Controlling the Pain of Cancer and Heart Disease

Kate Roach

June 2002

Cancer is the biggest killer in the UK and heart disease is the second biggest killer. Suffering from these conditions is bad enough, without having to endure the pain that often accompanies them. All of us have experienced pain and most of us fear it, but it takes so many forms that it almost defies description. There is the pain of heartache and loss, the pain and anguish of witnessing another's pain and the pain of actual physical hurt. In order to fight the pains of cancer and heart disease it's important that we understand the conditions and are aware of what treatments are available to us.

We only have one word for the short stab of a stubbed toe, the agony of mental despair, the life-sapping throb of a malignant tumour or the disabling bang of a migraine headache – that word is 'pain'. Now let our minds wander over some of the many words we use to describe our pains – throbbing, excruciating, punishing, tiring, miserable, aching, burning, scalding, terrifying, vicious, killing, unbearable, tender, stabbing ...

The late Professor Patrick Wall spent more than 50 years occupied with the problem of pain, investigating its mechanisms and methods of treatment. He found a common thread in our myriad of pains and for him whether your pain is physical or emotional it amounts to the same thing.

'Pain is a form of stress. Of course there can be stresses without pain, but as part of the whole syndrome of being in pain, the body is reacting, saying 'I hate this, I want to get out of this situation' – that's stress. In general, pain is utterly useless and everybody should be fighting against it because in the long run it's damaging.'

Cancer pain

'The greatest evil is physical pain'
St Augustine

When cancer is in its early stages, the cancer cells are not recognised by our bodies as foreign, sick or diseased. Our bodies interpret the cancer as part of us and don't react at all. In these stages, pain provides no protective signal and offers a very poor warning system.

The pain that often accompanies cancer doesn't kick in until the growth is big enough to press on vessels, nerves or organs. By which time the cancer is probably well-established and the pain is worse than useless. Once the pain of cancer sets in, it serves as a constant reminder of the disease and adds more stress to an already frightening situation.

The hospice movement pioneered the treatment of cancer pain in the 1950s and 60s. By concentrating on alleviating pain, hospices succeeded in making patients more comfortable and less stressed. They found that not only did they have a better quality of life, they also lived longer.

Thankfully, the philosophy of the hospice movement has spread widely into general practice. But if you are a carer or cancer patient it's important that you monitor pain and ask for drug treatment if pain is prolonged. Ongoing pain is depressing and frightening, it limits physical activity, suppresses the appetite and upsets sleep patterns. All of these things can weaken the body's defence systems and compromise its ability to fight the disease.

Drugs ladder

The World Health Organisation recommends an analgesic ladder for the treatment of pain. The aspirin family of drugs is on the first rung of the ladder. Above them are the narcotics. Of the drugs used to alleviate pain, 95% fall into these two families.

The aspirin family is the most common – it includes ibuprofen and paracetamol. These drugs are fairly safe and act at the site of injury itself, stopping the inflammatory changes that produce pain.

If they don't affect your pain you will need to progress up the ladder to the stronger formulations of narcotics – they include morphine, codeine, heroin, opium and many relatives. These drugs act on the brain itself and stop pain very effectively.

Morphine myths

One of the barriers to effective pain relief in cancer is a fear of narcotic drugs, like opium and morphine, in doctor and in patient. But most of those fears are completely unfounded. There is nothing to fear from morphine itself – the pain will do you a lot more damage than the drug.

Our views on this family of drugs has changed over the ages, as Professor Patrick Wall points out: 'Opium was commonly used in the 19th century in Britain, it was practically a 20th century invention that these were not only dangerous drugs, but morally dangerous, but this is confusing the idea of comfort with excessive luxury'

One of the most common, current beliefs is 'If I start on morphine, I'll get addicted and it will lose its effect'. For this reason, many people resist taking it until very late in the day. But studies have shown that when morphine is used for pain relief it's not addictive. Addiction is a condition in which the drug is used purely for pleasure. Neither will the drug lose its effect, as long as you receive the correct dose.

Another potentially frightening thought associated with the use of morphine is 'If I am given morphine, it means I'm going to die soon'. This isn't so. It's important to remember that pain is an unpredictable sensation that doesn't directly reflect the state of your illness.

Yet another myth is 'The morphine itself will kill me'. Of course it's possible to overdose on morphine, but doctors are usually very experienced in administering the drug in safe (if increasing) doses. There is no set maximum dose, but carers, patient and doctors should continually monitor pain levels and alter the dose as necessary.

Specific cancer pains

Whilst morphine and other narcotic drugs are very effective pain relievers, they are not a panacea. One type of cancer pain that is morphine-resistant arises from nerve damage in which pressure is exerted by the cancer infiltrating major nerves. This type of pain requires specialist drugs that are not always associated with pain relief. For example, anti-epileptic drugs can sometimes control this pain effectively. If morphine isn't working for you, make sure that you discuss it in detail with your medical carer.

Another type of cancer pain that is relatively difficult to treat is referred to as incident pain. This pain is short-lived and might be brought on by certain movements. It's debilitating in the sense that it might stop you from doing the things you enjoy. Several drugs have been developed to help this kind of pain, amongst them Fentanyl – a quick-acting and short-lived narcotic. You can even get this drug in the form of a lollipop that you can use as and when you need it.

Reviewing treatment

Finally, drug treatments that you have for pain must be continually monitored. The treatment of cancer pain is not a one-stop shop, it is an ongoing process. For example, breakthrough pain sometimes occurs when the drugs are wearing off. If the breakthrough pain becomes persistent then this is an indication that your drug regime needs to be reviewed.

When we are in pain it pervades our whole being. It rivets our attention and makes us miserable. If it's ongoing, it can lead to feelings of isolation, depression, fear and despair. It's natural to have these feelings if you have prolonged pain, but it's important that you are able to talk about them. If you are able to express your feelings then it will help your carers to help you. Most carers, both professional and non-professional will want you to enter into an equal partnership with them, so they can better help you get the quality of life that you deserve.

Heart disease pain

'Pain is a very sophisticated beast, it will use any trick that it can to spoil your enjoyment of life'
Michael Chester, Cardiologist and Director of National Angina Centre

110, 000 people die of heart disease every year in the UK. By no means all of these people have pain. In fact, many heart attack patients report nothing more than minor flu-like symptoms. But a significant number of those who suffer from heart disease are troubled by serious and persistent pain, despite the best efforts of clinicians to treat it.

Angina is the name given to these painful symptoms of heart disease. The heart is a chunk of muscle that needs regular nourishment with oxygen delivered through a constant supply of blood. Angina can occur if blood flow to the heart is hampered, say by blocked arteries, triggering pains in the chest, arms, back and jaw. The pain of angina signals that the heart doesn't have enough oxygen to keep it satisfied. The heart is greedy for oxygen and if it doesn't get exactly what it wants it complains. Angina doesn't mean that the heart is being damaged.

Understanding angina

Ordinary pain makes you feel bad, but pain that signals a potentially serious problem like a heart attack is also very frightening. Many people describe a feeling of panic that accompanies angina attacks. Panic is a feeling caused by the release of the hormone adrenaline. This is the body's way of preparing you for 'fight or flight' and one of the consequences is to make the heart beat harder. The paradox is that when the heart beats harder it wants even more blood. In effect the heart is saying 'I need more blood' and the brain responds by making it beat faster so that it needs even more blood. It's like pouring petrol on a fire.

Most of us believe that if we do something that hurts, it's nature telling us to stop what we are doing. In many cases this is an effective strategy, but not so in angina. Here the body produces pain in response to anything that puts extra strain on the heart – like exercise. But exercise, the medical profession tells us, is good for our hearts. From what most of us understand about pain, we interpret the angina as a warning to avoid doing anything that might provoke an attack. This mistaken belief often leads sufferers into inactivity, with devastating consequences in the long run.

If you have an episode of angina while exercising, sure, you should take a rest. But don't see it as a bad thing. When the heart doesn't have enough blood, the heart will fix it. If there is not enough blood getting through the main arteries, then the heart will attract more small blood vessels to bypass the main one. If you have 10 episodes of angina a day, then you'll have 10 more bypasses compared to someone who has no daily angina attacks. This is why gentle exercise is so important. And why in a paradoxical sense angina can be good for you.

Relieving angina pain

In some cases though, angina pain can be too much to bear. It can become so painful that exercise is impossible. But there is hope. One heart patient who had undergone nine operations on his heart and was still experiencing persistent pain was given a life expectancy of six months. As a last ditch option, he was given a nerve block in which pain-relieving medication is supplied directly to nerves in the neck. The pain stopped. Because he was pain-free he was able to get the exercise he needed to improve blood supply to his heart. Four years on he is fitter than ever, able to go on holiday, play golf and enjoy his life again. He has a nerve block every three months and has regained his life.

If angina pain is trapping you into inactivity, then don't put up with it. Ask for help with the pain. Discuss pain management with your doctor or consultant. There are several ways in which the pain can be tackled (including drug treatments) and it's a matter of finding the right one for you.

As well as nerve blocks there is the TENS (Transcutaneous Electrical Nerve Stimulation) machine which transmits a low-level electrical stimulation via electrodes placed on the skin. When the electrodes are placed on to a painful area, it stimulates large nerves that lead to a gentle tingling sensation. Whilst these large nerves are stimulated they have an inhibitory effect on the smaller nerves that relay pain messages to the spinal cord and brain. Many patients report a reduction in pain rather than a total absence, but describe a sensation that is no longer distressing.

An important element of managing pain is being able to talk to your clinician about what the pain has done to you. What does it mean for you? What would you like to be able to do that you can't? How anxious does it make you? Anxiety, for example, will make the pain of angina much worse, and if you feel calmer you will be indirectly attacking the pain. So, don't be afraid to talk and ask for the help that YOU need.

Find out more

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Websites

Pain Concern
www.painconcern.org.uk
UK charity offering information and support. Free leaflets can be ordered online and the website has details of a helpline for sufferers.

Pain.com
www.pain.com
Has lots of information and articles on pain and pain management.

Pain Support
www.painsupport.co.uk
Jan Sadler, author of Natural Pain Relief, promotes a multi-disciplinary approach, where conventional medicine and complimentary therapies work side-by-side.†Contains useful information for sufferers and their families and friends.

Pain Association Scotland
www.painassociation.com
Offers supports for those with chronic pain, based in Scotland.

The Pain Web
www.thepainweb.com
This website is for health professionals dealing in research, assessment and treatment of pain. There are some excellent articles and lots of information on drugs.

Chronic Refractory Angina
www.angina.org
Contains everything you need to know about angina. For patients, carers, nurses and other clinicians.

CancerBACUP
www.bacup.org
Advice, information and support services about cancer.

Pain FAQs
What is pain? Do women feel more pain than men? Some of your most frequently asked questions answered here.

Why We Can't Trust Pain
Is pain a necessary evil that protects us from injury? Sometimes. But pain is not only unpleasant it can also be harmful. Find out when pain protects and when it definitely doesn't.

Angina
Article for angina sufferers.

Caring at the End of Life
Article for those caring for the terminally ill at home.

Hospices
Article on hospices and the hospice movement.

Books

	Cancer Pain Management by Karen Simpson Cancer-related pain can be successfully managed in the majority of patients with the use of medication. Some patients, however, have pain that doesn't respond to narcotics, and require more specialised pain management techniques. Examples of such treatments are nerve blocks, radiotherapy, acupuncture and physiotherapy. This book focuses on alternative methods of pain management. Get this book
	Pain: The science of suffering by Patrick Wall This is a wonderful book written by a pain researcher with 50 years experience. Written for the layperson, it will give you a wonderful insight into the world of pain research. One of the most human of science books you'll find on the shelves at the moment. Shares a viewpoint with this article. Get this book
	Coping Successfully with Pain by Neville Shone Looks at the multiple causes of pain, examines the distinction between acute and chronic pain, and gives advice on the use of drugs, the work of the Pain Clinic and the need for physical exercise and relaxation. The book also explains the debilitating effects of long-term pain. Get this book
	Handbook for Pain Management by Ruth Kingdon et al This is a quick-reference handbook which features practical 'how-to' pain management strategies for all patient populations with separate chapters for the elderly, infants and children, substance abusers, cancer and AIDS patients. Get this book
	Pain – Its Nature and Management by Nicky Thomas This holistic textbook addresses the nature of pain and its management. It includes chapters on specific pain types such as cancer pain and sickle cell disease pain. It also contains chapters on specific groups: children and the elderly. Get this book
	A Referred Pain: Reflections on family life and cancer by Penny Snow At the age of 21, Penny Snow watched her father die – a victim of colon cancer. Fourteen years later she witnessed her mother's death from the same disease. This book aims to confront difficult emotions, and to help those who have lived or are living in similar situations. Get this book
	Reader's Digest Health and Healing the Natural Way: Managing pain Fear and lack of information are the chief barriers to the control of pain. This book uses clear information to help banish fear, and it explains the positive role that pain plays in the functioning of the body. It also suggests self-help measures and alternative therapies where appropriate. Get this book
	Healing Back Pain Naturally by Art Brownstein The author spent 20 miserable and almost suicidal years suffering acute back pain. He permanently cured himself and has cured thousands of others using his programme. This book explains how it works. Get this book
	Overcome Neck and Back Pain by Kit Laughlin This text presents a different approach to the self-treatment of neck and back pain. It offers an easy-to-learn programme that combines Eastern and Western healing practices, drawing on traditional hatha yoga, the contract-relax method of stretching and a selection of strengthening exercises. Get this book
	Massage for Pain Relief by Peijian Chen The Chinese understanding of health is based on the circulation of Qi (energy). If energy is low or becomes blocked it stagnates, leading to illness. Pressure point massage improves circulation of stagnated energy by working along energy channels. This book offers on-the-spot relief for toothache, headaches, shoulder pain and neuralgia, and there are sequences of massage strokes to relieve pain which seems out of reach – such as gastric ulcers and arthritis. Get this book
	Prolo Your Pain Away by Ross and Marion Hauser Prolotherapy is a simple, safe technique, which stimulates the body's healing mechanisms to grow new ligament and tendon tissue. It's claimed that the technique provides a permanent cure for many painful chronic conditions, such as back pain and arthritis. This book shows how the method works. Get this book
	Chest Pain by Richard Becker The wide range of conditions responsible for chest pain make it difficult to determine the single underlying cause and to decide upon the best possible plan of treatment. This is a quick-access handbook that includes chest pain in all adults and from all causes, in a pocket size reference format. It includes immediate assessment and treatment of acute causes of chest pain. Get this book

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