Cancer-related pain

Cancer patients may have several questions about pain and cancer.

I am in a lot of pain despite the treatment from the oncologist. What else can the pain clinic offer?
Cancer pain is very complex. Especially as the disease progresses, many different types of pain often coexist. Your pain is our main concern, and we therefore have experience in administering many medications that are not commonly used by oncologists. We also have the ability to apply techniques that allow for acceptable pain reduction even in very advanced stages of the disease, preserving consciousness and quality of life. It is always advisable to make therapeutic agreements in order to adapt pain management resources to the wishes of the patient and their family.

In advanced stages when chemotherapy is no longer possible, what can the pain clinic do?
Precisely in the most advanced stages of the disease, even if there are only a few weeks of life left, the presence or absence of pain will be very important. This means that techniques such as epidural blocks, nerve blocks, or epidural or intrathecal infusions of analgesic medication can be used to improve quality of life, allowing patients to live without pain and remain conscious. There is evidence that effective pain management by skilled professionals can prolong survival and improve quality of life.

Is it only advisable to go to the pain clinic in the final stages of the disease?
When pain that is difficult to control appears, you should go to the pain clinic, regardless of the stage of the disease. Our work should be understood as a service we provide to other specialities. Therefore, the ideal situation in this case is close collaboration with the oncology department, which applies the appropriate therapies that, in many cases when there is a response from the tumour, manage to reduce or eliminate the pain.

Will taking morphine lead to addiction?
The terms dependence and addiction should not be confused, nor should tolerance.
Tolerance implies the need for progressively higher doses to achieve the same therapeutic effect. This happens with morphine, but it does not usually cause problems because, firstly, there is no ceiling, in other words, every time we increase the dose, the desired effect increases. Secondly, tolerance to side effects also develops, meaning that over time, side effects such as nausea or sedation disappear.

Physical dependence means that if we abruptly stop treatment, a set of unpleasant symptoms may appear, which we call ‘withdrawal syndrome’ and which can be resolved by resuming medication or administering tranquillisers.

Psychological dependence is what is commonly referred to as addiction. It only happens when morphine is used to achieve a psychological state that is different from normal. Among people with chronic cancer-related or non-cancer-related pain, the frequency of addiction is less than 0.2%.

Why do I need more and more morphine?
As already explained, this may be due to a tolerance phenomenon specific to morphine, but it may also be because the progression of the disease involves an increase in requirements.

If I start taking morphine, will I never be able to stop?
In the same way that pain treatment begins by following a ladder of increasingly potent medications, it is possible to move down the ladder and withdraw morphine if the disease progresses favourably and the causes of the pain disappear.

They gave me morphine and it made me very nauseous. Does that mean I cannot take any type of opiate?
The response to different opioids (morphine, methadone, fentanyl, buprenorphine, oxycodone, tramadol, codeine) is individual and depends on the number and type of receptors we have for them. Therefore, a bad experience with one should not discourage us from trying another if we believe that the patient may benefit.

Are there other opiates besides morphine?
As mentioned above, there are other opium-derived or synthetic drugs that interact with the Mu and Kappa opioid receptors. Among them, the most commonly used are fentanyl, buprenorphine, methadone, tramadol and codeine. At present, we have options for oral, transcutaneous, oral transmucosal, intravenous, and epidural treatment. There are fast-acting, slow-acting and long-lasting (up to 72 hours) types. A long-acting medication for continuous pain is usually combined with a fast-acting medication for pain crises.

Practical advice on transdermal opioids
It is important to follow the manufacturers' recommendations. Extra care must be taken with the skin because the adhesives they use can cause local irritation. It is also very important to bear in mind that the speed at which the medication passes from the patch to the skin and from there into our bloodstream depends on the temperature of the skin. Therefore, in a situation of fever, there is a risk of overdose that must be prevented.

The medication in the patch does not have a localised effect under the patch, but rather passes into the bloodstream through the skin and has an effect on pain throughout the body.

I have rheumatic pain that is not improving. Can opiates only be used for cancer pain?
It is increasingly accepted that when pain is severe, it must be treated with powerful drugs regardless of its origin. There is considerable experience and literature supporting the use of opioids in patients with chronic non-cancer pain without complications or a higher incidence of addiction than that found in cancer patients.

Proper monitoring and an ongoing relationship between doctor and patient would virtually eliminate this type of problem.