Pain

What is pain?

Pain is the unpleasant experience you have when your body is hurt. Many different problems can cause pain, such as injuries, arthritis, or more serious diseases such as cancer. Everyone experiences pain differently.

It is common with most serious illnesses to have at least some pain. It is one of the ways that your body lets you know that there is a problem. The good news is that for the most part, pain can be controlled.

Causes of pain

Pain is caused when nerves with special endings called pain receptors, located in all parts of the body, send a message to the brain that there is damage to the body. In palliative care, pain can be due to:

• the disease itself, such as a tumour irritating nearby bones or nerves;
• problems related to the disease, such as stiffness from decreased activity;
• treatments, such as pain felt after surgery;
• problems unrelated to the disease, such as arthritis that has been there for years.

There are different kinds of pain, depending on the cause:

• Bones, muscles, connective tissue
  When the bones and muscles or the tissue that connects them together (called connective tissue) are damaged, the pain that results tends to be steady, aching, and felt in the area where the problem is. For example, someone with a sprained ankle, a bruised muscle, or a broken arm can tell quite accurately where the problem is.
   

• Organs of the body
  Pain caused by problems in the organs of the body (such as the stomach, the intestines, the liver, the kidneys, or the heart) tends to be felt in a more general area, and is more difficult to pinpoint. For example, cramps from a stomach flu are felt as a general discomfort in the abdomen. Sometimes, pain is felt in parts of the body that seem unrelated to the organ with the problem, such as when people having trouble with the heart feel pain in the neck and left arm.
   

• Nerves
  Damage to nerves in the body may result in pain or discomfort that can be hard to describe, since it doesn’t always feel like what we are used to calling “pain.” There may be tingling, prickling, burning, squeezing, or crawling sensations. Sometimes there are sudden pains that come and go quickly, almost like an electric shock feeling. The pain may extend down an arm or leg, along the path of the nerve that is damaged. The skin may become very sensitive, so that even a gentle touch or the weight of clothing is very uncomfortable. Most people have had the experience of accidentally banging the nerve that runs behind the elbow joint of the arm (“funny bone”), resulting in an unpleasant tingling sensation that travels down the arm to the fingers, along the path of the nerve. This sensation is very typical of pain related to nerve injury or damage.
   

There are other things that affect how people experience pain. Fatigue, worry or anxiety, or feeling sad or depressed can make living with pain more difficult. Also, the concern or knowledge that the pain is related to a serious illness such as cancer can decrease the ability to cope with pain.

Knowing what is causing the pain, what kind of pain it is, and what kinds of factors might be influencing how it is experienced are very important in helping treat pain. Ideally, the best way to treat pain is to treat what is causing it. If treating the cause is not possible, then relieving the pain will be the focus of treatment.

Sorting out symptoms

To determine possible causes of pain, the health care team will often ask questions, conduct a physical examination, or order some tests.

Questions from the health care team

The health care team may ask some of the following questions to better understand the pain you are experiencing. Describing the pain is the most important step in sorting out pain and working towards its treatment.

TIP: Consider keeping track of your pain in a daily pain diary.

• How bad is the pain?
  • Mild, moderate, severe?
  • Rating pain on a scale from 0 to 10 can be helpful. Zero means no pain, while a 10 means the worst possible pain. A rating scale from 0 to 10 can be used to describe how bad the pain most of the time, at its strongest, and at its weakest.
• Where is the pain?
  • One spot, or different areas of the body?
  • Starting in one area and spread to another?
  • Generalized, and hard to pin down to any one spot?
  • Deep down, or near the surface or skin?
• What does it feel like? What words describe it?
  • Aching, throbbing?
  • Burning, tingling, crawling, itchy?
  • Squeezing?
  • Are there areas of the skin that are very sensitive to touch, so that even gentle contact such as clothing or the spray of a shower is uncomfortable?
• How long does it last?
  • Always there?
  • Off and on? 
  • Is it stabbing? Like an electric shock, crampy?
  • Comes only with movement?
  • Varies in how bad it is?
• Has the pain been there before, or something like it?
  
  • What happened then?
• What makes it worse?
  • Movement, coughing, deep breathing, certain positions?
• What makes it better?
  • Certain positions, medications, relaxation, massage, imagery?
• Medications – past and present:
  • How effective are they?
  • How often are they taken?
  • Side effects or other problems? (cost, number of pills needed)
  • If they have been stopped – why?
• What is the effect of the pain?
  • What kinds of things are impossible to do because of the pain?
  • Are there feelings of discouragement, sadness, depression, or loss of hope?
  • Does the pain cause concerns about what might be happening related to the disease?

Physical examination

The doctor or nurse will usually check for areas of swelling, loss of muscle size or mass, tenderness, weakness, and changes in sensation.

Tests

Sometimes tests such as X-rays will provide important information about what is causing pain and what can be done about it.

What you can do

Treat pain early

Some people feel they should “be brave and bear” pain, but there is no medical reason to do so. In fact, treating pain early gives health providers time to adjust medications or sort through treatment options so that the pain does not get out of control. Early treatment of pain may also directly limit the progression of pain itself, resulting in better overall pain control throughout the course of the illness.

For some people, getting help to treat pain feels like “giving in” to the disease and may feel like admitting defeat. However, living with uncontrolled pain can be like giving up control of your day-to-day life to the disease and to the pain itself, since this usually means avoiding certain activities.

If pain is not treated, a person may:

• have difficulty interacting with friends and family;
• have difficulty doing things that would normally bring joy and pleasure, and help them feel part of the “real world;”
• become unable to eat or sleep;
• become depressed.

 Treatment of pain should be considered as taking back control and taking back the quality of life that has been stolen by the pain. Fortunately, treatment of pain is usually fairly straightforward for trained health care providers, and there are many different options that can be used to help find the approach that is right for you.

Use of pain medication

Take care with your pain medication

• Take pain medication on a regular schedule. Treating ongoing pain without a regular schedule will result in being “one step behind” the pain all of the time. At the end of the day, someone who takes pain medicine only when pain occurs will likely have used more pain medication than if the medication had been taken regularly, without waiting for pain to occur.
• Do not skip doses of medication.
• If pain occurs in between regular doses of medicine (breakthrough pain), take the medicine the doctor has prescribed for these episodes (called breakthrough or rescue doses). Keep track of how often this quick-acting medication is needed.
• If breakthrough doses are needed more than two or three time a day consistently, this usually indicates that the regular dose needs to be increased.
• The breakthrough dose of opioid must be increased in proportion to the overall dose of regular opioids being taken for pain. It is usually about 10% of the total daily dose of regular opioids, so that if a person is taking 200 milligrams a day of regular morphine doses, the breakthrough dose should be at least 20 milligrams.
• Only one doctor should be prescribing a person’s pain medicine. If this is not the case, the doctors should be discussing the treatment with each other.
• Pain medications work differently for different people. There is nothing wrong with two people having very different doses of the same medicine. The important issue is that the medication works.
• Never take someone else’s medicine.

Learn about new medication

Before beginning a new medication, you may want to learn more about what to expect. Here are some questions to ask health care providers after getting a new prescription:

• How much medication should be taken? How often? For how long?
• How long does it take the medication to start working?
• If the pain does not get better, should more medication be taken? How much more?
• What happens if the medication is not taken on time?
• Should this medication be taken with food?
• Should this medication be taken with something to drink?
• Is it safe to drink alcoholic beverages, drive, or operate machinery after taking pain medication?
• Are there possible side effects from the medication? What should be done if the side effects appear? Can side effects be prevented?
• Will this new prescription work safely with other medications?

Meet with health care providers

You may want to meet with health care providers if you experience any of the following:

• The pain is not helped by the medication.
• The pain medication does not start working when the doctor said it would.
• The pain medication does not work for the length of time the doctor said it would.
• Pain occurs in between doses of medication (breakthrough pain). There may be a need to increase the pain medication, or consider different options for managing the pain.
• Pain occurs only with certain activity (incident pain). This may require a change in strategy regarding the timing of extra doses of pain medications.
• There are side effects.
• There is a problem with the schedule for taking medication.
• Pain interferes will normal activities such as eating, sleeping, working and having sex.

Often a change in the medication, the amount of medication or the combination of medications will help deal with the problems listed above.

Alternatives to swallowing medicine

Sometimes people who are seriously ill have difficulty swallowing medication. If this is the case, then other ways of giving the medication can be used:

• Liquid drops may be given under the tongue.
• Medication can be given by intravenous or subcutaneously (under the skin through a small plastic catheter that stays in place).
• Skin patches contain a very effective opioid (fentanyl) and are changed every three days. However, it is important to note that these patches should only used when a person has pain that is stable and has been managed on a stable dose of opioid medication.

 See Also: Help with medications

Other strategies to manage pain

These are strategies to help manage pain and are usually used along with pain medications. Talk to a health care provider before using any of these techniques. Even simple things, like a heating pad, can have side effects.

Deep breathing
Focus on breathing deeply, listening carefully to the sounds of breathing in and breathing out. Concentrating on slow, regular breathing shifts the focus away from the pain.

Progressive muscle relaxation
Tense muscles can make pain feel stronger, so relaxing muscles may help to reduce pain. Progressive muscle relaxation is a technique where muscles are tightened and relaxed throughout the body. One way to do this is to start at the feet, squeezing and loosening the muscles there, and then slowly work up the body to the head. Another way to relax muscles is to breathe in deeply, squeeze a group of muscles, and hold for a couple of seconds. Then, let go of the breath and let the body go limp.

Imagery
The idea behind imagery is to imagine a scene that is relaxing, such as a quiet beach with the waves lapping on the shore. Imagery is like a deliberate daydream that can reduce stress and anxiety.

Distraction
Watching a TV program, listening to music or taking part in a conversation with family or friends are some ways to try to forget about pain.

Biofeedback
In biofeedback, people become more aware of how their bodies react to stress. Electrodes are placed on the skin to measure: 

• muscle tension
• temperature
• heart beat
• sweating. 

Then, with the help of a licensed biofeedback technician, people can learn how to influence these measurements. The heart rate, for example, can sometimes be lowered by releasing tension throughout the body.

Heat therapy
Heat can reduce pain by soothing sore muscles. A heating pad, gel packs, hot water bottles, electric heating pads or a warm bath can all be used for pain relief. Bath water should not be too warm, or it may make the person sleepier and weaker, making getting out of the tub difficult. There are some things to be careful about when using heat therapy:

• Heat should not be applied for more than 5 to 10 minutes.
• Heat should never be used over a new injury because it can increase bleeding.
• Heat should not be used over any area of the body that has received radiation treatment.
• Heat should not be used where circulation or the ability to feel is poor.
• Electric heating pads should not be placed on bare skin and they should not be left on before going to sleep for the night.

Cold Therapy
Cold relieves pain by freezing the painful area. Ice packs, ice cubes wrapped in a towel, and gel packs are all cold options. There are some things to be careful about when using cold therapy:

• Cold should not be applied for more than 5 to 10 minutes.
• Stop using cold if it starts causing new pain.
• If the person using cold therapy begins to shiver, the cold should be removed right away.
• People receiving chemotherapy should check with their doctors before using cold packs.
• Cold should not be used where circulation or the ability to feel is poor. 

Transcutaneous Electric Nerve Stimulation (TENS)
A TENS unit is a small power pack that sends an electrical current through electrodes taped to the skin. People describe the feeling of TENS as a buzzing, tingling or tapping sensation. The electrical current seems to help the pain, even after the electrodes have been taken off. TENS provides gentle stimulation and is not thought to be harmful. However, it is not recommended on unhealthy skin, such as skin that is swollen or infected. People with pacemakers should not use TENS either. Ask a member of the health care team where to get a TENS unit.

Acupuncture
Acupuncture involves placing needles into the body. The idea is to stimulate certain points on the body in order to get rid of pain in other parts of the body. For example, a needle put into a certain spot on the leg may help stomach pain. The feeling you get from acupuncture is a buzzing, tingling feeling. Needles usually stay in the body for about 15 minutes. Acupuncture is widely known to help pain, although it is not as helpful with treating burning or tingling pain. Acupuncture should be performed by a licensed acupuncturist using clean or disposable needles. Acupuncture is not recommended for people with serious blood clotting conditions.

Massage
The act of touching and being touched can be healing for some people. With a bare hand, muscles can be stroked, brushed or rubbed in a circular motion. Lotions are often used during massage to reduce friction on the skin. Massage relaxes muscles and encourages blood flow in the area that is being touched. Massage is often a very pleasant experience. Massage should be performed by a licensed massage therapist. Massage is not recommended when skin is swollen, red or raw.

Hypnosis
Hypnosis is a sleep-like state that leaves a person more open to suggestion. While the person is in a hypnotic state, hypnotherapists suggest that there is no pain, or that the pain has been taken over by another, positive feeling. A health care provider should be able to help find someone trained in hypnosis, likely a psychologist or a psychiatrist.

Counselling and Social Support
Feeling sad or anxious can make pain feel worse. These feelings are common and should be discussed with the medical team or someone who can provide social support. One option is to take part in therapy with a counsellor to help deal with these feelings. Another is to look for a support group where people with the same condition meet. Sometimes just talking with another person about feelings of anxiety can help to relieve some of the tension.
 

TIP: The best judge of pain is the person who is experiencing it. It is important for friends, family members and the health care team to believe what the person in pain tells them. Treatment for pain will not be successful unless people trust what the person in pain is saying.

What your health care team can do

Pain medicine

Many different kinds of pain medications work well at taking away pain. However, pain management is not a perfect science. Sometimes it takes awhile for health care providers to find the best combination of medicines and other treatments. That is because each person responds to medication differently, and people are affected by pain differently. Good communication between you and the doctor can help speed up this process of finding the best approach.

Health care teams will want to know about all the medications you are using, even if no prescription is needed to get the medication.

These are commonly used medications for treating pain:

• acetaminophen
• NSAIDs
• opioids
• anticonvulsants
• antidepressants
• steroids.

Acetaminophen

Acetaminophen is widely used for common aches and pains. It can be bought without a prescription and is the ingredient in Tylenol®. Acetaminophen has few side effects when it is used properly.

Too much acetaminophen can lead to liver damage, so people need to keep track of how much they are taking by reading product labels carefully. Acetaminophen is a common product in many cold and flu products, and you may mistakenly take too much acetaminophen just by taking several of over-the-counter medications at the same time if you are not aware of their ingredients.

Acetaminophen can work with other types of pain medications to add to their effectiveness. It can be safely taken in combination with opioids and NSAIDs.

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen are used for common aches and pains, especially if there is inflammation, such as in arthritis. In less powerful doses, these medications can be bought without a prescription. For more powerful doses, they need to be prescribed by a doctor. Most of these medications help muscle pain and headaches.

NSAIDs can have side effects, which have the potential to be very serious:

• They can slow the ability of the blood to clot, which can result in a tendency to keep bleeding when cut. This may be an important issue for people on chemotherapy, or for those about to have surgery. Newer medications in the NSAID family that belong to the group called COX-2 inhibitors have less of this side effect, if at all. There have been concerns raised, however, about the overall safety of COX-2 inhibitors, and their risk must be considered on an individual basis.
• They can prevent the kidneys from working properly, especially in people who already have problems with their kidneys, or who are not getting enough fluids and are dehydrated. All NSAIDs have the potential for this problem.
• They can irritate the lining of the stomach and small intestine, causing ulcers. This may result in bleeding, or even more serious conditions. Again, all NSAIDs have the potential for this problem.

Because of these potential serious side effects, it is important to check with your doctor before taking NSAIDs.

Opioids

For moderate to severe pain, opioids are often prescribed. These medications used to be called narcotics, but that term is not used any more because of the confusion with the world of law enforcement, where the word narcotics is used to refer to any type of drug that is used illegally. These medications must be obtained by prescription, with the exception of low doses of codeine combined with acetaminophen (Tylenol-1® and Tylenol-2®).

These are commonly used opioids:

• codeine
• morphine
• oxycodone
• fentanyl
• hydromorphone
• methadone.

Meperidine (Demerol®) is an opioid that should not be used for managing pain long term, because of the possible side effect of seizures (fits, convulsions). It has been removed from many hospital formularies.

Opioids are very effective at relieving pain. Often, they are started at a low dose and then increased gradually as needed. This method is called 'titration'. With medications containing acetominophen (such as Tylenol #3), there is a point beyond which dose increases do not seem to result in improved pain control (“ceiling effect”), however this is not the case for other opioids listed above. There is no specific upper limit to the amount of these opioids that can be given. They can be increased until the pain is relieved or until side effects limit further increases. If side effects become too much for the person to handle, a different opioid can be tried (sometimes called rotating opioids) or other means of addressing pain can be explored.

Opioids can also be combined with other types of pain killers to help with pain relief.

Potential Side Effects of Opioids

Opioids are very safe when used under the supervision of an experienced health care professional and adjusted in proportion to the amount of pain.

The following are some of the side effects that may occur:

• Constipation
  This is a side effect of all opioid pain killers, and will always occur. However, it should never limit the needed use of opioids. When starting an opioid medication, it is very important to start laxative medications at the same time. Laxatives should be adjusted so that the bowels move at least every two to three days. Common laxatives include Senokot® (a stimulant), docusate (a softener), lactulose, and PEG (polyethylene glycol).
   
• Sedation (sleepiness, drowsiness)
  When first starting opioids, or when increasing the dose, there may be two to three days of slight drowsiness. This feeling of being sleepy gets better after a few days, as the body becomes used to the medication.
   
• Nausea
  About one-third of patients started on an opioid will feel some nausea. Nausea tends to subside over a few days, however it may be necessary to use an antinauseant medication during the first few days of taking an opioid. Gravol® (does not need a prescription) may work and is worth trying first. However, prescription antinauseants such as metoclopramide (Maxeran®), domperidone (Motilium®), prochlorperazine (Stemetil®), or haloperidol (Haldol®) may be needed.
   
• Confusion
  Occasionally, people may become confused as a side effect of opioids. This can occur when by-products of the medications build up in frail or elderly patients. If the confusion is just caused by the opioid, switching medications or perhaps adjusting the dose may clear up confusion. It is important to seek medical attention if confusion occurs.
   
• Effects on breathing
  Although slowing of the breathing is a potentially serious side effect of opioid medications, it is extremely uncommon if doses are adjusted in proportion to the amount of pain, especially after the first two to three days when the body has become used to opioids. Titration of opioids (starting off at a low dose and gradually increasing as needed) should be done with the supervision of health care providers.

There are other, less common side effects to opioid medications. If you are having problems that you feel may be related to your medication, it is important to contact your health care provider.

Myths About Opioids

Unfortunately, there are many myths and misunderstandings about opioids, which continue to be a barrier to adequate pain control for people. These are some common misunderstandings:

• "Won’t I become addicted?"
  When opioids are used for pain control, addiction does not happen. The body does become more used to the medication, which will mean that the dose may need to be increased, however this is not addiction – it is called tolerance. Addiction is when there is an overwhelming preoccupation with obtaining more medication, without any medical need for it. This does not happen when opioids are used for pain control.
   
• "I don’t want to start morphine too soon because it won’t work when I really need it."
  This concern is without any scientific or medical basis. Opioids can be used with good effect for as long as they are needed, and the dose can be adjusted to whatever level is needed for pain relief. The best way to manage pain is to control it early.
   
• "Those drugs will speed up my disease."
  Opioids do not affect how an illness progresses, they simply help relieve suffering associated with the illness.
   
• "If I take morphine, I won’t be able to drive my car."
  For non-commercial driving in Canada, taking opioids does not mean that you can no longer drive. The decision about whether it is safe to drive is left to the individual. If there is drowsiness from the medications, then it is not safe to drive. However, if the dose of opioid has been stable and drowsiness is not a problem, then driving is allowed.

Anticonvulsants

Anticonvulsants are used to treat people who have seizures, but they can also be very effective in treating burning, tingling, and stabbing (shock-like) pain related to nerve damage. The most common anticonvulsant used for pain control is gabapentin. Potential side effects of gabapentin include tremors, confusion and drowsiness or sleepiness.

Antidepressants

Antidepressants are used to help depression but they be used to treat tingling and burning pain related to nerve damage. These medicines include:

• amitriptyline
• nortriptyline
• desipramine.

Potential side effects of these drugs include dry mouth, confusion, and drowsiness or sleepiness.

Steroids

Steroids (the kind used for treating inflammation, not the kind used to build muscles) are used to shrink swelling and relieve inflammation that can cause pain. They are useful in a wide variety of pain situations. However, they can have side effects that need to be watched for by your health care team.

Other options for treating pain

Radiation

High-energy radiation can shrink cancerous tumours, resulting in less pain. Pain decreases as the shrunken tumours put less pressure on bones, nerves or internal organs. A single radiation treatment may be enough to relieve pain, although sometimes it can take up to two weeks before the effectiveness of the radiation in relieving pain is fully known.

Nerve blocks

A nerve block also blocks pain messages to the brain. A doctor will use a needle to place medication near a nerve or into the spine to stop pain messages from reaching the brain. A nerve block may cause the muscles to become paralyzed or the injected area may lose all feeling.

Spinal analgesia

Pain killers (analgesics) can be given directly into epidural or intrathecal space around the spinal canal through a small catheter (a very thin plastic tube) that is placed there. After freezing the skin, a fine needle is used to guide the catheter into the epidural or intrathecal space, and medications are delivered using a medication pump through a flexible plastic tube that is left in place. Because the pain medications are being directly delivered to the spinal column where pain signals go, much smaller doses can be used (sometimes 100 times smaller than if the same medicine were to be swallowed in tablets).

There are risks of infection and bleeding related to spinal analgesia, which should be discussed with the health care providers involved.

Content reviewed May 2019