Pain Management for HRPC
Pain is the most common symptom of
metastatic prostate cancer. Some patients with bone metastases do
not develop pain and are considered asymptomatic. The vertebrae are one
of the most common sites for bone metastases and they can lead to spinal
cord compression, nerve root compression, or cauda equina syndrome.
Metastases to the base of the skull can cause pain by impinging on
cranial nerves. Clinical fractures are seen most commonly in the
Table of Contents
Pain Management for
HRPCa - R. Benson
Personal Experiences in Dealing with Pain
Management from Choices:
Living with cancer, dying with dignity by Molly Sower
following links will take you out of the HRPCa website. Use the BACK
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Publications on Pain Management
The use of marihuana for pain management is controversial. Lynch, ME et
al (1) followed 30 patients who received 1-5g of medicinal marihuana.
Ninety-three percent reported moderate or greater pain relief.
(1) Lynch ME, Young J, Clark AJ., A case series of
patients using medicinal marihuana for management of chronic pain under
the Canadian Marihuana Medical Access Regulations, J Pain Symptom
Manage. 2006 Nov;32(5):497-501. PMID: 17085276
Pain Management for Hormone Refractory Prostate Cancer
The time to take pain management seriously is before you experience serious
pain as a result of prostate cancer. When you do have serious pain--as a
result of the disease or as a result of a treatment side effect--nothing
else will matter. No matter what stage of the disease you are dealing with,
read this section, and know that its message will be available should you
You will hear, from medical professionals, that there is no need to suffer
pain from cancer. That may be true…theoretically. However, I know of no one
with metastatic cancer who has not experienced severe pain for some reason,
pain that by its severity became the foremost issue in their battle.
Eventually, a resolution was found; in the meantime there was considerable
suffering. This chapter is intended to help you reduce that suffering to a
minimum by giving you the knowledge and a strategy for working with your
doctor to relieve the pain and restore your quality of life.
Assessment of pain is subjective; therefore, what constitutes adequate
relief is also subjective. You want to control the pain to a level that
permits you to enjoy a good quality of life.
You may have to be persistent with your caregivers, but you should insist on
treatment for any level of pain that interferes with your ability to enjoy
It is important to control pain. Serious pain invariably leads to
depression, which becomes a threat to life.
This paper does not cover every treatment for pain, but it should be enough
that you can use the information to initiate meaningful discussions with
Drug dependency is a controllable issue
The risk of addiction should not keep you from getting adequate pain relief.
For most of us, the problem of pain is more severe than the problem of
dependency. Dependency, for most of us, is a non-issue, unless you are
already an alcoholic or an addict.
I became physically dependent on morphine during a single week, but found
myself eager to stop because of the unpleasantness of feeling drugged. I
stopped over a few days with some discomfort, but no difficulty. If you have
become dependent, you should stop gradually to minimize the discomfort and
prevent the serious risks associated with stopping “cold turkey.” Your
normal condition is that your quality of life is better when you don’t have
to take pain relievers.
In starting a pain management regimen, your purpose is to keep the pain
under control, to the extent that you can enjoy your normal activities. It
takes 2 to 3 days for an opioid pain drug to build to an effective level in
your blood stream and suppress the pain on a continuing basis. Do not stop
taking the opioid medicines when you no longer feel the pain. First discuss
that with the doctor. If you do stop, you may find yourself back in pain, at
the beginning of the process, and have to spend several days in pain
rebuilding the drug level in your blood.
Constipation with Opioids
When you use opioids, you are likely to experience constipation at the
outset and during the usage. In fact, up to 90% of patients placed on opiod
therapy experience bowel dysfunction. One suggestion is to drink prune
juice to wash down the pills.
The first drug approved (FDA April
24, 2008) for treating opioid-induced constipation is Relistor (methylnaltrexone.)
The approval was for terminal patients with late-stage diseases. It is
administered by subcutaneous injection every one or two days as needed.
Abdominal pain, nausea, gas and diarrhea are the most common side
effects. See www.relistor.com for
more information. See also Thomas J et al, Methylnaltrexone for
opioid-induced constipation in advanced illness, N Engl J Med. 2008;
Standard Laxatives Available for Opioid-Induced
Constipation. Rely on pulling or trapping water in the stool, thereby
making the stool softer, larger and easier to pass which promotes
|Class of Laxative
||Mechanism of Action
||Retention of water in the stool. Must be taken with adequate
||Useful in healthier people. Not recommended for debilitated
patients due to large fluid intake.
||detergent, traps water in the stool
||docusate (Imodium is a brand name).
||Can cause flatulence and bloating.
||osmotically pulls water into the stool
||lactulose, sorbitol, magnesium citrate, polyethylene glycol.
||Can cause flatulence and bloating.
||increases contraction of intestinal muscle and increases
||Can cause abdominal pain and cramping.
After an article in HemOnctoday 25
Diarrhea with Opioids
When you discontinue an opioid, especially morphine, you may experience
diarrhea. Be prepared for it with Imodium or other over-the-counter remedy.
Do not let diarrhea go on without treatment because it can dehydrate your
Whose help do you need?
Your primary contact for pain management is your oncologist, who is
experienced in dealing with pain associated with cancer. If you are unable
to find an acceptable solution, you may wish to consult a pain specialist
(frequently an anesthesiologist with special training), usually available at
Try to determine the source of the pain
Eliminating the source is always better than treating the symptom. If you
can determine the source, it may be easy to eliminate the pain. However,
with prostate cancer, the source is often in the bone, a difficult area to
treat. In some cases, nerves are involved in persistent pain, and the source
may be at a location different from the perceived pain. In still other
cases, the source may be unknown, and you can only treat the symptom.
Gastrointestinal pain may require a different approach than use of the
normal pain relief drugs. For example, acid reflux can cause severe pain up
and down the chest; sometimes it will respond to Pepto-Bismol or other acid
control medication. An ulcer may need different treatment. Pain may even be
caused by one of the drugs you are taking.
You are always better off if you can eliminate the pain at its source.
Determine the level of pain
Pain is a subjective issue; the headache that is “killing” one person may be
ignored by the next. However, the only opinion that counts is that of the
person with the pain. The pain level is a continuum; the numeric levels
listed below are designated as an aid to communication. The level will need
to be communicated to the doctor in order that the appropriate treatment can
Most medical practitioners are used to dealing with a scale of 1 to 10 in
severity. A level of 1 is a pain that is trivial; a level of 10 is the worst
pain you’ve ever experienced. For example, many people have indicated that
kidney stones cause level 10 pain. Hitting your thumb with a hammer is a
brief introduction to level 10 pain. For that instant, nothing else matters.
What the doctor needs to know is your estimate of the severity of your pain.
0 No pain.
1-2 Annoying, but bearable, such as a common headache; you may seek a remedy
or you may ignore the pain.
3-4 Sufficiently painful to cause you to seek a remedy.
5-6 Interferes with your ability to focus on normal
activities; stronger relief is needed.
7-8 Dealing with the pain has become your first priority;
You are prevented from doing normal activities. This is near to unbearable.
9-10 The worst pain you have ever experienced. The pain is unbearable.
Recently, Federal law has required that all hospitals include in their
review of your health status whether you are currently experiencing pain and
what level you are experiencing.
Treating level 1-2 pain
Take Tylenol, Ibuprofen or Advil according to the directions. If you are
being treated with chemotherapy, you may want to avoid aspirin because it
thins the blood by reducing platelet function and compounds the suppressing
action of the chemotherapy.
Treating level 3-4 pain
From this point all drugs require a prescription. First, try Tylenol with
codeine if you are fairly tolerant of the pain. If you cannot comfortably
tolerate the pain, try Vicodin.
If those do not control the pain, try Oxycontin next. (This name means “oxy”
for oxycodone—an opioid--and “contin” for continuous-release dose.) The
typical starting dose is one 10-mg tablet every 12 hours. This drug has an
effective time in the body of 12 hours, so it should be dosed on that
schedule. If more is needed, that larger dose should also be taken every 12
hours, rather than more frequently.
If the pain is not controlled, then the Oxycontin dose may be ramped up.
Over a long period, with pain that is nearly under control, the dose might
be ramped up by an additional 10 mg per dose every month. If the pain is
more severe, the ramping schedule can be shortened to every 2-3 days.
If the Oxycontin is not sufficient to control the pain, then MScontin
(morphine) can be started at 15 mg every 12 hours. Again, maintain the
12-hour schedule when ramping up.
Treating level 5-6 pain
Continue with Oxycontin or MScontin, ramping up as necessary to control the
At this time, consideration should also be given to hospitalization if you
are ramping up with morphine. High doses can lead to respiratory failure, so
emergency care may need to be at hand. This is a decision for the doctor.
Ramping up should be done no faster than necessary in order to give the
brain time to assimilate the drug. If the ramping up is done too quickly,
the individual will temporarily experience the notorious and unpleasant side
effects of opioids: lethargy, loss of mental alertness, confusion, loss of
emotional control, etc.
Treating level 7-8 pain
Hospitalization is required. To achieve the necessary higher doses of
morphine, intravenous dosing is needed. It will be necessary to have
emergency care at hand during administration of the higher doses.
Once the effective dose has been established by ramping up the IV, the dose
can be converted to pills for home use. An IV dose of 1 mg of morphine is
equivalent to 3 mg in a pill taken orally.
Treating level 9-10 pain
This pain requires continued ramping up of morphine doses from the previous
Fentanyl (an opioid) can be administered via a patch (Duragesic) or by a
drip when the patient cannot tolerate Oxycontin or morphine. Patches are
used when nausea and vomiting are a problem. A fentanyl portable pump can
also be worn, like a “fanny-pack,” for continuous administration.
If you are taking prescription drugs for chronic pain, you should also
discuss with the doctor what drug can be supplied in case you experience
temporary “breakthrough pain.” You should be prepared--ahead of time--in
case the regular dose effect is overwhelmed by the pain. Do not wait to
discuss this until the pain spikes—unless you are in the hospital, where
help is always at hand.
Some examples of prescription drugs for breakthrough pain include Percocet
If you are fighting pain at levels 7 to 10 and still have breakthrough pain,
there is a high-powered version of fentanyl with the brand name Actiq. It
comes in the form of a “lollipop” that can be sucked; the medicine is
absorbed by the mucous membranes of your mouth and in the GI tract. Because
of the strength of this drug, you must already be accustomed to an opioid
drug to avoid overdosing.
Nerve pain is more difficult to treat
Neurological pain can be a difficult problem to control. Identifying the
source may be the first problem.
For example, tumors growing in the spine can block the channel for the
spinal nerves (stenosis) and lead to painful compression. Strangely, though,
this pain may show up in a leg rather than at the point of compression. The
answer to this type of pain may be surgery to remove the compression. The
problem also entails the risk of permanent nerve damage.
Chemotherapy often results in “peripheral neuropathy,” (PN) or pain and
numbness at the extremities. We have been able to mitigate some of the
effects of PN by dosing glutamine amino acid, which helps in the repair of
damaged cells. The dose is 10 grams t.i.d. plus 50 mg magnesium and 50 mg
vitamin B-6 daily. Avoid taking with hot foods. (Discuss this with your onco
Another treatment for nerve pain is Neurontin. If the other pain-relievers
are ineffective, this may be an alternative.
Radiation and radioisotope injections for bone pain
External-beam radiation can sometimes be used (in a technique called “spot
welding”) to alleviate localized pain due to cancer in the bones. However,
the treatment is localized and may not be useful if there are many bone
Strontium-89 (Metastron) and samarium-151 (Quadramet) can be injected in a
generalized treatment of bone pain. From our experience, we prefer Quadramet.
These radioisotopes seek the bone, especially areas with bone lesions, i.e.,
tumors. Radiation is an effective and quick tool for eliminating pain,
although the injected radioisotopes can cause an initial pain flare before
the original pain subsides. Relief with these radioisotopes can last for as
long as a year.
There is a price to pay for the use of radiation. It also damages bone
marrow, especially when used in the pelvic area, where large concentrations
of bone marrow exist. A reduction in bone marrow will limit the amount of
chemotherapy that can be administered because chemotherapy also affects the
bone marrow and suppresses the immune system.
Radiation cannot be repeated indefinitely because of the damage to the bone
marrow, which is the source of white blood cells for the immune system and
red blood cells for oxygen transport. Radiation also damages other healthy
tissue in the body and may result in severe side effects, such as diarrhea
Chemotherapy for pain management
Chemotherapy can relieve bone pain by suppressing the cancer—the source of
the pain. It is not unusual to experience quick pain relief on starting an
effective chemotherapy. (See the sections on chemotherapy.) Any strategies,
including hormone therapy, that inhibit the cancer may also relieve pain.
Bisphosphonates for bone pain
The bisphosphonate drugs (Zometa, Aredia, Fosamax) have also been shown to
relieve pain by suppressing bone metastases. Anyone with HRPCa should be
using one of these drugs. (See Chapter 11. Protect
bone integrity. Also see Bones and
PERSONAL EXPERIENCES IN DEALING WITH PAIN
of our friends had an extended bout of pain associated with prostate
cancer and its treatment. He has offered the following thoughts:
have tried all the following pain medications, with varied success, and
I’ve listed them in relative order of strength:
= Ibuprofen, Tylenol
a combination of oxycodone and acetaminophen (RX) = Roxicet
5/325 = Endocet 5/325
(10- and 20-mg slow-release)
(fentanyl transdermal system) patch (delivers 25 micrograms/hr
of fentanyl for up to 72 hrs). Patch can be used in 25-, 50-,
and 75-microgram increments or portions thereof.
sulfate: 1-2 ml orally.
current ‘standard’ is the Duragesic patch (changed every 48 hours),
plus—for breakthrough pain—Ibuprofen (2 tabs @ 200 mg each) and
Percocet (1 pill, 325 mg)."
would not correlate pain levels with the medication, but I would start
with over-the-counter items (1) and then get the doctor to prescribe
items, such as (2). Items (3) and (4) are slow-release. I went to (5)
last night, but perhaps my dose level was too low (initially 0.25 mg,
then another 0.25 ml, then 0.5 ml). Pain finally subsided, and I slept
believe that most of these pain medications cause constipation as a side
effect. It’s not been a problem for me; however, it should be
considered a possibility."
on another pain pill of a different sort. It is called Neurontin (gabapentin,
which the PDR describes only as an anti-convulsant). It comes in 300-mg
tabs, and I take 3/day. I know a fellow who takes 9/day for pain and for
peripheral neuropathy. This is a drug that works differently than the
other palliatives; it was originally developed for seizures."
Another patient is reported to be
taking Methadone 10 mg every 8 hours and has Hydromorphone 2 mg
for breakthrough pain. This is working well for him.
2. To read
about another personal experience in dealing with pain and why it is
important to identify the source of the pain before treating it, click
here. In this case, Quadramet was
administered when it likely was not needed.
By: Bob Benson; Revised:
Last Updates 16 January 2009 by Howard
Management from Choices Booklet
section is an excerpt of an excellent booklet called "Choices:
Living with cancer, dying with dignity." Molly Sower Sugarman
wrote this booklet in honor of her husband, Matthew, who died
of prostate cancer in 1999. The Rotary Clubs of District 5190,
generously funded the publication of this brochure. Molly and
the Rotary Club have given permission to reprint this section.
You can obtain a complete copy of the brochure by sending an
e-mail request to Molly at
or by reading the copy at the
Pain is the most common problem faced by men with metastasized prostate
cancer. It is a problem with various causes and many effective solutions.
pain can be caused by damage to organs, bones, muscles or joints. It
can be caused by a tumor that has grown so large that it prevents proper
functioning of other parts of the body, such as the digestive system
or colon. Cancer also causes pain when it presses against nerves or
the spinal cord itself.
cancer pain can be controlled or even eliminated. In its publication,
Home Care Guide for Advanced Cancer, the American College of Physicians
states that pain can be controlled for 90 to 99 percent of cancer patients.
of pain may be as simple as taking aspirin on a regular basis. When
pain persists, narcotics, such as codeine, morphine or synthetic versions
of them may be prescribed. Most of these drugs take a few days to become
effective. If pain continues, ask your doctor about increasing the dose
or changing medicines.
medication falls into two categories: baseline, which provides constant
pain relief and "breakthrough" medication for pain spikes
that break through the baseline occasionally. Keep track of how often
you take breakthrough medication and why. Mark it in your calendar or
keep a pain log.
breakthrough medication is needed frequently, ask your doctor about
increasing the baseline medication or switching to another medicine.
If a particular part of your body is hurting frequently, such as your
hip, it may be possible to eliminate the pain by other means, such as
is not an issue when you have advanced cancer. "Saving" pain
medication for a really bad bout is unnecessary. "Bad bouts"
can be treated with stronger medicines or by other techniques.
pain medication comes in pills, time-released capsules and skin patches
that last as long as 72 hours.
of particular tumors or lesions on the bones also relieves pain. Strontium-89
is an injected radiation treatment that irradiates lesions in bones
throughout the body. It usually provides significant pain relief for
three to six months.
treatment affects healthy bone marrow as well. This may result in a
drop in the red blood cells used to carry oxygen throughout the body
and in platelets needed for blood to clot. This side effect may require
treatment itself. Because of this side-effect, it can be used only a
infusions of pamidronate (Aredia), which is used to strengthen bones,
may also reduce pain.
pain can eliminate fatigue, lethargy, stress and lack of interest in
normal activities. Working through pain uses a lot of energy and may
become a barrier to normal activity.
methods are often used with medical methods to relieve pain. Acupuncture
has been proven to relieve some pain. Meditation and visualization are
useful. Massage can also help, whether a full-body professional massage
or a foot massage by a friend.
most important thing to remember about pain is you don’t need to have
it. If one medication doesn’t work after a few days, ask your doctor
for something else.
must become a clock-watcher when on pain medication. To work effectively,
pain medication must be given before the pain starts and on a regular
basis to maintain a steady level of medication. Sleeping through a scheduled
dose allows the pain to reappear. It is much harder to eliminate pain
than to prevent it.
an alarm clock to remind you when the dosage is due. When you take your
medicine, reset the alarm for the next dose. For longer acting drugs,
mark your calendar.
your medication lasts four to six hours, you must get up in the middle
of the night to keep on schedule.
medication can be provided in 12-hour capsules, which makes adhering
to your schedule easier.
boxes with timers are available to make sure you don’t miss a dose whether
at work or at home. With or without a timer, always carry a pill box
in case you get home late or experience breakthrough pain. Both your
baseline and breakthrough medications should be within reach at all
that deliver pain medication, such as fentanyl, at a steady rate for
72 hours are a relief from the clock-watching. As the need for pain
relief increases, more patches can be added.
patches allow freedom from daily clockwatching and reduce the likelihood
of forgetting your pain medication, they have other problems. Patches
can be difficult to apply. The steady delivery of the medication may
be affected if the edges come loose.
& Johnson makes a patch to go over the fentanyl patch. It prevents
the medication patch from lifting up, or the edges of the fentanyl patch
can be taped down with medical tape.
adhesive on the fentanyl patches may cause an allergic reaction. As
a result, the skin may become red and sore where the adhesive touches
eliminate the allergic reaction, hydrocortisone cream can be spread
on the area before the patches are applied. After allowing time for
the cream to be absorbed, the area should be wiped thoroughly so all
greasiness is removed.
the patches can be painful. It is easier if the patches are pulled off
after a hot shower.
pain medications almost always cause constipation, which can be severe
and painful. A good rule of thumb is to take a stool softener every
time you take pain medication. Ask your doctor about the kind and amount
you should take. Adjust as the dosage if your pain medicine is increased.
these methods of pain relief require discipline. But all are portable,
easy to use and will not interfere with activities, such as work and