Chapter Twenty-Five


Living with Cancer

Chapter Twenty-five

Controlling Pain

Pain is, naturally, one of the possibilities that people with cancer fear most. Yet cancer patients usually spend much less time considering how to control pain than they do researching choice in cancer therapies. There are seven very important points to remember about cancer pain, however:

1. Cancer is usually considerably less painful than people fear it will be.

2. An estimated 90% of cancer pain can be very adequately controlled.

3. Most physicians are not well trained in pain control, which is a real art and science.

4. The inadequate control of cancer pain is considered a scandal by pain specialists.

5. The probability of becoming addicted to opiate medications for pain is usually low, because the body metabolizes these drugs differently when it is in pain.

6. There are important nonpharmacological approaches to pain control, including psychological approaches and acupuncture.

7. The people who know how to control cancer pain in most communities–doctors and nurses–work with hospice organizations, and you do not have to be dying to get their help.

This chapter is about understanding and controlling cancer pain.

Understanding Pain

Pain is remarkable in that there are few–if any–words that express it adequately. Elain Scarry, Professor of English at the University of Pennsylvania, in her classic study The Body in Pain, describes fundamental observations about pain that may help us to understand it better:

Physical pain has no voice, but when at last it finds a voice, it begins to tell a story. …. Whatever pain achieves, it achieves in part through its unsharability, and it ensures this unsharability through its resistance to language. “English,” writes Virginia Woolf, “which can express the thoughts of Hamlet and the tragedy of Lear has no word for the shiver or the headache.”…. True of the headache, Woolf’s account is of course more radically true of the severe and prolonged pain that may accompany cancer or burns or phantom limb or stroke. …. Physical pain does not simply resist language but actively destroys it, bringing about an immediate reversion to a state anterior to language, to the sounds and cries a human makes before language is learned [emphasis added].

Why pain should so centrally entail, require, this shattering of language will only gradually become apparent …. but an approximation of the explanation may be partially apprehended by noticing the exceptional character of pain when compared to all our other interior states …. Our interior states of consciousness are regularly accompanied by objects in the internal world, that we do not simply “have feelings,” but have feelings for somebody or something. …. [By contrast] physical pain, unlike any other state of consciousness, has no referential content. It is not of or for anything. It is precisely because it takes no object that it, more than any other phenomenon, resists objectification in language …. When physical pain is transformed into an objectified state, it (or at least some of its aversiveness) is eliminated. A great deal, then, is at stake in the attempt to invent linguistic structures that will reach …. this area of experience.1

To put it more simply, pain tends strongly to elude our capacity to put it into words, and unlike our other internal states it has no object in the outer world to which it is attached. This is part of the reason pain is difficult to express. But when we do begin to put pain into language, it begins to tell a story, and that story often diminishes or erases pain. So the effort to find a language for pain is both important and healing.

Scarry describes the extraordinary work of Ronald Melzack and Patrick Wall, who created the celebrated gateway control theory of pain and also developed the McGill Pain Questionnaire.

Melzack [recognized] that the conventional medical vocabulary (“moderate pain,” “severe pain”) described only one limited aspect of pain, its intensity; and that describing pain only in terms of this solitary dimension was equivalent to describing the complex realm of visual experience exclusively in terms of light and flux. Thus he and Torgerson, after gathering the apparently random words most often spoken by patients, began to arrange those words into coherent groups which, by making visible the consistency interior to any one set of words, worked to bestow visibility on the characteristics of pain.2

They developed sensory categories of pain that included: temporal dimensions (flickering, quivering, throbbing, beating sensations); thermal dimensions (hot, burning, scalding, searing); and constrictive pressure dimensions (pinching, pressing, gnawing, cramping, crushing). Other categories described dimensions of the affective (or emotional) and cognitive qualities of pain.

In contrast to physical pain, Scarry points out, psychological suffering is easily expressed in language. We can readily articulate our suffering, but for pain we have to use images, the language of “as if.”

The great contribution of Scarry’s work is that she counterposes the experience of physical pain and the possibility of human creativity. Pain, she suggests, unmakes us–it destroys our capacity to use language and takes over the content of consciousness in wordless agony. Finding a way to give pain a voice reconstructs or remakes us. Creativity, the act of making a voice for pain, makes us. Thus, for Scarry, the most profound relationship exists between the destructive power of pain (and pain is, after all, a signal that we are being destroyed) and the constructive power of creativity.

Now here we enter deeply into the real world behind the dry language of medicine and psychology with regard to what we can do with that aspect of cancer pain that can be worked with psychologically.

Imagery, Creativity, and Pain

Much of the most effective work in imagery and hypnosis with pain is quite literally in creating an opportunity that gives pain a voice, that enables it to express itself in the primordial and prelinguistic language of images. Thus the therapist may often, after inducing a state of relaxation, suggest: “Allow an image to form of your pain.” A careful viewing of this image and a dialogue with it can often be both physically and psychologically transformative, frequently markedly diminishing pain.

Cristoff Müller-Busch, M.D., a pain specialist at the anthroposophical hospital at the University of Witten-Herdecke in Germany, has reported his strong impression that creative people often suffer less cancer pain than those whose creativity is blocked. And indeed, many activities that stimulate creativity are found by clinicians to alleviate both pain and suffering.

The fact that pain is resistant to language may also be related to the fact that physical pain is so difficult to remember. We are apt to remember more easily inner states that are stored in linguistic structures. On the other hand, there are symbolic structures that do store pain in us, and it often can be recovered through techniques of imagery and hypnotherapy.

After a patient has recovered from the initial shock of receiving a cancer diagnosis, one of his greatest fears is often that of being trapped in excruciating pain. This fear is rarely justified. Curiously, many intelligent people will expend great efforts on researching choice in both conventional and complementary cancer therapies and yet make little effort to understand the two possible outcomes of cancer that they fear most: pain and dying. Yet in pain, knowledge, choice, skill, and control are available that can make an enormous difference.

Why Cancer Pain, So Feared, Is Poorly Treated

“In a survey of public opinion on cancer …. pain ranked next to incurability in people’s fear. …. It has also been found that the general public believes cancer to be much more painful than it actually is,” writes J.J. Bonica, Professor of Anesthesiology at the University of Washington.3 Moderate to severe pain, according to Bonica, is experienced by 30% to 45% of cancer patients at diagnosis, by 30% to 40% of patients with intermediate disease, and by 60% to 100% of patients with advanced or terminal cancer. This leads Bonica to pose a key question: “In view of the great advances in biomedical scientific knowledge and technology, and especially the great amount of interest in, and effort devoted to, cancer research and therapy, why is cancer pain inadequately relieved?” Bonica continues:

Serious consideration …. suggests that it is due to an inadequate appreciation or outright neglect of the problem of pain (in contrast to the problem of cancer) by oncologists, medical educators, investigators, research institutions, and national and international cancer agencies. …. Review of the curricula of medical schools reveals that few, if any, teach students the basic principles of the use of narcotics and other treatments that will effectively relieve cancer pain. Moreover, many physicians in residency training for specialization in surgical, medical and radiation oncology receive little or no teaching about the proper management of cancer pain….ê. Inadequate or total lack of interest or concern about the problem of pain by oncologists is further shown by the fact that very little, if any, information about the proper management of the pain problem is found in the oncology literature [emphasis added].3

Foley’s Classification of Types of Cancer Pain

One of the seminal articles on cancer pain was written by Kathleen Foley, M.D., a neurologist at Memorial Sloan-Kettering Cancer Center in New York, in the New England Journal of Medicine in 1985.4 Foley is well known for her diagnostic division of types of cancer pain. Her categorizations of cancer pain are classic in the pain literature, and it is useful for the cancer patient and the family to know how a trained specialist in pain control might approach the specific type of pain a patient has.

Foley starts by differentiating between acute and chronic cancer pain. The onset of acute pain is well defined and it is associated with objective physical signs and hyperactivity of the autonomic nervous system that can be used by the practitioner to substantiate the patient’s report of pain. Chronic pain, on the other hand, is pain that persists longer than 6 months, in which adaptation of the autonomic nervous system occurs. The objective signs common to acute pain are not present. Chronic pain leads to marked changes in personality, lifestyle, and functional ability: “Such pain requires an approach that encompasses not only treatment of the cause of pain but also treatment of its psychological and social consequences” [emphasis added].4

Starting with this distinction between acute and chronic pain, Foley then goes on to list five major types of patients with cancer pain.

The first group are those patients with acute cancer-related pain, in which the pain led to the diagnosis of cancer or where cancer therapy (surgery, chemotherapy, radiation) itself is the cause of the pain. Foley notes that for the former group, “pain has a special meaning as the harbinger of their illness. The occurrence of pain during the course of the illness, or after successful therapy, has the immediate implication of recurrent disease.” For these patients, effective cancer therapy–such as irradiation of bone metastases–can bring dramatic pain relief. For those patients with acute pain related to treatment, “the cause of the pain is readily identified, its course predictable and self-limited. Such patients endure pain for the promise of a successful outcome.”

The second group are patients with chronic cancer-related pain associated either with cancer progression or with cancer therapy. For those patients with chronic pain related to the progression of disease, combinations of pain strategies are often called for that may include direct antitumor therapies, analgesic drug therapies, anesthetic blocks, and psychological approaches to pain control. Psychological approaches, Foley emphasizes, may play a critical role with patients for whom palliative therapy may be of little value and would be physically debilitating:

The sense of hopelessness and fear of impending death may add to and exaggerate the pain, which in turn contributes to the overall suffering of the patient. Identification of both the pain and the suffering component is essential to the provision of adequate therapy. Saunders has used the phrase “total pain” to describe the etiologic components other than the noxious physical stimulus, including emotional, social, bureaucratic, financial, and spiritual pain. Those caring for this group of patients must be concerned with all aspects of distress and discomfort if the experience of physical pain is to be alleviated [emphasis added].5

Patients with chronic pain associated with therapy are, Foley emphasizes, critical to identify:

Treatment of the pain is often limited by the lack of available methods to remove the cause of the pain. …. This group of patients closely parallels those in the general population with chronic, intractable pain. Identification of this group is imperative because recognition of the cause of the pain as independent of the cancer markedly alters the patient’s therapy, prognosis, and psychological state. Approaches other than drug therapy provide effective alternatives for pain management [emphasis added].

The third group Foley identifies are those patients with preexisting chronic pain. These patients have a history of chronic nonmalignant pain in addition to cancer and its associated pain. Psychological factors play an important role for these patients, because their psychological and functional status is already compromised. They are therefore at high risk of further functional incapacity and escalating chronic pain. “However,” says Foley, “their history should not be used in a punitive way to minimize their complaints” [emphasis added].

The fourth group is composed of patients with a history of drug addiction and cancer-related pain. These patients’ history of drug addiction is compounded by cancer-related pain and the issues of medication. Active drug users represent a particularly difficult problem requiring consultation with drug-abuse specialists. Prior users can be treated just as other pain patients are, with the added recognition that they are at higher risk for recidivism.

The fifth group Foley identifies are dying patients. For these, maintaining the comfort of the patient is of paramount importance. The issues of hopelessness, death, and dying come to the fore, and the patient’s suffering must be addressed. “Inadequate control of pain exacerbates the suffering and demoralizes both the family and the medical personnel who feel they have failed in treating the patient’s pain at a time when adequate treatment may matter most” [emphasis added]. Foley concludes that rapid escalation of analgesic drug therapy and attempts to address symptoms should be employed.6

The type of cancer that one has obviously contributes greatly to the probability of pain. Foley found that 85% of patients with primary bone tumors had pain, compared with 52% of breast cancer patients, 20% of lymphoma patients, and only 5% of leukemia patients. Looking at cancer pain another way, the authors found that 78% of hospitalized cancer patients had pain due directly to tumor involvement, 50% had pain due to bone disease, in 25% pain was due to nerve compression, and in 19% it was due to treatment-related problems.7

Therapeutic Strategies in Pain Treatment

The first goal of the physician, according to Vittorio Ventafridda of the Italian National Cancer Institute, is to treat the cause of the pain. If this is not possible, treating the symptoms becomes the goal. The choice of methods for pain treatment should take into account the patient’s degree of activity and the preferences of the patient. A patient for whom activity matters a great deal may prefer to accept more pain in order to maintain the preferred level of activity. In the same way, a patient who particularly values a clear mind may accept more pain in order to stay mentally clear. A patient who is actively fighting for life using immunosupportive adjunctive therapies may accept more pain in order to avoid the immunodepressive characteristics of many pain medications. But a patient whose enjoyment of life is being destroyed by pain may prefer a more active intervention in pain control.

Immediate relief of pain is the first goal of therapy, followed by ongoing control of pain for the rest of the patient’s life. The ideal goal of this strategy–complete freedom from pain–is rarely possible, but pain can almost always be eased so that the patient can bear what was previously considered to be intolerable.

In planning the therapeutic strategy, it is necessary to pursue a series of objectives. Cancer pain may prevent the patient from getting adequate sleep, which will lower his pain threshold and result in constant tiredness and demoralization. This problem should be addressed first. Next, pain should be relieved when resting in bed or in a chair. Pain felt when standing and during activity should also be relieved. While the first and second aims are relatively easy to achieve, the third one requires a combined and sequential pattern of physical and psychosocial supports in order to be effective.8

This brings us to the greatest contribution of modern science to cancer pain management: the use of analgesic drugs and the concept of the analgesic ladder. The key points in analgesic pain management, according to Ventafridda, are:

The drug must be administered at fixed hours and not on the patient’s request to alleviate pain. Analgesics should be given regularly and prophylactically [with prevention as the goal]. The aim is …. to gradually increase the dose until we obtain the maximum relief with the minimal interference with activity. The next dose is given before the effect of the first one has fully worn off. In this way it is possible to erase the fear of pain.

The drug or drugs to be used should be selected and treatment …. started at once. While the nature and cause of the pain are being assessed, therapy should be started with analgesic drugs, which should then be given on a regular basis.

If a drug ceases to be effective, do not transfer to an alternative drug of similar strength but prescribe a drug that is definitely stronger.

Use analgesic drugs primarily by mouth–the route of administration is important because it has a substantial impact on the patient’s way of life. The patient taking oral medication is free to move around, travel as he wishes and, most important, be at home. Injections promote dependence on the person administering the drug. Oral administration eliminates muscle trauma and enables the patient to maintain control over his own drug administration.

Use pure drugs, not compounds. With a compound an increase in the dose of one drug will automatically increase the dose of the other whether it is necessary or not.

Check interaction with any other substances (chemotherapeutic, hormonal, etc.) which the patient is receiving.

Control side effects.

Learn how to use a few drugs well. The three basic analgesics are aspirin, codeine and morphine. Certain adjuvant drugs can also be helpful in certain specific cases. Learn to be familiar with one or two alternatives for each type of agent for use in patients who cannot tolerate the first choice drug. Your basic analgesic ladder, with alternatives, should include no more than nine or ten drugs in total [see figure 25.1 and table 25.1].9

Table 25.1

Basic Analgesic Drug List

Type, First choice, Alternatives

Nonopioids, Aspirin, Paracetamol (acetaminophen)

Weak opioids, Codeine, Dextropropoxyphene

Strong opioids, Morphine, Methadone
Standardized opium

Anticonvulsants, Carbamazepine, Phenytoin

Antidepressants, Amitriptyline, Clomipramine

Anxiolytics, Diazepam, Hydroxyzine

Corticosteroids, Prednisolone, Dexamethasone

Muscle relaxants, Diazepam, Baclofen

Psychotropics, Chlorpromazine, Haloperidol

Reproduced by permission of MTP Press Limited, Lancaster, England, from M. Swerdlow and V. Ventafridda, eds., Cancer Pain, © 1987.

Psychological Approaches to Pain

Approximately 50% of cancer patients report good to excellent relief of cancer pain from medications alone.10 Psychological approaches to cancer pain, as Foley indicated, offer an important complement to drug therapy. Tearnan et al. describe the important benefits of psychological approaches to cancer pain. First of all, psychological factors often color the perception of pain. Secondly, patients can be taught to manage pain through behavioral techniques, and this approach can be applied to other areas of patient distress, such as anxiety and depression. These approaches may also help to increase the patient’s sense of mastery over his health environment. And finally, they have no negative side effects.11

According to Tearnan and colleagues a fascinating contrast between pain and life adjustment problems in patients with benign chronic pain and patients with chronic cancer pain is reported by some researchers:

The relationship between pain and life adjustment problems for patients with chronic pain is well known. Many of these patients report difficulties in their marriages, work, and recreational activities. They also admit to significant levels of depression and other mood disturbance. Surprisingly, cancer pain does not appear to be strongly correlated to psychosocial problems, negative mood in particular [emphasis added].12

Many clinicians would find these data suspect based on direct experience with hundreds of patients who attribute their illness directly to life problems and emotional difficulties. Another explanation for this strange finding might be sought in the fascinating work of Lydia Temoshok with melanoma patients: some melanoma patients, Temoshok found, were extraordinarily out of touch with their emotional responses to life. Such patients might simply fail to report life adjustment problems and emotional difficulties that patients in pain with a benign chronic disease do report.13 Other people with cancer may have developed cancer for reasons entirely unrelated to life adjustment or emotional problems, and so would logically not report the difficulties of most patients with benign chronic pain. However, many cancer patients do in fact consistently report serious life adjustment problems, and their pain is often responsive to psychological work that addresses these problems.

Psychotherapy and Hypnosis for Cancer Pain

While researchers reasonably assure us that definitive controlled studies of most psychological approaches to pain have not been done, there is no question in the minds of many clinicians who work with cancer pain that many of the psychological approaches described above routinely diminish, or sometimes even erase, cancer pain. In general, psychological approaches to pain work best with a therapist skilled in combining them as the individual patient requires. Thus a session may be part psychotherapy dealing with internal and interpersonal issues, part progressive deep relaxation and imagery or hypnotherapy, and part cognitive restructuring.

Tearnan and his colleagues14 divide the psychological approaches to treating cancer pain into the following major categories15:

1. Psychotherapy as an approach to pain control “is based on the assumption that the perception of pain occurs within a personal and interpersonal context. The general assumption is that dealing with critical intra- and interpersonal issues will reduce the impact of pain.”

2. Hypnosis is the oldest and most widely used approach. “Numerous clinical reports have appeared in the literature over the last three decades to support its efficacy in treating cancer pain. Hypnosis has also been reported to be effective in treating emotional distress, anxiety or treatment-related discomfort in cancer patients. Although the literature reports that 20%-50% of cancer patients benefit from hypnosis, this evidence is largely anecdotal and based on uncontrolled studies.”14

3. Relaxation techniques and biofeedback, which are closely related to hypnosis, may also be useful. Relaxation training includes yoga, meditation, and progressive muscle relaxation, as well as autogenic relaxation techniques that use suggestions that the body is getting heavy, warm, or relaxed. Biofeedback uses instruments to induce physiologic awareness of the capacity to achieve responses such as relaxation.

4. Cognitive approaches include assessment of beliefs, expectations, and fears, and assistance to the patient in restructuring and reconceptualizing the pain.

5. Behavioral approaches focus on the role of environmental reinforcement of cancer pain. The authors suggest this approach is of limited value in cancer pain because the “the report of pain is important in the assessment of the disease process and should not be ignored.”14

Virginia Veach’s Work with Pain

The most effective psychological work with cancer pain that I have personally witnessed has been that of Virginia Veach, Ph.D., a psychotherapist and physical therapist who is also one of the senior co-leaders in the Commonweal Cancer Help Program. Veach is frequently able to help participants relieve pain, sometimes dramatically. I have watched her help participants in the Cancer Help Program reverse pain so frequently that I have come to trust her method. I have also tried her approach with others, and found that I too could sometimes–far less expertly–help with pain.

What Veach characteristically does is to elicit from the participant a detailed description of the pain. Is it sharp or dull? Pulsating or steady? Where exactly is it located? What shape is it? How wide, deep, and long is it? How big is it? Then she often asks whether the participant is willing to try to get out of the way of the pain and allow it to spread. This is usually a shocking idea to someone in pain. Veach reassures the participant that he can return to his effort to minimize the pain shortly. And, she emphasizes, she is not asking the participant to make the pain spread, but simply to see if it is possible to get out of the way and to allow the pain to spread.

Pain, Veach explains, acts like fire: it “wants” to spread. And often in the course of spreading it changes its character, becomes less intense, less sharp. The “hot” pain turns to warmth, and sometimes even to a tingling sensation that in many traditions is associated with healing.

The Story Pain Tells

We saw at the beginning of this chapter how few words adequately describe pain; how pain can “unmake” us. The other side of the coin is that the exploration of our inner lives–often prompted by pain–may shift our inner lives in relation to the pain. As we change, the pain may change. This phenomenon of pain shifting, when we pay attention to it, is deeply related to a distinction I introduced in chapter 2: the distinction between pain and suffering. Recall the diagram in which we contrasted:

Biomedicine (Science) Biopsychosocial Medicine (Human experience)

Disease   Illness

Pain   Suffering

Curing   Healing

In each case, biomedicine is focused on the biological phenomena–disease, pain, curing–while biopsychosocial medicine attends both to the biological phenomena and the human experience of the biological phenomena. Thus, illness is the human experience of disease; healing is the human experience of the effort to recover health; and suffering is the human experience of pain.

So suffering is in large part the story that we tell ourselves about our pain. And that story can sometimes profoundly shift the experience of that pain. A widely cited example are the studies conducted in Korea and Vietnam of wounded American soldiers. Those who received lesser wounds that could be patched so that they could return to the lethal risks of the battlefield consistently reported worse pain than those with more serious wounds who were being sent home. The meaning of the wound amplified the pain for those being sent back in harm’s way, and diminished the pain for those who knew they had escaped with their lives.

No Pain, No Gain?

In the face of serious pain, thoughtful people should learn to look beyond the initial simple and natural thought that the pain is always a direct result of the cancer, and that medication is the only response to the deeper messages that pain often elicits from us. The idea that we can benefit from pain is difficult to grasp, one that is often mocked or simplistically overstated. But consider this question: Have you learned more from the painful things in your life, or from the easy ones? Is it a mistake that Jesus was “a man of troubles and acquainted with grief?” Or that Gautama Buddha’s journey toward enlightenment began with the direct perception of pain and suffering? One of my favorite quotations from the Yoga Sutras, the greatest yoga text, says this: “The acceptance of pain as an aid to purification, the study of holy books, and complete surrender to the Divine within us, constitute yoga in practice.”

Sometimes pain is too great to accept. In that case, medication is a great blessing to bring the pain down to levels where we can work with it. At the Lukas Klinik in Arlesheim, Switzerland, the great anthroposophical hospital for cancer patients inspired by Rudolf Steiner, it is part of the creed of the staff that the goal of pain medication is to make pain tolerable–but not remove it completely–so that the patient can put it to spiritual use.

Morphine, Metastases, and Addiction

Not everyone can or does subscribe to the idea that pain has any benefits at all. That is, after all, simply another one of the stories that pain may elicit from us. Some people faced with pain simply want to be “snowed” with as heavy a dose of pain medication as possible. One physiological disadvantage to an excessive reliance on opioid drugs (like morphine) is that they may depress the immune system. In some animal studies, morphine has been shown to increase the rate of metastases in cancer-bearing rodents.16 Other animal studies show a cancer-inhibiting effect of opioids. No human studies have been conducted on the important question of whether the best of pain killers are a double-edged sword. But their known immunosuppressive effect makes that a legitimate concern, and certainly justifies people who seek strategies to shorten or minimize the need for opiates.

On the other hand, the old concern that use of opiates would cause cancer patients to become drug addicts has been significantly reduced by recent studies showing that opiates are metabolized differently by people in pain.17 Addiction turns out to be an uncommon phenomenon among pain patients who take prescribed opiates. This may also put a different light on the rodent studies showing increased cancer metastases in animals given opiates. The treated animals were not, presumably, in pain. Perhaps the different way that humans metabolize opiates when in pain lessens the threat of addiction. On the other hand, some clinicians do report addiction problems with patients recovering from cancer who used large amounts of opiates.

Other Approaches to Pain

There are other approaches to pain worthy of careful consideration.

First, acupuncture is well known to help control many kinds of pain, and is very effective with some forms of cancer pain, as indicated in chapter 19.

Second, there are herbal medications that may be helpful with pain, particularly when the pain stems from tight muscles and a herbal relaxant would be effective.

Third, massage and acupressure can both be effective in reducing pain, especially (as above) pain associated with muscular tension.

Finally, physicians can prescribe the use of an electrical nerve-stimulating device that greatly reduces some kinds of pain. This device, called a TENS (transcutaneous electrical nerve stimulator; manufactured by the 3M company); looks like a miniature portable radio. The patient pastes wires coming out of it to the skin and adjusts the level and pulse of the electrical charge. Some patients take use of the device a step further and paste the wires to acupuncture points that their traditional Chinese medicine practitioner has identified as specifically related to the pain. One friend of mine was able to discontinue opiates for some time using this device.


Pain, the more one considers it, is a remarkable subject. We have reviewed seven key points about pain: (1) that cancer is generally less difficult than many people think; (2) that most cancer pain can be controlled; (3) that most physicians are not adequately trained in pain control; (4) that cancer pain is undertreated by most physicians; (5) that addiction to pain medication should not be a primary concern if you are in pain; (6) that there are important nonpharmacological ways to control pain; and (7) that the best pain control experts in most communities are doctors and nurses associated with hospice programs, and that you do not have to be dying to get their help with pain.

We looked at how wordless we are in pain and how pain “unmakes” us. We saw how being in touch with creativity may lessen pain. And we considered both the pharmacological and nonpharmacological approaches to controlling pain.

One potent pain reliever-acupuncture and traditional Chinese medicine–we did not discuss. Its potent benefits for some kinds of pain is discussed in chapter 19.

Notes and References

1 Elaine Scarry, The Body in Pain (New York: Oxford University Press, 1985), 3-6.

2 Ibid., 7.

3 J.J. Bonica, “Importance of the Problem.” In M. Swerdlow and V. Ventafridda, eds., Cancer Pain (Boston: MTP Press, 1987), 3-8.

4 Kathleen M. Foley, “The Treatment of Cancer Pain,” New England Journal of Medicine 313(2):85 (1985).

5 Ibid.

6 Ibid., 85-6.

7 K.M. Foley, “Pain Syndromes in Patients with Cancer.” Cited in B.H. Tearnan et al., “Psychological Management of Malignant Pain.” In C. David Tollison, ed., Handbook of Chronic Pain Management (Baltimore: Wilkins & Wilkins, 1989), 403.

8 Vittorio Ventafridda, “Therapeutic Strategy.” In Swerdlow and Ventafridda, eds., Cancer Pain, 57-8.

9 Ibid., 58-61.

10 Tearnan et al., “Psychological Management of Malignant Pain.” In Tollison, ed., Handbook of Chronic Pain Management, 402.

11 Ibid.

12 Ibid., 403.

13 Lydia Temoshok, “Repressive Coping Reactions in Patients with Malignant Melanoma as Compared to Cardiovascular Disease Patients,” Journal of Psychosomatic Research 28(2):151-2 (1984).

14 Tearnan, “Psychological Management of Malignant Pain,” 408-12.

15 See the Psychological Approaches to Cancer section of chapter 10 for more information on these techniques.

16 Edward W. Bernton, Henry U. Bryant, and John W. Holaday, “Prolactin and Immune Function.” In Robert Ader, David L. Felten, and Nicholas Cohen, Psychoneuroimmunology, second edition (San Diego: Academic Press, 1991), 412-3.

17 Ronald Melzack, “The Tragedy of Needless Pain,” Scientific American 262(2):27-33 (February 1990).