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Pain control for advanced gallbladder cancer

Pain is a common symptom of advanced gallbladder cancer. The pain may not be near your gall bladder, but in other areas where the cancer has spread. This may be in your spine or abdomen. The main method of controlling pain is to use painkillers such as morphine. But there are other painkillers. And there are other ways of reducing pain.

Both chemotherapy and radiotherapy can be used to help control pain. If you have pain that is difficult to treat, you may be offered a nerve block. This is a way of killing or numbing a nerve to stop it causing pain. There are also many other ways you and your family can help control your pain. These include relaxation, breathing, massage, and hot and cold packs.

Pain control is a complex area of medicine. There are nurses and doctors who are highly skilled in managing people's pain. You really do need their advice and help. Whatever you take, make sure your doctor and nurse know. If it isn't working, tell them. With the right prescription, it should be possible for just about everyone to be pain free at least when they are at rest, if not all the time.

 

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Pain and advanced gallbladder cancer

Pain is a common symptom of advanced gallbladder cancer. The pain may not be near your gallbladder, but in other parts of the body the cancer has spread to. This may be in your spine or abdomen. The main way of controlling pain is using painkillers. There are many types of painkiller and there are other ways of reducing pain. We have a large section about pain and pain control which you may find this useful.

 

Painkillers for advanced gallbladder cancer

There are many different painkillers. Some are available over the counter from your chemist, such as paracetamol. These drugs can be very useful for mild pain, but they do not control more severe pain. If you have been taking a mild painkiller and you are still in pain, you need to talk to your doctor about getting something that works better for you.

The most common painkillers in cancer care are morphine based drugs. Drugs that are similar to morphine are called opioids. There are many different types of opioids. Some are natural and made from the opium poppy, like morphine. Others, such as fentanyl are man made. There is more about morphine below.

Opioids are grouped into weak and strong types. Codeine and dihydrocodeine (DF118) are weak opioids. If you are taking a weak opioid and are still in pain, you may need change to a strong opioid. Depending on the type and cause of the pain you have, you may find that the weak opioid and an anti inflammatory drug, such as ibuprofen (Nurofen) or diclofenac (Voltarol) will be enough.

Pain control is a very complex area of medicine. Some nurses and doctors specialise in pain and symptom control and are highly skilled in managing people's pain. It is best to get their advice and help. You can ask your doctor to refer you to a specialist pain team. If you try to control your pain yourself, you may give yourself problems with side effects. Some painkillers even cancel each other out, so you might be in more pain. Whichever painkillers you take, make sure that your doctor and nurse know. If they aren't working, tell them. With the right prescription, it should be possible for just about everyone to be pain free at least when they are resting, if not all the time.

There is much more information on different types of painkillers in our pain and pain control section.

 

Morphine type painkillers

Morphine is a strong opioid. It is a very effective painkiller. Used properly, it doesn't tend to cause bad side effects. Very few people cannot take it.

Morphine is often given along with other drugs that can help to reduce pain. For example, it may be given with an anti inflammatory drug to take away swelling that increases pressure of the cancer on nerves. Morphine can be given in lots of different ways including

  • As a liquid or tablet every 2 - 4 hours
  • Slow release tablets, taken every 12 hours
  • As an injection
  • Through a drip
  • Through a pump connected to a small needle under the skin
  • As suppositories

The painkiller Fentanyl can be given as a stick on skin patch. That way, you don't have to take any tablets or medicine or have any injections.

Fentanyl patches and slow release morphine tablets can take up to 72 hours to get to the right level in your bloodstream. So it is important that when you start using them, you carry on taking your previous painkillers for a while and gradually reduce the dose. Your symptom control nurse (Macmillan or palliative care nurse) or your doctor should advise you about this. It also takes up to 72 hours to get these medicines out of your system once you stop using them.

The most important thing with any painkiller is to take it regularly. Then it has a much better chance of working. And you should not be in pain before your next dose. If you get pain before the next dose is due, talk to your doctor or nurse. They may need to increase the dose.

When you start on painkillers, it is best to take the short acting type every 4 hours. That way the dose can be increased easily until your pain is under control. It is best to have a specialist nurse to help you through this process. Once you and your nurse know how much painkiller you need to get your pain under control, your doctor or nurse can give you tablets that you only need to take morning and night. These will be the same strength as the dose of morphine you had in one day.

 

Controlling side effects of painkillers

Most strong painkillers have side effects. Just about all of them cause constipation and so it helps to start taking regular stool softeners or laxatives as soon as you begin regular painkillers. If your doctor doesn’t prescribe these along with your painkillers, ask them.

Strong painkillers can cause other side effects at first, including

Usually these side effects happen because you are not used to the drug. After a few days they lessen and disappear. Many doctors give an anti sickness drug along with morphine type drugs for the first week or so. This stops you feeling sick. Once you get used to your painkillers you can stop taking the anti sickness medicines.

If you have other cancer treatment to reduce your pain, such as chemotherapy or radiotherapy, you may find that your painkillers make you drowsy again. If this happens, tell your doctor. If your other treatment has lessened your pain, you will need to reduce your dose of the painkiller.

Many people worry that they will become addicted to morphine or need to take more and more. When you take it for pain, that does not usually happen. This has been researched and less than 1% of people who use morphine to control pain become addicted.

 

Chemotherapy or radiotherapy to control pain

Both chemotherapy and radiotherapy can help to control pain. If your gallbladder tumour is pressing on a nerve or another organ and causing pain, chemotherapy or radiotherapy can shrink the tumour to ease pressure and reduce the pain. You may be able to cut down on your painkillers after chemotherapy or radiotherapy treatment.

 

Nerve blocks for advanced gallbladder cancer

If you have pain that is difficult to treat, you may be offered a nerve block. This is a way of killing or numbing a nerve to stop you feeling pain in that area of the body. There are different types of nerve block, named after the nerves that are treated.

The coeliac plexus is a complicated network of nerves at the back of the tummy (abdomen). Gallbladder cancer can put pressure on the coeliac plexus and cause persistent pain. Doctors can inject alcohol into the coeliac plexus to kill off the nerves and control the pain. This is called a coeliac plexus nerve block. You will be given a CT scan so that your doctor is sure of putting the needle into the right place. The injection itself is done with a long needle. You have a smaller injection of local anaesthetic beforehand, to numb your skin. Then the needle goes in through your back to the coeliac plexus. Sometimes you have a coeliac plexus nerve block done using endoscopic ultrasound to guide the needle to the right place.

The splanchnic nerve can cause continuing pain in pancreatic or gallbladder cancer. It goes from the spinal cord in the chest to the bowel. Your doctor may think it better to cut this nerve, rather than just inject it. You have to have a general anaesthetic for this small operation and it may be done during other surgery (for example bypass surgery). Cutting the nerves is called splanchnicectomy. Injecting the nerve is called a splanchnic nerve block.

Gallbladder cancer may press on nerves called the sympathetic nerve chain in the chest. Your doctor may suggest a nerve block called thoracoscopic sympathectomy. To have this procedure, you may have a general anaesthetic or a sedative. A few small cuts are made between your neck and breastbone. The surgeon passes a thin tube into the cuts. The tube is called a thoracoscope and has a camera, eyepiece and light. The surgeon can look inside the body and find the sympathetic chain nerves to inject or cut them.

There are not usually many side effects to nerve blocks. You may get low blood pressure for days or weeks afterwards. This can make you feel light headed if you stand up too quickly. This problem usually gets better over a few days or weeks.

 

Other ways of controlling pain

There are many ways you and your family can help to control your pain. You may notice that your pain seems worse if you are anxious or worried. It often seems worse at night when you can't sleep and there is nothing else to distract you. Here are some things to try

  • Relaxation - use CDs or listen to some calming music and think of somewhere beautiful you would like to be
  • Breathing - try to breathe slowly and deeply when you are tense
  • Change your position at least every two hours to prevent stiffness and sore skin
  • Massage - ask your family or friends to give gentle massage to your back, hands or feet
  • Hot or cold packs can help relieve pain (wrap them in a soft towel so you don't damage your skin)
  • Watching TV, reading or chatting can help to take your mind off your aches and pains

These are not magic cures. But they can all help you to take some control over your pain and make it seem better for a while. If you can't sleep, learning relaxation exercises can be very helpful. Remember not to get overtired. Visitors are a wonderful distraction but it may be better to see people frequently for a short time if possible.

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Updated: 19 June 2014