the complete guide to relieving cancer pain and suffering may 2004

The
Complete Guide
to
Relieving
Cancer
Pain
and
Suffering
Information
in
this book
is not
intended
to be, and is
not,
a
substitute
for
direct med-
ical
or
psychological care based
on
your individual
condition
and
circumstances.
Please
consult
a

mental health provider about your personal questions
or
concerns.
The
Complete Guide
to
Relieving Cancer
Pain
and
Suffering
RICHARD
B.
PATT,
M.D.
and
SUSAN
S.
LANG
OXFORD
UNIVERSITY
PRESS
2004
OXPORD
UNIVERSITY
PRESS
Oxford
New
York
Auckland
Bangkok Buenos Aires Cape Town

Chennai
Dar
es
Salaam Delhi Hong Kong
Istanbul
Karachi Kolkata
Kuala
Lumpur Madrid Melbourne Mexico City
Mumbai
Nairobi
Sao
Paulo Shanghai Taipei Tokyo Toronto
Copyright
©
2004
by
Richard
B.
Patt
and
Susan
S.
Lang
Published
by
Oxford
University Press, Inc.
198
Madison Avenue,
New

York,
New
York
10016
www.oup.com
Oxford
is a
registered trademark
of
Oxford
University Press
All
rights reserved.
No
part
of
this publication
may be
reproduced,
stored
in a
retrieval system,
or
transmitted,
in any
form
or by any
means,
electronic, mechanical, photocopying, recording,
or

otherwise,
without
the
prior permission
of
Oxford
University Press.
Library
of
Congress
Cataloging-in-Publication
Data
The
complete guide
to
relieving cancer pain
and
suffering
/
Richard
B.
Patt,
Susan
S.
Lang.—Rev.
and
expanded
ed.
p. cm.
Previously

published
in
1994 under
the
title:
You
don't
have
to
suffer;
Lang
listed
as the
first
author
on
t.p.
Includes bibliographical references
and
index.
ISBN
0-19-513501-6
1.
Cancer pain.
I.
Lang, Susan
S.
II.
Lang, Susan
S. You

don't
have
to
suffer.
III.
Title.
RC262.L27
2004
616.99'406—dc22
2003017317
10987654321
Printed
in the
United States
of
America
on
acid-free
paper
To
yesterday's, today's,
and
tomorrow's cancer
and
pain patients,
who
deserve
the
best.
And to my

mother
and
father,
who
always
did
their level
best:
her
passing humbled
me and
opened
my
heart
to his
love.
And fi-
nally
to my
wife,
Pauline,
who
means everything
to me.
R.B.P.
In
loving memory
of my
mother,
Beatrice

Lang,
and my
in-laws,
Jerry
and
Mickey
Schneider. They taught
me
invaluable
lessons
of
life,
love,
and
death.
S.S.L.
This page intentionally left blank
Contents
Preface
ix
Acknowledgments
xiii
A
Note
for
Chronic
Pain
Sufferers
Who
Don't

Have
Cancer
xv
Part
I
CANCER
AND
ITS
PAIN
1 How
Cancer Pain Undermines Health
and
Treatment
3
2
Understanding Cancer
and
Pain
27
3
Assessing Pain
and
Planning Treatment Strategies
54
4
On
Being
an
Active Health Care Consumer
85

Part
II THE
PAINKILLERS
5
Understanding Medications Used
to
Treat
Mild Pain
97
6
Understanding Medications Used
to
Treat
Moderate Pain
121
7
Understanding Medications Used
to
Treat
Severe Pain
135
8
Understanding
How
Adjuvant Drugs Relieve Pain
and
Suffering
171
9
High-Tech Options

212
Part
III
OTHER
APPROACHES
AND
CONCERNS
10
Dealing with
Constipation,
Diarrhea,
Nausea,
and
Vomiting
231
Vll
viii Contents
11
Dealing
with
Other
Side
Effects
and
Discomforts
248
12
Mind-Body Approaches
to
Easing Pain

279
13
Special Cases:
Children,
the
Elderly,
and
Patients with Special
Needs
306
14
Dealing with Feelings
318
15 If
Death Approaches
345
Appendix
1:
Where
to
Find More Information
365
Appendix
2:
Common Drugs Used
for
Cancer Pain
and
Foreign Names
for the

Drugs
379
Appendix
3:
Detailed Relaxation Instructions
384
Appendix
4:
Planning
for
Your
Mental
and
Physical
Health Care
and
Treatment
389
Notes
406
Glossary
1:
Pain
and
Cancer Terms
410
Glossary
2:
Terms
Associated with

End-of-Life
Issues
and
Care
418
Selected
Bibliography
421
Index
430
Preface
Tremendous strides have been made
in the
field
of
cancer pain
and
suffer-
ing
since
the
first
edition
of our
book
one
decade ago.
Today
almost every
state

has a
cancer pain
initiative—coordinated
efforts
of
health
care pro-
fessionals
to
overcome barriers, promote education, disseminate accurate
information
regarding
pain
control,
and
advocate
for the
removal
of
regu-
latory
and
legislative barriers
to
allow physicians
to
more appropriately
use
pain control measures.
In

recent years numerous professional organi-
zations also have
forged
collaborations
and
have issued updated pain
guidelines
and
position papers that advocate
the
appropriate
use of
pain
control treatments.
The
U.S. Congress
has
declared
the
years 2001 through
2010
the
Decade
of
Pain Control
and
Research
to
help promote greater
public

and
professional
awareness
of
scientific, clinical,
and
personal
is-
sues concerning pain
and
pain management.
And in
April
2003
the Na-
tional Pain Care Policy
Act of
2003, H.R. 1863,
was
introduced
into
the
House
of
Representatives
to
provide important
federal
recognition
of

pain
as
a
priority health problem
in the
United States
and to
establish
the Na-
tional
Center
for
Pain
and
Palliative Care Research.
Although tremendous
scientific,
medical,
and
educational advances
have
been made
and
public perceptions have changed,
the
undertreatment
of
pain associated with cancer
is
still

a
major
public health problem,
ac-
cording
to
almost every
professional
society associated
with
cancer
or
pain.
Inadequate knowledge, inappropriate attitudes
on the
part
of
health
care
IX
x
Preface
workers
and
families,
fears
and
misconceptions about narcotic drugs
and
the

importance
of
pain
relief
for
promoting health
and
well-being,
a
puni-
tive
and
complex drug regulatory system,
and
problems with insurance
reimbursement
and
drug delivery systems still abound.
As
recently
as
1998 researchers reported that more than
a
quarter
of
cancer
patients
in
daily pain
did not

receive pain
relievers.
1
When Kathleen
M.
Foley,
one of the
nation's
most highly regarded
and
outspoken cancer
pain experts
from
Memorial
Sloan-Kettering
Cancer Center
and the
Weill
Cornell Medical College, testified
before
the
Senate Committee
on the Ju-
diciary
in
2000
on the
state
of
pain

relief
in
this country,
she
cited studies
indicating that
37
percent
of
children dying
of
cancer were
undertreated
for
pain; that although
40
percent
of
elderly cancer patients experience
pain, less than one-quarter receive
any
pain
relief;
and
that
of ten
thou-
sand
dying hospitalized
patients,

half
suffered
from
significant unrelieved
pain
in the
last days
of
life.
2
We
write this book
for
families
and
loved ones, hospice workers,
and
health care professionals,
to
help prevent this tragedy
from
recurring
day
in
and day
out.
In
this
second
edition

we
totally update
and
revise
all the
information
on
medications (including foreign medications)
and
medical
interventions
to
relieve pain
and
other kinds
of
suffering
associated with
cancer,
cancer treatment,
and
dying,
as
dozens
of new
medications
and
techniques
are now
available.

We
also have significantly expanded
the
sections
on
mind-body techniques, such
as
relaxation techniques, psycho-
therapy,
meditation, yoga, biofeedback,
and
music therapy, among oth-
ers, since research
has
substantiated
the
powerful role that such strategies
can
play
not
only
in
minimizing worry,
pessimism,
and
depression
but
also
in
helping

to
arrest
or
perhaps even reverse
the
disease process
and
promote longevity.
This
new
edition also includes numerous
forms
that
families
can use
for
documents such
as
living
wills
and
health care proxies,
and we
pro-
vide detailed appendices
to
refer
readers
to
dozens

of
other resources.
This book
is
intended
to
serve
as a
reference
for
families
and
health
care
workers
on how
pain relievers work, what doctors need
to
know
to do
their
job
best,
how
other kinds
of
medications
or
treatment
can

contribute
to
com-
fort,
and how to
relieve side
effects
and
other distressing symptoms,
in-
cluding depression
and
anxiety,
all of
which
can
contribute
to the
suffering
associated with cancer.
We
also
offer
many
comfort
care tips.
We
recommend that readers
who are new to the
needs

of
cancer
pa-
tients
be
sure
to
read Chapter
1 to
understand
the
importance
of
treating
pain
and why
many doctors
and
other health care providers neglect
to
treat
it
appropriately. Chapter
2 is
background information about cancer
and
pain, including types
and
causes
of

pain. Chapter
3 is
critical
to un-
Preface
xi
derstanding
how to
describe
different
kinds
of
pain, learning
how to
make
the
most
of a
pain assessment,
and
understanding
the
strategies doctors
use in
treating cancer pain. Chapter
4
covers
how to
identify
doctors

who
use
modern approaches
to
treating pain
and how to be
assertive
in
ensur-
ing
that pain
and
suffering
are
being appropriately treated.
Chapters
5, 6, and 7
include detailed information about medications
typically
used
to
treat
pain
and
should
be
used
as
reference. Chapter
8

discusses
why
medications that aren't widely known
as
pain relievers
are
often
used
in the
treatment
of
cancer pain,
and
Chapter
9 is for
reference,
explaining
the
various high-tech options used
for
pain that
is not
con-
trolled
by
conventional means.
Chapters
10 and 11
should
be

read
carefully;
they include many tips
on how to
relieve
suffering
other than pain, including
the
side
effects
from
medications
as
well
as
treatments. Chapter
10
focuses
on
gastrointestinal
problems (such
as
nausea
and
constipation),
and
Chapter
11
covers
all the

other symptoms that might arise. Chapter
12
covers nondrug approaches
to
relieving
suffering,
including relaxation exercises, coping skills, bio-
feedback,
and so on.
Chapter
13
focuses
on
special cases, most notably
children, teens,
and the
elderly. Chapter
14
discusses
the
psychological
aspects
of
both
the
patient
and the
caregiver. And,
finally,
Chapter

15
cov-
ers the
process
of
dying:
how to
provide
comfort
to the
dying patient,
and
coping
tips
for
caregivers.
This book
is not
intended,
however,
to
substitute
for the
care
of a
phy-
sician.
We
mean
to

educate
and
offer
tips
for
comfort
care,
but not to
pre-
scribe
a
treatment plan
for any
particular patient. Only qualified health
care
providers
are
equipped
to use the
judgment required
to
treat
a
par-
ticular patient with
a
particular illness. This book
is
intended
to

serve
as a
tool
to
foster
open communication between
the
health care team
and the
patient
and
family,
and to
foster
self-education—not
as a
recommenda-
tion
or
prescription
for any
particular treatment.
We
hope that
our use of
pronouns
and
references
to
family

members
and
loved ones will
not
offend
anyone.
For
simplicity's sake
we use
mas-
culine pronouns, although obviously there
are
many
female
physicians
and
many
female
patients.
Likewise,
we
often
refer
to
family
members
as
synonymous with caregivers. There are,
of
course, many nontraditional

family
units
and
loving primary caregivers
who are not
family
members.
The
dark ages
of
cancer pain
are
behind
us. You
might
say we are now
striving
for
a new
era,
an era of
enlightenment when
it
comes
to
attending
to the
pain
and
suffering

of
cancer.
We now
have
the
means
to
relieve
most
pain
in
almost
all
patients.
Now we
just need
the
appropriate
use of
the
arsenal
of
pain treatment options available
to us so
that
no one
suffers
needlessly. Patients with cancer
and
their

families
and
friends
need
to
know
xii
Preface
that
much
of the
pain
and
suffering
of
living with cancer
can be
success-
fully
treated.
Finally,
there
is the
last
frontier:
the
countless patients without cancer
who
suffer
from

undertreated chronic pain that will persist
for
years
to
come. Much
of
what
we
have learned about cancer
pain
can be and is
being applied
in
large populations
of
cancer survivors
and
patients with
other
illnesses.
Over
the
next
decade
we
look forward
to
better
distin-
guishing what aspects

of
cancer pain control
can
be
safely
applied
to
these
other groups.
Richard
B.
Patt,
M.D.,
and
Susan
S.
Lang
Acknowledgments
Humble
thanks
to my
coauthor, Susan
Lang,
a
true professional,
for her
patience,
understanding,
and
hard work,

and to our
editor,
Joan
Bossert,
for
her
continued support
and
confidence.
R.B.P.
Endless
thanks
to my
father,
Solon
J.
Lang,
for his
love
and
hard work,
which gave
me
opportunity;
to my
husband,
Tom
Schneider,
for his pa-
tience

and
abiding love
and
support;
and to our
daughter, Julia.
And
with-
out the
continued
support
of
our
editor, Joan Bossert,
we
never could have
done
it.
S.S.L.
Xlll
This page intentionally left blank
A
Note
for
Chronic Pain
Sufferers
Who
Don't
Have Cancer
Although

this book
is
about
the
pain
and
symptoms associated with can-
cer,
much
of the
information presented
is
surprisingly relevant
to
people
who
don't
have cancer
but who
suffer
from
unrelenting
or
progressive
chronic
pain. These materials include Chapters
3 and 4 on
assessing pain
and
being

an
active health-care consumer,
all of
Part
II
that details medi-
cation
use and
much
of
Part III, including Chapter
12 on
mind-body
ap-
proaches
to
easing pain.
Just
as
cancer pain
is
still
often
severely
undertreated,
so too is
chronic
non-cancer
pain that accompanies trauma, degenerative, infectious dis-
eases,

and
other medical
disorders
as
well
as
chronic pain that simply
cannot
be
explained.
Sufferers
are
commonly disbelieved
and
untreated,
leaving them feeling ridiculed, humiliated,
depressed,
and
even suicidal.
Often
amplified
by the
absence
of the
drama associated with cancer,
the
barriers
to
good pain management (Chapters
1 and 2) are

largely
the
same
for
chronic
pain.
Below
are
some
of the
barriers that both
patients
with
chronic
pain
and
cancer pain experience
in
trying
to
obtain
satisfactory
pain treatment.
•
Fears
of
addiction that
are not
based
on

scientific
evidence
but on
anecdote
or
personal experience,
outdated
myths,
and
social con-
ventions. Using opioids
to
treat pain does
not
transform
people
who
were
not
inclined
to
become addicted into drug abusers.
No
xv
xvi
A
Note
for
Chronic Pain
Sufferers

Who
Don't Have
Cancer
drug
is so
potent that
the
values,
behaviors,
and
sense
of
what
is
meaningful,
which have been established over decades, suddenly
erode.
In
fact,
far
less
than
1
percent
of
patients
become addicted
to
even
the

strongest medications when they
are
prescribed
un-
der
close
supervision
for
pain.
Although
the use of
opioids
has
jumped
more than
1,000
percent
in the
last decade, there
has
been
no
corresponding increase
in the
incidence
of
drug abuse.
•
Medical education about pain control remains grossly inadequate.
•

Although
we are
still unable
to
cure many serious medical disor-
ders,
the
treatment
of
symptoms,
including
pain,
is
almost always
an
afterthought,
if it is
considered
at
all, preventing untold num-
bers
from
living
fully
with their disease
and
maintaining dignity
and
their best
functional

status.
•
Inaccurate assumptions persist that
the use of
opioids
for
chronic
pain
might mask
or
hide
important clinical findings.
In
fact,
when
pain
is
relieved, people remain articulate
and can
usually describe
their
problems much more accurately.
• A
lack
of
understanding
persists
that patients
in
pain

who
take
opioids
are
dependent
on
those medications
for
quality
of
life,
just
as
diabetics
are
dependent
on
insulin. This does
not
consti-
tute addiction.
•
Fears
of
legal reprisals inhibit physicians
from
prescribing opio-
ids as
often
as

they should
and in
appropriate doses.
•
Most doctors
lack
the
skills, experience,
and
confidence
needed
to
establish pain management strategies
and
address
patients'
fears.
•
Both
cancer
and
chronic pain
can be
complex
and
difficult
to
con-
trol;
a

pre-packaged
set
of
recommendations will
not
produce con-
sistent results. Good pain treatment
often
requires time-consuming
adjustments
and
consultations.
•
Patients
who do not
receive adequate
relief
from
medications need
to
pursue
other avenues, such
as
nerve blocks,
implantable
pumps,
physical therapy, behavioral interventions,
and
vocational evalu-
ation

and
training;
these treatments usually involve
the
coordi-
nated interaction
of
multiple specialists.
Just
as
with cancer, even when
a
cure
is not
achieved
for the
underly-
ing
disorder,
that's
no
reason
why
aggressive treatment should
not be
sought
to
relieve pain
and
suffering

and
improve physical
and
mental
functioning.
A
Note
for
Chronic Pain
Sufferers
Who
Don't Have Cancer
xvii
Chronic
pain
sufferers
can
glean
a lot of
other
useful
information
from
this
book. Whether
you
have cancer pain
or
chronic pain
due to an

injury
or
an
ongoing medical
disorder,
in
this
day and age you
should
be
able
to
obtain adequate control
of
pain.
If
chronic pain
is
severe, chances
are it
interferes
with sleep, nutrition, concentration, energy levels, mental health,
sexual
function,
and
social relationships. Chronic pain compromises quality
of
life.
Just
as

with cancer pain,
don't
accept
it.
Below
are
some
of the
features
common
to
both chronic
and
cancer pain that
the
informed
pa-
tient should
be
aware
of and
which should
be
addressed
by
treatment.
• The
need
for a
comprehensive pain assessment

at the
start
of
treat-
ment (Chapter
3),
familiarity
with pain rating scales (Chapter
3) and
the
importance
of
being
an
active health
care
consumer (Chapter
4).
• The
need
to
be
knowledgeable
and
prepared
to
discuss pain rather
than
be
stoic

and
silent.
Recognize that
pain
is
hazardous
to
health
and
is
best addressed early
on
(Chapters 1-3).
• The
need
to
find
physicians
who
will
not
ignore pain
but
will pre-
scribe opioids when appropriate.
• The
willingness
to
take
the

extra time
to
explore
the use of
adju-
vant analgesics, medications originally developed
for
purposes
other
than pain
relief
which
may
relieve certain types
of
pain
(Chapter
8).
• The
need
to
understand that achieving good pain control
is a
pro-
cess that usually requires some time
to
establish,
after
which peri-
odic

adjustments
are
frequently
needed. Some patients will
benefit
from
an
interdisciplinary approach (Chapter
3).
•
Recognition
of
the
trial
and
error strategy employed
by
most phy-
sicians
treating
pain
(Chapter
3).
•
Although
efforts
may be
made
to
make only

one or two
changes
at
once, many patients
benefit
from
simultaneous treatment with
multiple medications, each
of
which
is
adjusted
to
achieve
the
right
dose
of the
right drug
in the
right patient
at the
right time (all
of
Part
II).
•
Understanding
how to
balance

a
medication's
relative
effective-
ness versus
its
side
effects
against
the
medication's expected
ac-
tions over time (all
of
Part II).
•
Awareness
of
the
World
Health
Organization
three-step
analgesic
ladder (Chapter
3).
•
Understanding
the
desirability

of
achieving basal pain relief with
long-acting
medications administered
on an
"around-the-clock"
xviii
A
Note
for
Chronic Pain
Sufferers
Who
Don't Have Cancer
schedule
and the
role
of
short-acting
"as
needed"
medications
for
acute
or
breakthrough pain.
Carefully
selecting
the
route

by
which
analgesics
are
administered, despite
the
perception that
injected
drugs
are
better (Chapters
2 and 3).
•
Although using opioids
for
chronic pain
is
controversial,
in
many
cases
it is
appropriate
and
patients
on
such medications should
be
carefully
monitored

to
manage adverse side
effects
(constipa-
tion, sedation, rebound pain,
and
cognitive impairments)
and to
chart
progress
(Chapters
6 and 7).
•
Understanding
the
differences
among tolerance, dependence,
ad-
diction,
and
pseudoaddiction
(Chapter
1).
• The
beneficial
effects
of
behavioral, nondrug
approaches,
includ-

ing
relaxation, cognitive therapy
techniques,
acupuncture, hyp-
nosis, biofeedback,
focused
breathing, imagery, distraction, skin
stimulation
and
massage, herbal remedies,
and
more (Chapter
12).
• For
intractable pain,
the
possible need
for
a
high-tech option, such
as
nerve blocks, epidural steroid injections, trigger-point injection,
implantable
epidural
and
intrathecal
drug pumps,
and
spinal cord
stimulation

may be
necessary
and
consultation with
a
pain spe-
cialist necessary (Chapter
9).
And,
of
course,
the
goal
of
good cancer pain management
is the
same
as
good management
of
non-cancer chronic pain: improved quality
of
life.
Parti
CANCER
AND ITS
PAIN
Pain
is a
more terrible

lord
of
mankind than even death
itself.
—Albert
Schweitzer
How
Cancer Pain Undermines
Health
and
Treatment
To
be
struck with
cancer,
or to
have
a
loved
one
afflicted
with cancer,
is
one of the
most frightening events imaginable.
To
endure
the
dehumaniz-
ing

pain
of
cancer without
relief
is
overwhelming.
To
helplessly witness
that anguish
in a
loved
one is
heartbreaking.
To
discover
later,
however,
that
the
suffering
might have been prevented
is
perhaps
the
worst
of
all.
Uppermost
in the
minds

of
many cancer victims
are
fears
and
anxiety
about
pain.
We are now
finally
entering
an era in
which these
fears
may
finally
be put to
rest.
Today
we are
equipped with
a
modern arsenal
of
drugs
and
techniques capable
of
eradicating cancer pain
in

most cases.
Around
the
country,
in
doctors'
offices
and
pain clinics, many patients
are
successfully
being properly treated
and
relieved
of
most
of the
suffering
from
cancer
and
cancer treatment. Yet, tragically, many cancer patients
are
not
appropriately treated
for
pain
and
side
effects;

too
many people
are
unaware that modern approaches
to
treating pain
are
almost always
successful.
Cancer
Pain
Is
Needless,
Yet
Undertreated
Far
too
many physicians overlook
and
undertreat cancer pain,
often
be-
cause
they
are
misinformed
or
fearful
of
reprimands

for
prescribing pow-
erful
painkillers.
As a
result, pain treatment methods that
are
relatively
1
3
4
Cancer
and Its
Pain
simple
to use are
still
not
adequately applied. Although this situation
is
improving
daily,
needed changes still come
too
late
for
many.
Each
minute
of

every
day,
people
are
dying
of
cancer
and
suffering
needless pain
in
hospitals
and
clinics around
the
world. Many cancer patients
try to
keep
a
stiff
upper lip; they bear
an
enormous physical
and
psychological burden,
not
realizing that everyone around them bears that burden too. Cancer
patients
don't
suffer

in
isolation; their
family,
friends,
and
other caregivers
who
helplessly bear witness
suffer
along with them. Patients with cancer
and
their
families
and
friends
need
to
know that much
of
this pain
is un-
necessary
and
that they
can
take
a
proactive approach
to
make sure that

they
or
their loved ones
don't
suffer
needlessly.
Patients,
families,
and
friends
have
a job to do:
educating
and
assert-
ing
themselves. Armed with
the
facts
presented here, they
can
learn
to
overcome
their
fears
about
the use of
narcotic medications (also called
opiates

or
opioids),
ask for
additional help when pain
persists,
and, ulti-
mately,
learn
to
adopt strategies that help doctors take
full
advantage
of
available
resources
to
fight
cancer
pain.
The
bottom
line:
you
never
need
to
give
up or
assume that little
can be

done
to
ease
the
pain
and
suffering
of
cancer.
How
Pain
Is
Harmful—Even
Hazardous—to
Health
There
is no
benefit
from
enduring cancer pain. Pain
relief
is of the
utmost
importance,
not
only
for
humanitarian reasons
but
also

for
medical rea-
sons. Pain
is
harmful
and
debilitating.
It
interferes
with eating,
sleeping,
mood,
and
maintaining
a
strong fighting spirit, which
are all
vital, espe-
cially
in
times
of
stress.
It
robs people
of
the
energy needed
to fight
illness

and
hinders their ability
to
tolerate demanding cancer
treatments—treatments
that
can
affect
their outcome. Pain also makes people irritable, anxious,
fearful,
angry,
depressed,
and
sometimes even suicidal.
In
fact,
pain
is one of the
major
reasons
why
patients request physician-assisted suicide. Cancer
pa-
tients
in
pain
are
twice
as
likely

to be
depressed,
anxious,
or
have
a
panic
disorder compared
to
those without pain. Pain also compromises general
well-being, interfering with work, social relationships, recreational inter-
ests, mobility,
and
even
the
ability
to
take
care
of
oneself, which
in
turn
affects
self-esteem, body image,
and
feelings
of
competence
and

control.
Perhaps most
important,
experts
are
finding
that persistent pain
can
weaken
or
inhibit
the
immune system
and may
even
influence
tumor
growth
and the
risk
of
death. Animal experiments have shown,
for ex-
ample, that
the
tumors
in
rats with pain that
was not
treated with mor-

phine grew much
faster
than
the
tumors
of
rats that received morphine.
How
Cancer Pain Undermines Health
and
Treatment
5
And
a
Johns Hopkins Hospital study showed that patients with pancre-
atic
cancer whose pain
was
aggressively treated with
a
nerve block (which
blocked pain signals)
not
only
had
less pain, used less
medication,
and
were much more
functional,

but
also lived considerably longer than
the
group receiving
a
placebo.
1
Moreover,
patients with pain
are
ranked lower
on
performance
status
(how well they
function
and get
around), making them less likely
to be
candidates
for
experimental procedures
or
therapies.
Pain must
no
longer
be
regarded
as

just
a
side
effect
of
cancer.
Rather,
it
is a
legitimate health problem that
is
part
of the
disease process
and
warrants ongoing treatment that
is as
aggressive
as
treatment
of the tu-
mor
itself.
You
usually have only
one
chance
to
mount
the

most
effective
possible
fight
against cancer,
and
for
the
best chances
of
success, pain must
be
treated early
and
aggressively.
Most Families Will
Be
Affected
Despite
the
millions
of
dollars spent
on
research
in the
quest
for a
cure,
each

year
10
million people
are
diagnosed with cancer worldwide, includ-
ing 1.3
million Americans,
and 6
million will
die
from
it.
2
The
second most common
cause
of
death
in the
United
States,
cancer kills
one in
every
four Americans, accounting
for
more than half
a
million
cancer

deaths
each
year; that's fifteen hundred
a
day,
or
more than
one
cancer death
every
minute.
American
Cancer
Society,
Cancer
facfs
and
Figures,
2003.
Men
have
a
little less than
a 1 in 2
lifetime
risk
and
women have
a
little

more than
a 1 in 3
lifetime
risk
of
developing
cancer.
3
More than
85
million Americans living today will develop
cancer.
4
The
disease costs this
country some $171.6 billion
a
year.
5
When
a
person
is
first
diagnosed with cancer,
the
first
two
questions
that typically come

to
mind
are "Am I
going
to
die?"
and
"Will
I be in
pain?"
But
studies show that people think cancer
is
more
painful
than
it
really
is.
Granted, pain
is one of the
most common symptoms
of
cancer—
about one-third
of
those
in its
early stages
and up to 90

percent
of
those
with advanced cancer will have pain that
is
severe enough
to
warrant
treatment with strong pain medications.
On any
given day, about
half
of
cancer
patients experience pain; about one-third report moderate
to se-
vere pain.
6
Cancer
and Its
Pain
Yet
up to 40
percent
of
cancer patients receive inadequate
relief.
6
Studies
published

in the
Journal
of
the
American
Medical
Association
and
elsewhere
document that that one-fourth
of
U.S. cancer patients with daily pain
re-
ceive
no
pain
medication,
and
that
up to
half
of
dying hospitalized
pa-
tients
experience
significant
pain
in
their

final
days.
7
Elderly cancer patients
are
40
percent more likely
to be
treated inadequately
for
pain; although
almost
40
percent
of the
elderly
in
nursing homes report daily
pain,
only
one-quarter receive pain
medication.
8
Thirty-seven percent
of
children with
cancer
die
suffering
from

undertreated
pain.
9
Minorities
and
women
are
particularly
vulnerable; studies show their cancer pain
is
much more likely
to
be
ignored
or
sorely
undertreated.
10
Despite twenty-first-century technology
and
medical advances that
offer
a
high quality
of
life
despite cancer,
up to 60 to 90
percent
of

those
with cancer pain
suffer
unnecessarily—as
many
as 3.5
million people
around
the
world every
day.
11
The
World Health Organization,
one of the
strongest proponents
of
treating cancer pain aggressively, asserts: "Freedom
from
pain should
be-
come
the
right
of
every cancer victim,
and
access
to
pain therapy

is a
mea-
sure
of
respect
for
this
right."
12
"You
have
a
right
to
request pain
relief.
In
fact,
telling
the
doctor
or
nurse
about pain
is
what
all
patients should
do. The
sooner

you
speak
up, the
better. It's often
easier
to
control
pain
in its
early
stages,
before
it
becomes severe."
Source:
National
Institutes
of
Health,
National Cancer
Institute,
"Get Relief from Cancer
Pain,"
http;//oesi,nci.nih,gov/RELIEF/RELIEF_MAIN.htm
In
recent years,
the
American Academy
of
Pain Medicine, American

Pain Society, American Cancer Society, National Comprehensive Cancer
Network, American Society
of
Addiction Medicine, Drug
Enforcement
Administration,
and
many more
authorities
have
issued
consensus
state-
ments acknowledging that although preventing drug abuse
is
important,
it
is
unrelated
to and
should have nothing
to do
with
the
aggressive treat-
ment
of
cancer pain (and other chronic pain) with opioids.
Ten
years ago,

the
state
of
Wisconsin took
the
lead with
its
Wisconsin Cancer Pain Initia-
tive;
today every state participates
in the
American Alliance
of
Cancer
Pain Initiatives,
a
national network
of
efforts
to
raise awareness
of the
proper
use of
pain control treatment (www.aacpi.org).
In
1989
the
first
Intractable Pain

Act was
passed
in
Texas
to
make sure
that
no
Texan
requiring narcotics
for
pain
relief,
for
whatever reason,
was
denied them because
of a
physician's real
or
perceived
fear
of
disciplinary