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Pain control in pancreatic cancer

Although pain is common in pancreatic cancer, it can be kept under control in nearly all patients. If you are having any pain, the sooner you get help the better.

There are many different painkillers. Morphine based drugs are the most common type of painkillers used in cancer. Some painkillers are given as skin patches, liquid medicines or tablets. Sometimes they are given through a small tube put just under the skin. 

Both chemotherapy and radiotherapy can help control pain by shrinking the tumour. If you have pain that is difficult to treat, your doctor may suggest a nerve block. This is a way of killing or numbing a nerve to stop it causing pain. 

There is a lot more information in our cancer and pain control section.

 

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Pancreatic cancer and pain

Many people are very worried about having cancer pain. Although pain is common in pancreatic cancer, it can be kept under control in nearly everyone. If you have any pain, the sooner it is treated the more easily it can be brought under control.

The information below is a useful overview. But we also have a large section about pain and pain control, as part of our section on managing symptoms of cancer and treatment. You can find more detailed information there.

 

Painkillers

Painkillers are also called analgesics or analgesia. There are many different types and strengths of painkillers suitable for different types of pain. If you have mild pain you usually have simple painkillers, such as paracetamol. If you have moderate pain you usually have treatment with weak opioid painkillers, such as codeine. If you have ongoing or severe pain you usually have morphine type (opioid) painkillers.

An experienced doctor or nurse can judge which type of painkiller is best for you. The important thing is that you have the right type of painkiller for your pain and the right dose. You might also have anti inflammatory drugs such as ibuprofen (Nurofen) alongside any of the other painkillers. Or anti depressants or anti epileptic drugs to help with nerve pain.

Many people use complementary methods of pain control alongside painkillers.

 

Opioid painkillers

There are many different painkillers. The most common type used in cancer care are morphine based (opioid) medicines.  Used properly, morphine type drugs do not usually have too many bad side effects. Painkillers can be given in different ways, including

  • As a liquid or tablets every 2 to 4 hours
  • As tablets every 12 hours
  • As injections into a muscle or a tube put into a vein
  • Through a drip
  • As stick-on skin patches
  • By a pump connected to a small needle under the skin

The skin patch Fentanyl can take up to 72 hours to get to the right levels of drug in your bloodstream. So when you start on it, you need to carry on taking your previous painkillers for a while. It also takes 72 hours to get the Fentanyl out of your system once you stop using it. Your doctor or nurse will advise you about how to deal with any changes in your painkiller medicines or doses. 

You may have other types of medicines alongside an opioid, to help reduce pain. For example, you may have morphine and an anti inflammatory drug to take away swelling that is adding to the pressure of the cancer.

The most important thing with any painkiller is to use it as your doctor or nurse prescribes. That way, it has a much better chance of working. Taking painkillers regularly keeps the pain under control. If you are getting pain before your next dose of painkiller is due, let your doctor or nurse know so that they can adjust the dose to keep the pain under control.

 

Side effects of painkillers

Most painkillers have one or two side effects. Most cause constipation and so it helps to start taking regular stool softeners or laxatives when you begin regular painkillers. Morphine type painkillers (opioids) can also cause

  • Dizziness
  • Drowsiness
  • Feeling or being sick

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 opioids for the first week or so. This should stop you feeling sick. Once you get used to your painkillers you can stop taking the anti sickness drug.

If you have other cancer treatments to reduce your pain, such as chemotherapy or radiotherapy, you may find that your painkillers are making you drowsy again. If this happens, tell your doctor. You may need to reduce your dose.

Many people worry that they will become addicted to morphine type drugs or will need more and more. When you are taking it for pain, you are very unlikely to develop an addiction. Research has shown that fewer than 1 in 100 people (1%) who use morphine properly become addicted. Your dose will be carefully controlled by your doctor or nurse.

 

Drugs to treat nerve pain

Many people with pancreatic cancer have nerve pain. This is because the tumour may put constant pressure on large groups of nerves as it grows. Drugs that may be helpful in treating this sort of pain include amitriptyline and gabapentin. Amitriptyline is usually given as an anti depressant, but can help to reduce pain that is difficult to treat with other painkillers. Gabapentin is an anticonvulsant drug. This means that it helps to control fits (seizures), but it can also relieve burning or tingling pain. Other anticonvulsant drugs may also be used. There is more information about the side effects of these drugs in the cancer and pain control section.

 

Chemotherapy or radiotherapy to help pain control

Cancer treatment can help to control pain. Your pancreatic tumour may be pressing on a nerve or another organ and causing pain. If treatment can shrink the tumour, pressure on the nerve will be eased and you will have less pain. You may be able to cut down on your painkillers after chemotherapy or radiotherapy treatment.

 

Nerve blocks

If you have pain that is very difficult to treat, your doctor may suggest a nerve block. This is a way of killing or deadening a nerve to stop it causing pain. There are different types of nerve block, named after the nerves that are treated. There are not usually many side effects to nerve blocks. You may get low blood pressure for days or weeks afterwards. This may make you light headed if you stand up too quickly. This problem usually rights itself in time.

How long the nerve block lasts for varies in different people. It may last between a few days to a few months. Although nerve blocks can be helpful for many people, they don't work for everyone.

The coeliac plexus is a complicated web of nerves at the back of the abdomen. It can cause persistent pain in people with pancreatic cancer. In a coeliac plexus nerve block, the doctor injects alcohol into the coeliac plexus to deaden the nerves. You have a CT scan first, so that your doctor can be sure of putting the needle into the right place.

Nerve blocks are sometimes done using endoscopic (endoluminal) ultrasound (EUS). EUS can also be used to take biopsies of the cancer. The doctor passes a tube (endoscope) containing an ultrasound probe down your food pipe. This sends out high energy sound waves which bounce off your internal organs and build up a picture of the inside of your body. The doctor can find the coeliac plexus using this picture, and use a needle from the endoscope to inject alcohol into the nerves to permanently block them.

Doctors might also deaden the nerve with a treatment known as radiofrequency ablation. This uses radio waves to heat up and deaden the nerve. The doctor puts a needle through your skin, using X-rays to guide it. Radio waves then pass down through the needle to treat the nerve.

The splanchnic nerves send signals from the spinal cord to the organs in the chest and abdomen. If pain is caused by pressure on these nerves, your doctor may think it better to cut the nerves causing the pain, rather than just inject them. This is called a splanchnicectomy (pronounced splank-nik-ectomy). It is not commonly done because you have to have a general anaesthetic. It is a small operation and you can have it done during other surgery, for example during an operation to bypass a blockage caused by cancer.

Another type of nerve block is called thoracoscopic sympathectomy. The doctor uses a tube with a camera, eyepiece and light (thoracoscope) to look inside the body. You have this procedure under a general anaesthetic or sedation. The surgeon makes a few small cuts (incisions) between your neck and breast bone. They put the thoracoscope through these incisions to find a chain of nerves called the sympathetic nerve chain. They then cut part of the nerve.

 

Other ways of controlling pain

There are many ways you and your family can help to control your pain. You may have noticed that your pain seems worse if you are anxious or worried. It often seems worse at night when you cannot sleep and there is nothing else to distract you. Your doctor may suggest some medicine for anxiety or to help you sleep. Your doctor may also suggest anti depressants. If you are depressed, it can make it harder for you to cope with pain. But doctors also use anti depressants to treat nerve pain in people who are not depressed. Ask your doctor if you are not sure why particular medicines have been suggested for you.

There are other things you can do for yourself. Here are some things to try

  • Relaxation - use relaxation 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 2 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 to prevent damaging 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 time. If you can't sleep, learning relaxation exercises can be particularly helpful. Remember not to get over tired. Visitors are a wonderful distraction but you may find it best to see people frequently for a short time, if possible.

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Updated: 4 June 2014