Pain / Discomfort

To ensure that a pain scale is serving its intended purpose, it helps to understand how it works. A pain scale is used to help assess severity of pain. Only the person experiencing pain can know exactly what it feels like, but describing it with words or numbers helps other people, particularly health care providers, at least understand something about it. This then helps them assess whether they’re providing enough pain relief.

The most common pain scale asks you to describe the severity of your pain on a scale of 0 to 10. On this scale, “0" represents "no pain" and "10" represents "the worst possible pain." You’re not comparing your pain to anyone else's; you’re comparing how you feel with the worst you could ever imagine feeling. Of course, it depends somewhat on your past experience. If you’ve had extremely bad pain before, it influences how you rate pain that’s less intense. People who’ve not had very painful experiences have a different idea of the worst possible pain.

Health care providers who specialize in pain understand this. Your care provider doesn’t expect you to feel exactly the same as someone else who gives the same pain rating. If you say you have pain that is 9 out of 10, it’s understood to mean that the pain you feel is almost as bad as anything you could ever imagine. Very occasionally, people say their pain is 11 or 12 out of 10. This is understood to mean that they’re feeling worse than they could ever have imagined. On the other end of the scale, if you describe your pain as 2 out of 10, this lets your care team know that you have pain, but it’s far from being intolerable.

When you’re trying to assign a number to the pain you’re feeling, remember first what "0" and "10" mean. Then compare your current pain to what you would rate as the worst possible pain. Remember that the purpose of doing this is to give others an idea of how you’re feeling so they can treat your pain in the best possible way. There is no right or wrong answer; this simply is a communication tool to help others understand your experience.

Using a pain scale to rate the severity of your pain is only one part of assessing pain. It’s also important to let your health care team know what your pain feels like and where you feel it. Pain can feel different and can be described as stabbing, sharp, dull, burning, tingling or pressure. Different types of pain are treated differently. For example, additional medications are used for a pain that’s described as burning. If you suddenly have a new type or new location of pain, it’s vital to tell your health care team.

There are several options that can be considered for pain relief with bone pain.

Tylenol® is the brand name of acetaminophen. It’s a good painkiller for bone pain, but it may not be strong enough to relieve completely the pain of cancer in the bones. The maximum dose of acetaminophen is 4,000 mg a day. It’s very important to check with the physician before taking a dose close to this upper daily limit. Doses near the maximum may be unsafe, as they may affect the liver or cause other serious problems.

Anti-inflammatory agents are often used for bone pain, but they may have serious side effects such as kidney damage and intestinal bleeding. There is no good evidence that they’re more effective in relieving bone cancer pain than Tylenol® or low dosages of opioids. While serious side effects are uncommon, the physician prescribing the medication needs to consider all the risks and benefits of these types of medications for a given situation.

If a regular dosage of Tylenol® is not effective, then a low dosage of an opioid is usually added. As a first step, this is often done by using Tylenol with codeine. This can be Tylenol® #2 or Tylenol® #3. Both contain a combination of acetaminophen and codeine. Codeine is called a pro-drug. This means the body itself changes the codeine into the effective drug, in this case morphine. Some people’s bodies don’t have the capability to make codeine into morphine, and in such circumstances it’s important to use a different pain medication.

If someone is taking regular dosages of Tylenol® #3 and still feels discomfort, then it is usually time to start taking morphine or something similar. For many people, this is a frightening concept, but it is useful to realize that codeine is really morphine in another form. People taking codeine convert it to morphine in their bodies, and have adjusted to morphine already.

Other pain relief options may depend on the tumor involved. Some tumors start in the bone, but more commonly in adults the cancer starts somewhere else and spreads to the bone. Radiation therapy, hormone therapy, chemotherapy and medications called bisphosphonates all may help relieve bone pain. Discussion with the health care team can determine the best option for each person’s circumstances, as there are many factors to consider.

Any time someone is using opioid medications (including codeine), there needs to be attention to the bowels. Constipation is almost always an issue, and laxatives such as docusate and Senokot® need be taken while on opioids.

Almost all pain is controllable at all stages of an illness and at the end of life. It’s important to treat pain whenever it’s felt. There are many medications and options available. Dosages of some medications may be increased, or the medications may be changed. Several pain medications do not have an upper limit, so they can be increased if pain increases. These types of medications often are used when someone’s pain is tremendous, as is your brother’s.

Many areas in Canada have pain or palliative care programs and services. The experts in these areas can help with various aspects of care, especially controlling complex pain. They often have consultation services that your brother or his care provider can call on whether he’s at home or in a hospital. You may want to contact your brother’s health care team to find out if there’s a specialized service that can be called in to help control his pain.