Pain control in pancreatic cancer

• A quick guide to what's on this page
• Pancreatic cancer and pain
• Painkillers
• Opioid painkillers
• Side effects of painkillers
• Drugs to treat nerve pain
• Chemotherapy or radiotherapy to help pain control
• Nerve blocks
• Other ways of controlling 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 all patients. If you are having any pain, the sooner you get help the better.

We have left the information below in this section because you may find it a useful overview. But CancerHelp UK now has a large section on pain and pain control in general, as part of our section on managing symptoms of cancer and treatment.

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 pain killer 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 antidepressants or anti-epileptic drugs to help with nerve pain.

Many people use complementary methods of pain control alongside painkillers.

There are many different painkillers. The commonest type used in cancer care are morphine based, or opioid, drugs. This is because morphine is the most effective painkiller we have. Used properly, it does not have too many bad side effects. Very few people are allergic to it or cannot tolerate it.

There are other drugs available if morphine does not suit you. For example, there is a drug called fentanyl that you can have via an adhesive skin patch. That way, you do not have to take any tablets or medicine or have any injections.

Fentanyl can take up to 72 hours to get to the right levels of drug in your blood stream. So when you start on it, you carry on taking your previous painkillers for a while. It takes as long to get the fentanyl out of your system once you stop using it.

You may have other drugs with 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.

You can take morphine in lots of different ways including

• As a liquid or tablets every 2 to 4 hours
• As tablets every 12 hours
• As an injection
• Through a drip
• Through a pump connected to a small needle under the skin

The most important thing with any painkiller is to take it regularly. That way, it has a much better chance of working. And you should not have to put up with being in pain until you allow yourself the next dose.

When you start on morphine, it is best to have the type that you take at least every 4 hours. That way your dose can be increased quite quickly until you are comfortable. It is best to have an experienced Macmillan or Symptom Control nurse to help you through this process. Once you and your nurse know how much morphine you need to get your pain under control, your doctor can give you 'slow release' tablets equal to that dose. You only need to take those morning and night.

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 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 morphine for the first week or so. This should stop you feeling sick. Once you get used to your painkillers you can stop taking it.

If you have other cancer treatment 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 or need more and more. When you are taking it for pain, that just does not happen. This has been researched - fewer than 1 in 100 people (1%) who use morphine properly become addicted.

Many people with pancreatic cancer suffer from 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 amitryptilline and gabapentin. Amitryptilline is usually given as an antidepressant, but can help with 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.

Cancer treatment can help to control pain. Your pancreatic tumour may be pressing on a nerve or another organ and causing you 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 more chemotherapy or radiotherapy.

If you have pain that is proving 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. The coeliac plexus is a complicated web of nerves at the back of the abdomen. It can be responsible for 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.

The injection itself is done with a long needle. You have a smaller injection of local anaesthetic first to numb your skin. Then the doctor puts the needle in through your chest to the coeliac plexus. 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.

This can now be done using endoscopic, or endoluminal, ultrasound (EUS). EUS can also be used to take biopsies of the cancer. Using EUS to block the coeliac plexus nerves is called 'EUS-guided neurolysis'. An endoscope is a tube that is passed down your foodpipe. You may need to have a sedative before this is done, or a local anaesthetic sprayed onto the back of your throat, to help you to swallow the tube. An ultrasound probe is passed down the endoscope. This sends out high energy sound waves which are bounced off your internal organs, and picks up the echoes to build up a picture of the inside of your body. The doctor can find the coeliac plexus using this picture, and uses a needle from the endoscope to inject it with alcohol. The aim is to permanently block these nerves. Having this done endoscopically means that a shorter needle can be used, and there should be less danger to nearby organs.

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

Your doctor may think it better to cut the nerves causing the pain, rather than just inject them. This is done less often because you have to have a general anaesthetic. It is a small operation and you can have it done during other surgery (for example a bypass).

You may hear this procedure called 'splanchnicectomy'. This just means cutting the splanchnic nerve, which is the nerve that can cause this continuing pain in pancreatic cancer.

Another type of nerve block used more often these days is called thoracoscopic sympathectomy. This means the doctor uses a thorascope to get to the nerves. This is a tube with a camera, eye piece and light that enables the surgeon to look inside the body. It is much the same as an endoscope, except that it is used inside the chest. To have this procedure, you may have a general anaesthetic or a sedative. The surgeon has to make a few small incisions between your neck and breast bone. The surgeon puts the thoracoscope tube through these incisions to look inside the body and find a chain of nerves called the sympathetic nerve chain. It is these nerves that will be blocked.

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 antidepressants. If you are depressed, it can make it harder for you to cope with pain. But doctors also use antidepressants to treat nerve pain in people who are not depressed. Ask you doctor if you are not sure why any medicine has been suggested for you.

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

• Relaxation - use tapes 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 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 cannot 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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