There is a stigma attached to patients who are diagnosed with cancer. People automatically think that a diagnosis of cancer is equivalent to being sentenced to die soon even if some patients have better prognoses than patients who have moderate to severe forms of heart disease. People experience fear just by hearing the word cancer.

Cancer is no longer a death sentence. However, the psychological impact of being diagnosed with cancer can still be devastating. Having to go through the long period of treatment can be traumatic and can exert its toll on the physical, social, emotional, psychological, spiritual and financial well-being of the patient and family.

Much of the focus on cancer (and most of the common diseases) now has been on treating the cancer after it is diagnosed. Considerable efforts have also been placed on early detection. However, so much more emphasis should be given to raise awareness about CANCER PREVENTION through changes in lifestyle and we, physicians and patients, should pay very close attention and take the matter more seriously.

Answer the following questions to give you an idea of how detrimental our lifestyles are

1. Do your meals consist mainly of processed carbs (white rice, white bread, white flour) and protein (chicken, fish, beef or pork) without vegetables or only traces of vegetables serving as garnish?
2. Do you lack recommended servings (5 or more) of fruits and vegetables in your diet?
3. Do you consume a lot of cured or smoked meats or fish?
4. Do you consume a lot of sugar on a regular basis?
5. Do you live a sedentary lifestyle without any form of exercise or only very occasionally?
6. Do you smoke?
7. Do you consume more than 1 serving of alcohol per day for women, more than 2 servings for men?
8. Is your diet very high in fat or fried foods?
9. Are you sexually promiscuous especially without protection?
10. Are you always stressed out and harbor a lot of negative emotions?
11. Are you overweight?
12. Do you stay under the sun for long periods without protection?
13. Do you have a family history of cancer?

If you answer yes to any of the above questions then perhaps you need to seriously consider about changing paradigms.

When prescribing morphine to patients (Please note that the discussion applies to all opioids in general. The following are the opioids available in the Philippines: Tramadol, oxycodone, codeine, fentanyl), I always take time to explain the potential side-effects that the patient may encounter. The idea behind this is that I found that it lessens patient’s anxiety and prepares them to deal with the situation. This has also lessened their unnecessary trip to the clinic or emergency department.

CONSTIPATION

Constipation is the most common side effect of opioids. There is no particular dose when this will occur. As a rule, I prescribe medicines to prevent this especially when I am giving Morphine or Oxycodone. With Tramadol, I do not immediately ask the patient to take a laxative but advise the patient to observe for its occurrence and let me know immediately.

Constipation is more severe and more difficult to manage among elderly patients. It is easier to prevent constipation than treat it. I also advise patients to increase the fiber in their diet. A corollary of constipation is urinary retention. Patients experiencing difficulty in urinating especially for those patients who have prostate enlargement.

Nausea and Vomiting

It is very important to inform patients that these can potentially occur. Many patients stop taking their medicines when they experience these effects and sometimes say that they felt better before taking the medicines. They feel traumatized and we lose the opportunity to provide relief and comfort. Patients should also know that these effects may wane after a few days. Anti-emetics (medicines to prevent vomiting) can be given during the first few days of taking the opioids.

Sedation, Drowsiness and Dizziness

These effects are also very common among elderly patients. Similar to nausea and vomiting, these effects may also wane over time. We avoid giving long acting preparations such as “sustained-release” or “controlled-release” preparations so that we can easily withdraw or adjust the dose.

When you notice that the patient is overly drowsy or overly sedated, inform your doctor so that he can adjust the medication. This is not necessarily an indication to completely withdraw the medicine especially when it is needed.

Respiratory Depression

When going through medical literature, respiratory depression is stated as a very prominent adverse effect of opioids. This is one of the reasons why a lot of healthcare professionals are reluctant to prescribe opioids. However, I have not experienced a patient who is in legitimate pain and taking opioids who has experienced this side effect. It is still prudent to watch out for this adverse effect especially for patients who have lung problems (emphysema, bronchitis, asthma) but it is not a sufficient reason for withholding treatment.

Kenneth is a 50 year old patient who experienced an accident a year ago. He had to undergo several surgical procedures to correct a fracture in his hip. He has been taking pain medicines for a year now and since the effects of the accident have already been corrected and he is no longer in pain. He abruptly stopped his medicine and had to be hospitalized for withdrawal symptoms.

Marie is 60 year-old lady with chronic back pain. She noticed that when she started taking morphine, her dose was only 10 mg every 4 hours. Now, she is on 20 mg every 4 hours.

Carlo is a drug addict. He is suffering from “Addiction”.

Kenneth has experienced “Physical dependence” on morphine but he is not a drug addict.

Marie is exhibiting “Tolerance” to morphine. She is not a drug addict.

How are They Different?

“Addiction”, “Physical Dependence”, “Tolerance” have been used interchangeably, sometimes even by healthcare professionals, in referring to the effects of opioids but they are not one and the same.

All of them may be brought about by opioids but not all are “undesirable”.

Addiction is the one which is undesirable but rarely is a problem among cancer patients. It involves psychological dependence on a drug wherein the person craves for the drug to get a fix in the absence of pain. Addiction can be a real problem among patients who are in pain but it may be avoided if the patient is managed by an expert.

Physical dependence is not necessarily undesirable. It is a normal phenomenon among dose who have been taking certain medicines, especially opioids. The body has become used to the presence of the medication with chronic usage and this is not abnormal. The remedy to prevent the patient from experiencing “withdrawal symptoms” is to slowly taper the dose of the medicine instead of withdrawing abruptly when no longer needed.

Tolerance is also not undesirable among cancer patients. It is the phenomenon of “needing to take slightly higher doses of the medicine to achieve the desired pain relief”. There is nothing abnormal with this. It is a normal reaction of the body when a drug is being taken over a long period.

There is no need for cancer patients to suffer in so much pain. Let us educate ourselves so that we can be a force to provide comfort to those who need them.

Her doctor already prescribed her morphine but she said that it only gave her relief for a few days but the pain has now returned.

I then asked her about the dose and frequency of her intake of morphine. She gave an answer which seemed quite adequate for her level of pain.

I became perplexed and made my reaction obvious to her. After a few more questions, I told her that I will be giving her additional medicines and I will increase her dose of morphine.

I Don’t Want to Get Hooked!

When I told her that I will increase the dose of morphine, she became concerned. She told me that she does not want to become addicted to the drug and said that she was actually adjusting her dose of morphine without telling her doctor when the pain diminished.

On further questioning, it became clear that the pain recurred when she started doing this.

The Myth of Addiction

Patients’ fear of becoming addicted to pain medicines is universal. This has largely been due to the anti-drug campaigns. Unfortunately, this has also brought a lot of harm to the patients who need pain relief.

Cancer patients think that opioids (Tramadol, Morphine, Oxycodone, Codeine) are drugs for addicts. These fears and misconceptions have overshadowed the true benefits that cancer patients who are in pain can get from them and have proven to be barriers in the effective management of cancer pain.

The opioids are front line drugs in the management of moderate to severe cancer pain. My experience in managing cancer patients has proven to me time and again that these fears about the opioids are irrational, unfounded and have caused needless pain and suffering.

Addiction is rarely a concern among cancer patients. Addiction has a very strong psychological component in that the patient thinks he needs the medicine in the absence of physical pain. This is not the case among cancer patients.

Cancer patients experience actual pain brought about by the presence of the tumor or as a consequence of treatment and therefore, these patients are seeking relief from real pain whereas drug addicts crave for the drug to get a “high” or to relieve anxiety and not really relief of physical pain.

Opioids are generally well-tolerated. Their side effects are minimal and can be easily managed. There is no justification for our cancer patients to suffer in pain.

For those who are interested to learn more about opioids or cancer pain, you may visit the following sites:

www.cancer-pain.org
http://whocancerpain.wisc.edu/?q=node/244

1. It is generally better to take your medicine on a fixed schedule instead of taking them on an as needed basis only.

This is true especially for patients who are already having mild to moderate pain. For patients who are in pain, very few of them have mild pain on whom we can recommend taking the medicines on an as needed basis only. The reason why we recommend taking the medicine on a fixed schedule is because we want to maintain a constant level of drug in the blood. This prevents the patient from having episodes of severe pain and when they eventually occur, the intensity is not as severe as when the patient is not taking the medicines regularly. Cancer pain is sprinkled with intermittent spikes in pain intensity. Taking the medicines intermittently instead of round the clock exposes the patient to more intense episodes of pain.

2. Breakthrough pain

There are instances when even despite good compliance with the prescribed pain medicines, the patient still experiences “flares of pain” or “Breakthrough Pain”. This is a normal phenomenon in cancer pain. The patient need not worry that the medicines are no longer effective.

Breakthrough pain is managed by giving additional doses of medicine. Patients should not necessarily be concerned that the disease is getting worse.

3. Be alert on the timing of worst pain as well as those things that aggravate the pain

There may be certain times of the day when the pain becomes severe or movements or activities that may aggravate the pain. I advise patients to keep a diary of their observations of their pain as well as the effect of the medicines. It allows us to see the pattern of the pain and know when we need to take precautionary doses. Discuss with your doctor if you can take additional pain medication before engaging in an activity that you have noticed to precipitate the pain.

4. Remember that all medical interventions have potential side-effects.

Some patients encounter side effects while on their medicines. This should not be a reason to stop them. I always make it a point to discuss these things with the patient and give them pre-emptive medicines to avoid experiencing the trauma of surprise from a nasty side effect. It becomes difficult to convince patients that those medicines will help them when they were surprised by the side-effects. However, when they understand that these unwanted effects may happen and that they can be managed, I find that they are willing to cooperate and go through these slight difficulties with some ease and a lot of patience. Most of the side effects, especially of opioids will wane over time.

After your doctor has fully evaluated the kind of pain that is affecting you, he will now make a plan as to how to maximize pain control. There are different modalities available such as pain medicines, non-drug management such as acupuncture, medicines that strengthen bone for patients with bone metastasis, radiation therapy and other special procedures.

Mild, Moderate and Severe

Most of the patients I encounter are those in the moderate intensity of pain. The type of treatment that your doctor will give you depends on the severity of pain. We generally follow the guidelines given by the World Health Organization (WHO) in giving medicines.

We divide patients into those with mild, moderate or severe pain.

Mild Pain

Patients with mild pain are given any of the following:

• Paracetamol or Acetaminophen
• Non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen, Mefenamic Acid, Naproxen
• COX-2 inhibitors such as Celecoxib, Eterocoxib

Moderate Pain

Medicines given for moderate pain are the opioids. Opioids are drugs that control pain by exerting their action in the central nervous system. These drugs are regulated and patients cannot buy them over the counter such as those given for mild pain.
Examples of Opioids used for Moderate Pain:
• Tramadol
• Codeine
• Oxycodone

Your doctor may decide to continue prescribing the medicines previously used for mild pain and combine them with any of the opioids above.

Patients need a doctor’s prescription with an S2 license number for Tramadol. Be sure to check that your doctor’s S2 license is written to prevent the inconvenience of having to go back to your doctor. The pharmacy or drugstore will only honor these prescriptions up to one month from the date on the prescription. After than time period, the pharmacy will not serve the medicines even if the number of drugs on the prescription has not yet been entirely dispensed.

Severe Pain

Severe pain definitely require stronger opioids. The strong opioids include:

• Morphine
• Fentanyl
• Hydrocodone
• Oxycodone

These medicines are also classified as regulated drugs. Unlike Tramadol where an ordinary doctor’s prescription pad will be honored as long as his S2 license number is affixed, all the other opioids will require a special prescription that we call a “Yellow Pad”.

Not all doctors have a yellow pad even if they have an S2 license. Doctors who do not often prescribe the strong opioids don’t bother to get the yellow pad because they are we don’t like dealing with government agencies.

The yellow pad comes in triplicate. The first 2 copies are given to the patient and the 3rd copy is left with the doctor. Upon dispensing the drugs, the pharmacy is required to get the original copy which will serve as their file copy. Pharmacies that dispense these drugs undergo a lot of scrutiny by the Philippine Drug Enforcement Agency (PDEA). If the pharmacy did not dispense the entire number of tablets or ampoules prescribed, they will mark your prescription with a stamp and indicate the number prescribed as well as the number remaining. Remember that the yellow pad will also expire 1 month from the date written on it. The pharmacy will not serve you the remaining drugs when your yellow pad has already lapsed.

I always say that healthcare management is a shared responsibility between physician and patient. With regards to pain management, you must remember that if you are in pain, even if your doctor does not ask about it, do not be afraid to volunteer that you are in pain and that you would like to have it addressed.

During your consultation, be ready with the following information:

• Character of the pain.

Be able to describe the pain. Is it dull, sharp, aching, a feeling of warmth or tightness, does it feel like lightning hits your part of the body? Do you feel numbness or tingling sensation? Other terms that are commonly used to describe pain are pinching, piercing, lancinating, throbbing, stabbing, crushing. Be specific when describing because there are different types of pain and they are managed differently. Your doctor needs to determine which one it is to give you the right medication.

• Location of pain

• Intensity of pain

Patients often use vague terms to describe the intensity of pain. In the clinic, there are several ways to do this. The one I find easiest is to ask the patient to grade the intensity of pain from 0 to 10 with 0 having no pain to 10 being the worst.

• Timing of the pain

Is there a particular time of day when the pain occurs or worsens? Is the pain continuous or intermittent? How long does the pain last? How often do you experience the pain?

• Aggravating or relieving conditions

Are there movements that precipitate pain? What other situations can aggravate the pain? What do you normally do to help ease the pain?

Do you use medications for pain? If so, enumerate all those medicines and be ready to explain the dose and frequency that you have been taking them. What are the effects of the medicines on your pain? Are there side-effects of your medicine?

• How the pain has affected you

Sometimes patients do not immediately realize the impact of the pain in their lives. However upon close scrutiny, we find that it has affected many aspects such as activities of daily living, work, social functioning and relationships.

Keep in mind also that not all types of pain in patients with cancer should be attributed to cancer. There are instances when a new problem is evolving that needs to be addressed differently

Filipinos have a high threshold for pain. Sometimes, they do not inform that they are in pain and just suffer through it (Matiisin). They think it is but normal to suffer in pain and sometimes, they think that God is punishing them with pain.

I once asked a patient whether he has pain or none. He replied “Meron po pero ok lang po ako, kaya ko naman po” (I’m in pain but I’m alright. I can handle it). So I asked the patient to give me a numerical value of his pain or “the pain score”. We ask patients to grade the severity of pain using a numerical scale from 0 to 10, 0 being absolutely no pain and 10 being the worst pain. The patient replied 6 (moderate severity of pain). I could just shake my head in disbelief at how he can say he is ok and handle such intensity of pain without any help.

Myth #1 If the patient does not mention it, he is not in pain

This is a very common mistake even among health care professionals. Not all patients with cancer experience pain but Not because the patient does not mention it means that it does not exist. Patients experience a whirlwind of emotions such as fear, helplessness, depression that can affect their judgment, confidence, worthiness and ability to communicate.

Patients often have this notion that pain goes hand in hand with cancer and there is nothing to be done but endure the pain. Some are afraid to tell their pain because they fear that it is a signal of worsening condition while others think that showing pain is a sign of weakness.

We need to make it imperative to ask about pain and recognize pain all the time. There may be a lot of instances that we cannot get rid of the tumor but there is no excuse NOT TO COMFORT.

Myth #2 Having pain means you are hopeless, dying or the disease is getting worse

Patients are often reluctant to communicate their pain because they fear that they will be viewed as hopeless and dying soon. Some fear that if people know that they are dying or diagnosed with cancer, people will feel sorry for them or that they may not get the help they need or that nothing can be done.

These beliefs are absolutely false. Being diagnosed with cancer is not a death sentence. Many treatment options are available. Even if the patient may already be dying, there is still so much that can be done to minimize suffering. There is now a specialty in medicine called Palliative Care which focuses on alleviating suffering among terminally ill patients. (Palliative Care does not cater only to cancer patients but all patients who need relief from their suffering)

Myth #3 The medicines used to treat pain are addictive

This is one of the most difficult beliefs to eradicate from the minds of patients and families, especially with the advent of drug abuse by celebrities. Patients sometimes adjust the medicines by themselves for fear of being addicted. Patients who are in pain need not worry about addiction. Drug addicts are those who use the drug for a different purpose other than pain control. Patients who use medicines for pain relief will never fall in this category as long as there is reason to use the medicine. Nature has installed safeguards to prevent drug overdose among patients who are experiencing REAL pain.

I also hear statements like “I don’t want to become dependent on the medicines”. There is nothing wrong with being dependent on these medicines as long as there is pain. Problems arise only when patients continue using the medicine when no longer needed and when not supervised by a physician.

Myth #4 The patient is just inventing the pain

Cancer pain is what and how the patient describes it. WE NEED TO BELIEVE THEM. Sometimes we are quick to judge that patients are feigning the symptom. This attitude is bound to dismiss the patient’s suffering and inflict not only physical but psychological pain as well. There are really times when pain is intensified by psychological or social situations because pain is formed by an interplay of physical, social and psychological components. The best way to address these problems is to pay attention and heed but never to dismiss.

Myth #5 The doctor did not give any pain medicine. I probably don’t need it

Unfortunately, not all healthcare professionals are always mindful of the patient’s pain or well-equipped to provide adequate pain control. Bring up the subject even when the healthcare providers don’t ask. Be insistent on good pain control. Demand it from your healthcare provider. If you are not satisfied with your level of pain control, ask to be referred to the right specialists – oncologists, anaesthesiologist, neurologist, palliative care specialist. Many hospitals also have pain clinics.

Myth #6 Leave it to the healthcare professionals to manage the pain

This is a very common misconception for all types of health problems, not only pain. The cornerstone of good healthcare is patient responsibility and adherence to the treatment regimen. After leaving our clinics, it is the responsibility of the patient to carry out what needs to be done. Even if patients are under the care of a superb team, if he does not follow the plan, there is nothing else that the team can do for him.

Many patients keep on coming back to their doctors with the same complaints. Upon evaluation, we find out that the main reason why the problem still exists is because of poor compliance. I have also encountered countless patients who adjust their medicines without letting us know and without asking about the consequences of thsose actions. In my experience, those patients who are diligent are the ones who are most comfortable and are likely to get well.

Myth #7 Pain medicines should be taken on an as needed basis only

A lot of patients, especially if they are in severe pain, will follow the doctor’s order diligently. However, once they start becoming comfortable, they adjust their medicines only to return to the emergency department with severe pain again. They think that because the pain is gone, they don’t need to continue taking the medicines or that it is ok to decrease the dose. Pain goes away with the right dose of medications. Once we remove these medicines or give them at inadequate doses, the pain will come back. Most of the time cancer patients will need to rely on these pain medicines for life. There is nothing wrong with that.

There are times when medicines can be adjusted by the patient but you need to ask your doctor when this is appropriate. Pain medicines are usually given round the clock to maintain an adequate level of medicine in the body especially when the pain is moderate to severe in intensity.

We may not always get rid of the physical illness but we can always provide comfort. Pain eats up the patient’s energy. It robs them of life and the ability to make the most of everyday. There is no point in enduring unnecessary pain.

Another patient, Mrs. B, an elderly woman, who was previously well, developed back pain, difficulty of breathing and weight loss over a span of 2 months.  Upon examination, she was also discovered to have lung cancer.  When I saw her, she looked very very weak, she had very poor appetite, she was very irritable towards her relatives and they were complaining to me about their difficult in adapting to her recent behavior.

Those were not isolated cases.  These kinds of reactions and complaints are very very common among cancer patients.  Relatives often complain that the patients become difficult to deal with.  Ninety-nine percent of the time, the reason why they react in such a manner is because they are in severe, excruciating pain.

Pain and Cancer

A large majority of patients with cancer will experience pain at some point in the course of their illness. Almost one third of patients with pain will experience severe pain.  Most of these patients are those with advanced stage disease.

The causes of pain may be any or a combination of the following:

1. 1. The Cancer itself

-       The tumor can compress other structures such as bone and nerves.

-       Cancer can obstruct blood vessels that supply blood to other organs

-       The tumor can release chemicals that can make pain nerves more sensitive to pain

1. 2. Side-effects of treatment or procedures

-       Chemotherapy can cause mouth sores that can produce pain

-       Surgical procedures such as biopsies or mastectomies

-       Other treatment related procedures such as blood extractions

Effects of Cancer Pain

All of us know that nobody wants to experience pain because it is extremely unpleasant.  However, the effects of pain go beyond this unpleasant sensation.  Pain affects the overall quality of a patient’s life.  It not only affects the individual afflicted with pain but the entire family or those people around him.  These effects include:

-       Lack of appetite

-       Inability to sleep

-       Irritability, behavioural changes, depression

-       Inability to carry out tasks

-       Shortened period of survival

-       Loss of joy in living

-       Family misunderstandings

-       Feelings of isolation

No Need to Suffer

The next time I saw Mr. A, he had a smile on his face and greeted me when I entered the clinic.  He was seated upright, his face shaven and it took me a while to recognize him.  He spoke calmly and told me how grateful he was since he started taking the pain medications.  He regained his appetite and was able to sleep at night without the need to give additional medications to put him to sleep.  He felt well-rested after a very very long time.  He never said he wanted to die anymore.

The next time I saw Mrs. B, she was sound asleep and the relatives greeted me with a smile and a lot of gratitude.  They said that it was the first time that she was able to sleep very soundly after a long while.

These and countless patients need not suffer from pain anymore.  In fact, many patients would tell me that they are not afraid to die but are afraid of experiencing pain.  The good news is they don’t need to experience the pain.  There should be no reason for concern.  Medicines that reduce pain are widely available, generally affordable and tolerable.  Concerns about safety, especially in the light of celebrities dying from drug overdose, do not pertain to cancer patients.

Pain medicines are generally safe when used properly and under supervision.  Our bodies will not easily go into overdose when there is and as long as there is pain to control.  I have patients who take hundreds of milligrams of morphine but if you chance upon them in the mall, you wouldn’t suspect that they are taking that much morphine.  Have no fear.  The celebrities suffer their fate because of inappropriate use and combination of these drugs.