Cameron, J.L. (2001). Pancreatic Cancer-American Cancer Society Atlas of Clinical Oncology. London: B.C. Decker.
  2. Cherny, N.I. (1999). Update in the Management of Cancer Pain. Principles and Practice of Supportive Oncology Updates, 1, 1-16.
  3. Lillemoe, K.D., Yeo, C.J., & Cameron, J.L. (2000). Pancreatic Cancer: State-of-the-Art Care. CA-A Cancer Journal for Clinicians, 50, 241-268.
  4. Ruger, T., Cunningham, M., & Thorpe, D. (2000). Update and Review of Pharmacologic Therapy for Cancer Pain. M.D. Anderson Cancer Center Nursing Reports on: Strategies for Pain Management, 3, 1-18.
  5. Sheidler, V.R. (1998). Pain. In C.R. Ziegfeld, B.G. Lubejko, & B.K. Shelton. (Eds.), Manual of Cancer Care Oncology Fact Finder (pp. 369-385). Philadelphia: Lippincott.
  6. Smith, T.J., Staats, P.S., Deer, T., et al. (2002). Randomized Clinical Trial of an Implantable Drug Delivery System Compared with Comprehensive Medical Management for Refractory Cancer Pain: Impact on Pain, Drug-Related Toxicity, and Survival. Journal of Clinical Oncology, 20, 4040-4049.
  7. Yeo, C.J., & Cameron, J.L. (1999). Pancreatic Cancer. Current Problems in Surgery, 36, 57-152.

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