CANCER PAIN: THE MANAGEMENT OF ACUTE, CHRONIC AND CANCER PAIN

For thousands of years, doctors have been helping to relieve their patients' pain with a variety of medications and treatments. Like other areas of medicine, a new subset of doctors have become specialists in treating pain. They are focused on managing all types of pain — studying what causes it, how the body reacts to it, how different medications dull or eliminate the pain, and how other treatments can be used to relieve many painful conditions.

Doctors Who Specialize in Treating Pain

Doctors who manage pain are frequently anesthesiologists. Anesthesiologists are doctors of medicine (M.D.) or osteopathy (D.O.) who make sure that you are safe, pain-free and comfortable during and following surgery. They also provide their services in other areas of the hospital — especially in the labor and delivery area — or in doctors' offices where painful medical tests or procedures are performed.

But not everyone realizes that decades of research and work done by anesthesiologists have led to the development of newer, more effective treatments for patients who have pain unrelated to surgery. Many techniques used to make surgery and childbirth virtually painless are now being used to relieve other types of pain. In fact, the work pioneered by anesthesiologists that led to these new medications and treatments also has created a new category of medicine called pain medicine.

Frequently the anesthesiologist heads a team of other specialists and doctors who work together to help you manage your pain. The anesthesiologist or other pain medicine doctors (such as neurologists, oncologists, orthopedists, physiatrists and psychiatrists) and non-physician specialists (such as nurses, nurse practitioners, physician assistants, physical or rehabilitation therapists, and psychologists) all work together to evaluate your condition. Then this "team" of specialists will develop a treatment plan designed just for you.

What Type of Training Does a Pain Medicine Doctor Have?

Like other physicians, anesthesiologists earned a college degree and then completed four years of medical school. They spent four more years learning the medical specialty of anesthesiology and pain medicine during residency training. Many anesthesiologists who specialize in pain medicine receive an additional year of fellowship training to become a "subspecialist," or an expert in treating pain. Some also have done research, and many have special certification in pain medicine through the American Board of Anesthesiology (ABA). The ABA is the only organization recognized by the American Board of Medical Specialties to offer special credentials in pain medicine.

When Would I Need To See a Pain Medicine Doctor?

People develop pain for many reasons. Pain from a recent surgery, injury or medical illness is called acute pain. In many cases, this pain can be managed immediately and will usually get better in just a short time. For more serious pain, however, your primary care doctor may ask a pain medicine doctor to help manage your pain while you are healing.

If your pain persists after the healing process should be over, you might have what is called chronic pain. If the current treatment you are receiving stops working or your pain begins to get worse over time, your primary care doctor may suggest that you see a pain medicine doctor.

Cancer pain is another condition that can be managed by a pain medicine doctor while the patient continues to receive treatment for various types of cancer. The pain can be due to cancer surgery or treatment procedures, including radiation therapy and chemotherapy, or the tumor itself.

What Does a Pain Medicine Doctor Do? Can These Doctors Find Out Why I Hurt?

Pain medicine doctors are experts at diagnosing why you are having pain as well as treating the pain itself. Some of the more common pain problems they manage include: arthritis, back and neck pain, cancer pain, nerve pain, migraine headaches, shingles, phantom limb pain for amputees and pain caused by AIDS.

They also manage acute pain caused by surgery, a debilitating illness or a serious injury. Examples include: pain after a knee-joint replacement, pain during recovery from a car accident, pain following stomach or chest surgery, or pain associated with sickle cell disease. You may be treated in the hospital or in an outpatient clinic.

The pain medicine doctor will work closely with your primary care doctor. Pain medicine doctors will review your medical records and X-rays as needed. They will ask you to describe your pain in detail, such as where it hurts, for how long, what makes the pain worse or what makes it feel better.

They may ask you to fill out a detailed questionnaire that helps them to assess the impact that your pain is having on your lifestyle and if it is interfering with your daily activities. They also will do a complete physical examination on you. They may need to order other tests and will then review all of their findings to determine what is causing your pain and how the problem can be corrected.

Medications for Managing Pain

Due to rapid advances in medicine, a wide variety of medications and treatments are available for acute, chronic and cancer pain. Patients often will be prescribed medications before receiving other forms of therapy. In addition, your pain medicine doctor may conclude that a combination of medication and treatments may be right for you. Your therapy plan will be tailored to your specific needs and circumstances.

Your pain medicine doctor may suggest that you use certain over-the-counter pain relievers or may prescribe stronger medicine for your condition. DO NOT MIX PAIN PRESCRIPTION DRUGS WITH OVER-THE-COUNTER PAIN RELIEVERS WITHOUT CONSULTING YOUR DOCTOR. Advise your doctor if you are taking any herbal medicines or dietary supplements.

· Common Pain Relievers — Nonaspirin pain relievers, such as acetaminophen (Tylenol®), can relieve headaches and minor pain but do not reduce swelling. They are sometimes used in combination with other drugs to provide greater pain relief.

· Anti-Inflammatory Drugs — Aspirin (Anacin®, Bayer®), coated or buffered aspirin (Ascripton®, Bufferin®), and aspirin with acetaminophen (Excedrin®) may be used to reduce swelling and irritation as well as to relieve pain. There also are non-steroidal anti-inflammatory drugs (NSAIDs, commonly called "N-sayeds") such as ibuprofen (Advil®, Motrin®) and naproxen (Aleve®). Anti-inflammatory drugs are used to relieve pain, inflammation and fever. There also are steroidal drugs (like cortisol and prednisone), available only by prescription, that are used to treat more serious inflammatory conditions such as chronic arthritis.

· Opioid Pain Medications — Morphine-like drugs called opioids are prescribed to treat acute pain or cancer pain. They are occasionally used for certain chronic, noncancer pain as well.

· Anti-Depressants — These drugs were originally used only to treat depression. Studies now show, however, that they also can relieve certain pain. Available only by prescription, they often are used to help you sleep better at night.

· Anti-Seizure Medicines — These medications are used to relieve what some patients describe as "shooting" pain by decreasing abnormal painful sensations caused by damaged nerves.

· Other Medicines — The doctor also may prescribe other types of medication that will be helpful for your specific pain problems. In addition, medications that counteract the side effects of opioids or treat the anxiety and depression associated with pain also may be prescribed.

Treatments for Managing Pain

Medication alone may not be enough to manage certain kinds of pain. Some medicines are more effective in fighting pain when they are combined with other methods of treatment. In some cases, the patient's pain condition may respond to treatment instead of medication. In fact, for some patients, certain therapies may eventually replace the need for taking any pain medicine, or less of it, over time. Here are just some of the available treatments being used successfully to treat pain patients.

· Injection treatments — Local anesthetics (such as Novocain®), with or without cortisone-like medicines, can be injected around nerve roots and into muscles or joints. These medicines reduce swelling, irritation, muscle spasms and abnormal nerve activity that can cause pain.

· Nerve blocks — Often a group of nerves, called a plexus or ganglion, that causes pain to a specific organ or body region can be blocked with local anesthetics. If successful, another solution that numbs the nerves can then be injected.

· Physical and aquatic therapy — The physiatrist or physical therapist may suggest an exercise program tailored for you that will increase your daily functioning and decrease your pain. Other treatments may include whirlpool therapy, ultrasound and deep-muscle massage.

· Electrical stimulation — Transcutaneous electrical nerve stimulation (TENS) is the most common form of electrical stimulation used in pain management. It is not painful and does not require needles or medicine. TENS consists of a small, battery-operated device that can diminish pain by stimulating nerve fibers through the skin.

· Acupuncture — This ancient Chinese practice uses very thin needles at very specific points on the skin to treat disease and pain. Practitioners of acupuncture undergo specialized training in these techniques and may offer this treatment for certain painful conditions.

· Psychological support — Many patients who are in pain feel the emotional effects of suffering along with the physical aspects of pain. These may include feelings of anger, sadness, hopelessness or despair. In addition, pain can alter one's personality, disrupt sleep, interfere with work and relationships, and often have a profound effect on family members. Support and counseling from a psychiatrist or psychologist, combined with a comprehensive pain treatment program, may be needed to help you manage your condition. These trained professionals also can teach you additional self-help therapies, such as relaxation training or biofeedback, to relieve pain, lessen muscle spasms and reduce stress.

· Surgery — When necessary, surgical treatment may be recommended. In rare instances when severe pain has not responded to other treatments and procedures, surgery on certain nerves can be done to give the patient some relief and allow them to resume near-normal activities. Usually all other avenues of treatment are tried before surgery is considered.

Pain Treatment Centers

Because this is a highly specialized field of medicine that is still growing, not every community has a pain treatment center yet. These centers are called by many different names, including: pain clinic, pain management center, pain center, pain unit or pain service. These facilities may be in a wing of your local hospital or medical center, in a separate medical-professional building, or in a doctor's office. Some are affiliated with medical schools and large health care centers.

Where can I find a pain treatment center, and how do I decide if it's the right one for me?

There are many different forms of pain treatment and therapy, and one center may offer a service or specific kind of specialist that another center does not have. Some have pain medicine doctors on staff, and others may offer only nonmedical treatments such as acupuncture and massage therapy. Thus before consenting to treatment, it is best to find out what types of pain therapies are offered, what the specialists' credentials are, and if they have successfully helped others with your type of pain.

To find a pain medicine doctor or pain specialist, generally your regular doctor should be able to refer you to an individual or group who offers services that are best for helping your specific pain problem. If your doctor is not able to refer you, try the sources below:

1. Call your local hospital or medical center and ask if they have a pain treatment center there or if they are affiliated with a pain treatment center or clinic nearby.

2. If your area does not have a specialized pain treatment center, ask the hospital to connect you to the Department of Anesthesiology. They may have doctors on staff who can provide treatment or who can refer you to another hospital.

3. If your local hospital does not have information on a pain treatment center, contact the nearest school of medicine, which is usually affiliated with a private college or state university. (Medical school listings are available at the public library.) Ask them if they offer pain treatment or if they have research programs that study pain.

4. If you have access to the Internet, you can obtain information through the American Society of Anesthesiologists (ASA) at www.asahq.org. While ASA does not maintain a list of pain centers nationwide, we may be able to assist you with some additional information in your area.

Throughout the generations, pain has been a unique, often misunderstood condition that affects every age, gender, ethnic and social group all over the world. It can occur for many reasons, and there is no one "silver bullet" that can cure pain. Yet great progress in pain medicine has been made in recent years and is expected to advance further as doctors learn more about the causes of pain.

Anesthesiologists, through ASA, will continue to support research, medical training and patient education to help those who suffer from pain — whether it is acute, chronic or cancer pain — so these patients can live comfortably and be productive members of their families and communities.

"The Management of Acute, Chronic and Cancer Pain" has been prepared by the American Society of Anesthesiologists through the cooperative efforts of the Society's Committee on Communications and the Committee on Pain Medicine.

Certain product names used in this brochure are included as a point of reference for patients and should not be considered all inclusive or construed as an endorsement by ASA, its committees or its members.

Patients should consult their physicians for recommendation or prescription of an appropriate course of treatment.