Guide to

Controlling
Cancer Pain

Talk to your doctor or nurse about your pain.

What do I need to know

about pain control?
This information is written to help people with cancer
learn about pain control. Reading this can help you:
Work with your doctors, nurses, and pharmacists to

find the best ways to control your pain.

Know about different types of pain and how each

type is treated.
Learn about different types of pain medicines.
Know about other ways to help manage pain.
Take your medicines safely.
Talk with your cancer care team about your pain

and how well your pain treatment plan is working.

Having cancer does not always mean having pain. But
for people who do have pain, there are many different
kinds of medicines, different ways to take the medicines,
and non-drug methods that can help relieve pain.
Pain can affect all parts of your life. If you have pain, you
may not be able to take part in your normal day-to-day
activities. You may have trouble sleeping and eating.
You may be irritable with the people you love. Its easy to
get frustrated, sad, and even angry when youre in pain.
1

Family and friends dont always understand how youre

feeling, and you may feel very alone in your distress.
You should never accept pain as a normal part of having
cancer. All pain can be treated, and most pain can be
controlled or relieved. When pain is controlled, people
can sleep and eat better, enjoy being with family and
friends, and continue with their work and hobbies.
Only you know how much pain you are in. Telling your
cancer care team when youre in pain is very important
because pain is easier to treat when it first starts. Pain
can also be an early warning sign of the side effects of
cancer treatment or some other problem. Together, you
and your cancer care team can talk about how to best
treat your pain. You have the right to be treated for
cancer pain, and you should insist on it.

Be sure you
and your family
members know
how to contact
the cancer care
team anytime, day
or night, and on
weekends
and holidays.

In this booklet
Facts about cancer pain treatment

What causes pain in people with cancer?

Pain from the cancer
Pain from procedures and surgery
Pain from other cancer treatments

10
10
11
13

Types of pain
Breakthrough pain

15
15

Treating cancer pain

Developing a plan for pain control
Keep a record of your pain.

18
19
22

Medicines used to relieve pain

For mild to moderate pain
For moderate to severe pain
For breakthrough pain
For tingling and burning pain
For pain caused by swelling or pressure

25
25
26
26
27
27

How is pain medicine given?

28

Different ways to treat

chronic and breakthrough pain
Treating chronic pain
Treating breakthrough pain
Common questions about breakthrough pain

30
30
30
32

Non-opioid pain medicines

Brand-name drugs and generic drugs
Non-steroidal anti-inflammatory drugs
Acetaminophen
Aspirin, acetaminophen, and ibuprofen in other medicines

36
36
40
42
43

Opioid pain medicines

Common opioids by generic name
Opioid tolerance
How to get proper pain relief
with opioids
Be safe when taking opioids.
Side effects of opioids
When you no longer need opioids

45
45
46
47
48
49
53

Other types of pain medicine

55

Other medical methods to relieve pain

Stopping pain impulses from going through the nerves
More cancer treatment may be given to shrink the tumor.

57
57
58

Non-medical treatments for pain

Relaxation
Biofeedback
Imagery
Distraction
Hypnosis
Skin stimulation
Acupuncture
Emotional support and counseling

60
61
65
65
67
69
70
75
76

To learn more about cancer pain 78

More information from your American Cancer Society
78
National organizations and websites
79

Facts about cancer pain

treatment
Cancer pain can almost always be
relieved or lessened.
There are many medicines and methods that can be
used to control cancer pain. You should expect your
cancer care team to work with you so that you can
be as comfortable as possible. But even though a lot
of progress has been made, some doctors and nurses
dont know the best ways to treat cancer pain.
If youre in pain and your doctor has nothing more
to offer, ask to see a pain specialist or have your
doctor consult with a pain specialist. Pain specialists
may be oncologists, anesthesiologists, neurologists,
neurosurgeons, other doctors, nurses, or pharmacists.
A pain control team may also include psychologists
and social workers.
If you have trouble finding a pain specialist, contact a
cancer center, a hospice, or the oncology department
of your local hospital or medical center. They should
be able to recommend someone to you.

Controlling your pain is part of your

cancer treatment.
Your cancer care team wants and needs to hear about
what works for your pain and what doesnt. Knowing
about the pain will help them know more about how
the cancer and the treatment are affecting you.
5

Talking about pain wont distract your cancer care

team from treating the cancer.

Keeping pain from starting and

keeping it from getting worse are the
best ways to control it.
Pain is best relieved when treated early. Dont try to
hold off as long as possible between doses of pain
medicine. Pain may get worse if you wait. Then it may
take longer for the medicine to work, or you may need
larger doses.

You have a right to ask for pain relief.

Talking about your pain is not a sign of weakness. Not
everyone feels pain in the same way. Theres no need
to tough it out or be brave. In fact, as soon as you
have any pain you should speak up. Remember, its
easier to control pain right when it starts rather than
waiting until it becomes severe.

People who take cancer pain

medicines the way the cancer care
team tells them to rarely become
addicted to them.
Addiction is a common fear of people taking
pain medicine. Such fear may keep you from taking
the medicine. Or it may cause family members to
encourage you to hold off as long as you can
between doses.
6

Addiction is defined as uncontrollable drug craving,

seeking, and continued use. When opioids (also
known as narcotics) the strongest pain relievers
available are taken for pain, they rarely cause
addiction as defined here. When youre ready to stop
taking opioids, the doctor will lower the amount of
medicine youre taking over a few days or weeks. By
the time you stop using it completely, your body has
had time to adjust. Talk to your cancer care team
about how to take pain medicines safely and about
any concerns you have about addiction.

Most people do not get high or lose

control when they take cancer pain
medicines the way theyre told to.
Some pain medicines can cause you to feel sleepy
when you first start taking them. This feeling usually
goes away within a few days. Sometimes you become
drowsy because now that the pain is under control,
youre able to get the much-needed sleep you missed
when you were in pain. Sometimes, people get dizzy
or feel confused when they take pain medicines.
Tell your cancer care team if this happens to you.
Changing your dose or type of medicine can often
solve these problems.

Side effects from pain medicines can

be managed and often prevented.
Some pain medicines can cause nausea and vomiting,
itching, constipation, or drowsiness. A few can cause
7

liver or kidney damage. (We talk about side effects in

more detail in the sections on the different types of
pain medicines commonly used.) Your cancer care
team can help you manage these side effects. Some
of these problems go away after a few days of taking
the medicine. Many side effects can be managed by
changing the medicine, the dose, or the times when
the medicine is taken. Others, like constipation, can
often be prevented with stool softeners and other
measures.

Your body does not become immune

to pain medicine.
Pain should be treated early, and stronger medicines
should not be saved for later. Its important to take
whatever medicine is needed when its needed. Your
body may get used to the medicine youre taking, so
over time the medicine may not relieve the pain as
well as it once did. This is called tolerance. Tolerance
is seldom a problem with cancer pain treatment
because your cancer care team can increase the
amount of medicine youre taking or add other
medicines. Some people are alarmed by this because
they think it means theyre addicted, but its not the
same thing. It only means that your body has learned
to adjust to the drug over time.

When pain is not relieved, you may feel:

Tired
Depressed
Angry
Worried
Lonely
Stressed

When cancer pain is relieved,

youre more able to:
Enjoy being active.
Sleep better.
Enjoy family and friends.
Eat better.
Enjoy sexual intimacy.
Prevent depression.

What causes pain in people

with cancer?
Pain is most often caused by the cancer itself. But
pain can also be caused by cancer-related treatment
or tests. You may also have pain that has nothing to
do with the cancer or its treatment. Like anyone, you
can get headaches, muscle strains, and other aches
and pains.

Pain from the cancer

Whether you have pain and the amount of pain you
have depends on the type of cancer, its stage (extent),
and your pain threshold (tolerance for pain). People
with advanced cancer are more likely to have pain.
Pain from the cancer can be caused by a tumor
pressing on bones, nerves, or body organs.
Spinal cord compression
When a tumor spreads to the spine, it can press on
the spinal cord. This is called spinal cord compression.
The first sign of compression is usually back and/
or neck pain, sometimes with pain, numbness, or
weakness in an arm or leg. Coughing, sneezing, or
other movements often make it worse. If you have
this pain, get help right away. This compression must
be treated quickly to keep you from losing control of
your bladder or bowel or being paralyzed. Your cancer
care team can treat the cause of the pain and give you
10

medicine to help relieve the pain. If youre treated for

the compression soon after the pain begins, you can
usually avoid serious outcomes. Treatments usually
involve radiation therapy and steroids to shrink the
tumor. Or you may have surgery to remove a tumor
thats pressing on the spine, which may then be
followed by radiation.
Bone pain
This type of pain can happen when cancer spreads
to the bones. Treatment may be aimed at controlling
the cancer, or it can focus on protecting the affected
bones. External radiation may be used to treat the
weakened bone. Sometimes a radioactive medicine
is given that settles in the affected areas of bone
and helps to make them stronger. Bisphosphonates
are other medicines that can help make diseased
bones stronger and help keep bones from breaking.
These are examples of treatments that are aimed at
stopping the cause of the bone pain. You may still
need pain medicines, but sometimes these treatments
can greatly reduce your pain.

Pain from procedures and surgery

Procedures and testing
Some tests used to diagnose cancer and see how well
treatment is working are painful. If such a procedure is
needed, concern about pain should not keep you from
having it done. Any pain you have during and after
the procedure can usually be relieved. Your needs and
the type of procedure to be done should dictate the
11

kinds of medicine you get for the pain. You may be told
that the pain from the procedure cant be avoided or
that it wont last long. Even so, you should ask for pain
medicine if you need it.
Surgical pain
Surgery is often part of the treatment for cancers
that grow as solid tumors. Depending on the kind
of surgery you have, some amount of pain is usually
expected. Youll be given pain medicines so you
wont be in pain when your surgery is over. Pain due
to surgery can last from a few days to a few weeks,
depending on the type of surgery.
Phantom pain
Phantom pain is a longer-lasting effect of surgery,
beyond the usual surgical pain. If youve had an arm,
leg, or even a breast removed, you may still feel pain
or other unusual or unpleasant feelings that seem
to be coming from the absent (phantom) body part.
Doctors are not sure why this happens, but phantom
pain is real; its not all in your head.
No single pain relief method controls phantom pain
in all patients all the time. Many methods have
been used to treat this type of pain, including pain
medicine, physical therapy, antidepressant medicines,
and transcutaneous electric nerve stimulation
(TENS). If youre having phantom pain, ask your
cancer care team what can be done.

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Pain from other cancer treatments

Some of the side effects that occur with chemotherapy
and radiation treatments may cause pain for some
people. Pain can even cause some people to stop
treatment if its not managed. Talk to your cancer
care team about any changes you notice or any pain
you have.
Here are some examples of pain caused by cancer
treatment:
Peripheral neuropathy (PN)
This condition refers to pain, burning, tingling,
numbness, weakness, clumsiness, trouble walking,
or unusual sensations in the hands and arms and/or
legs and feet. Peripheral neuropathy is due to nerve
damage caused by certain types of chemotherapy, by
vitamin deficiencies, cancer, and other problems. Be
sure to tell your doctor right away if you notice these
kinds of problems.
You can learn more about peripheral neuropathy
online at www.cancer.org, or call us at 1-800-227-2345
to have free information sent to you.
Mouth sores (stomatitis or mucositis)
Chemotherapy can cause sores and pain in the mouth
and throat. The pain can cause people to have trouble
eating, drinking, and even talking.

13

Radiation mucositis and other radiation

injuries
Pain from external radiation depends on the part
of the body thats treated. It can cause skin burns,
mucositis (mouth sores), and scarring all of which
can result in pain. The throat, intestine, and bladder
are also prone to radiation injury, and you may have
pain if these areas are treated.

14

Types of pain
The type of pain you have affects the treatment you
will need. Pain may be acute or chronic:
Acute pain is severe and lasts a fairly short
time. Its most often a sign that the body is being
injured in some way. This pain generally goes
away as the injury heals.
Chronic or persistent pain lasts for long periods
of time. It may range from mild to severe. Youll
notice that here we talk mostly about chronic
pain, because it can disrupt your life if its not
well treated.
Theres a third type of pain thats very important in
managing chronic cancer pain. Some people with
chronic pain thats mostly controlled by medicine
can have breakthrough pain. This is when moderate
to severe pain breaks through the medicine thats
giving pain relief and is felt for a short time.

Breakthrough pain
People with cancer pain often notice that their pain
changes throughout the day. Many people with
chronic cancer pain (pain that lasts longer than 3
months) have 2 types of pain persistent or chronic
pain and breakthrough pain. Chronic pain doesnt go

15

away, but it can usually be controlled by taking pain

medicines on a regular schedule. Breakthrough pain
is pain thats not controlled by the regular doses of
pain medicines.
Breakthrough pain is a flare of pain that happens
even though youre taking pain medicine regularly for
chronic pain. Its called breakthrough pain because
it breaks through the pain relief you get from the
regular pain medicine.
Breakthrough pain may be different for each person,
and the person usually cant tell when it will happen.
As a rule, it comes on quickly, lasts as long as an
hour, and feels much like chronic pain except that its
more severe or intense. It may happen many times a
day, even when the chronic pain is controlled by the
regular pain medicine.
Breakthrough pain is shown in the picture on the
next page as spikes through the relief provided by
the around-the-clock analgesic (pain medicine taken
regularly to treat chronic pain). Breakthrough pain
varies in intensity and usually cant be predicted.

16

Breakthrough pain often has the same cause

as chronic pain. It may be the cancer itself, or it
may be related to cancer treatment. Some people
have breakthrough pain during a certain activity,
like walking or dressing. For others, it happens
unexpectedly without any clear cause.

ain
gh p
u
o
r
kth
Brea

k
-cloc
-the
d
n
u
Arolgesic
ana

in
c Pa
i
n
ro

n
Pai
r
e
c
Can
h
g
u
hro
t
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a
Bre
e
Tim

17

Treating cancer pain

Your doctor will want to find out more about whats
causing your pain because that will affect how its
treated. Drugs, procedures, cancer treatments, or
even surgeries may be used in special ways to manage
your pain.
If you have severe pain, your cancer care team will
try to find the treatment plan that best relieves your
pain with the fewest side effects. Youll need to stay in
touch and let them know how the pain treatment is
working and how youre doing day to day. The goal is
an effective pain control plan that works for you.
Cancer pain is usually treated with drugs called
analgesics, also known as pain relievers. Many pain
relievers are available without a prescription (for
example, aspirin, acetaminophen, or ibuprofen).
These medicines are called non-prescription or overthe-counter (OTC) analgesics. OTC pain medicines
can be used alone for mild pain, and along with
other medicines for more severe pain. For other pain
medicines, youll need a prescription.
Check with your cancer care team before you take any
medicine for pain, even OTC medicines, because some
of them can interact with cancer drugs or worsen
certain problems. Medicines are mostly safe when
theyre used properly, but they can be very harmful if
not managed carefully.
18

In some cases, medicines and non-medical treatments

may not work well. But there are special pain
treatments that can often be used for these kinds of
cancer pain. For instance, things like:
Radiation to shrink the tumor
Surgery to remove all or part of the tumor
Nerve blocks, in which medicine is injected into or

around a nerve or into the spine to block the pain

Neurosurgery, where nerves are cut to relieve

the pain
There are other methods that may be used, too. See
the section called Other medical methods to relieve
pain on page 57 for details.
You may also use non-medical treatments such as
relaxation techniques, biofeedback, guided imagery,
and others along with the medicines. See the section
called Non-medical treatments for pain on page 60.

Developing a plan for pain control

The first step in developing a pain control plan is
talking with your cancer care team about your pain.
You need to be able to describe your pain to your
family or friends, too. You may want to have your
family or friends help you talk to your cancer care
team about your pain, especially if youre too tired or
in too much pain to talk to them yourself.

19

Using a pain scale is a helpful way to describe how

much pain youre feeling. To use the Pain Intensity
Scale shown here, try to assign a number from 0 to 10
to your pain level. If you have no pain, use a 0. As the
numbers get higher, they stand for pain thats getting
worse. A 10 means the worst pain you can imagine.

0 1 2 3 4 5 6 7 8 9 10
No pain

Worst pain

For instance, you could say, Right now, my pain is a 7

on a scale of 0 to 10.
You can use the rating scale to describe:
How bad your pain is at its worst
What your pain is like most of the time
How bad your pain is at its least
How your pain changes with treatment

Tell your cancer care team and your family or friends:

Where you feel pain
What it feels like for instance, sharp, dull,

throbbing, gnawing, burning, shooting, steady

How strong the pain is (using the 0 to 10 scale)

20

 How long it lasts

What eases the pain
What makes the pain worse
How the pain affects your daily life
What medicines youre taking for the pain and how

much relief you get from them

Your cancer care team may also need to know:
All the medicines youre taking now, including

vitamins, minerals, herbs, supplements, and nonprescription medicines

The pain medicines youve taken in the past,

including what has and has not worked for you

Any known allergies to medicines, foods, dyes, or

additives
When working on a pain control plan, it helps to take
all your medicines, vitamins, minerals, herbs, and
non-prescription drugs with you. Show them to your
cancer care team and explain how you take them.
Questions you may want to ask about pain medicine
include:
How much medicine should I take? (Whats the

dose?)
How often can I take it?
How do I take it?

21

 If my pain is not relieved, can I take more? If so, how

much?
Should I call you before increasing the dose?
What if I forget to take it or take it too late?
Should I take the pain medicine with food?
How much liquid should I drink with the medicine?
How long does it take the medicine to start

working?
Is it safe to drink alcohol, drive, or operate

machinery after Ive taken this pain medicine?

What other medicines can I take with the pain

medicine?
What medicines should I stop taking or not take

while Im taking the pain medicine?

What side effects from the medicine are possible?

How can I prevent them? What should I do if I have

them?

Keep a record of your pain.

You may find it helpful to keep a record or a diary to
track details about your pain and what works to ease
it. You can share this record with those caring for you.
This will help them figure out what method of pain
control works best for you. Your records can include:
Words to describe the pain

22

 Any activity that seems to increase or decrease the

pain
Any activity that you cant do because of the pain
The name, dose, and time you take your pain

medicines
The times you use other pain-relief methods (such

as relaxation techniques, distraction, or imagery)

The number you rate your pain at the time you use a

pain-relief measure (medicine or method to reduce

pain)
Your pain rating 1 to 2 hours after using the pain-

relief measure
How long the pain medicine works
Your pain rating throughout the day (to get an idea

of your general comfort)

How pain interferes with your normal activities,

such as sleeping, eating, sex, or work

Any side effects you have that may be from the

medicines

23

24

Pain
score
(0 to 10)

3/12
7:40 a.m. 8

Date &
time

What I was
doing when
it began

Getting out
of bed

Where pain is and how

it feels (ache, sharp,
throbbing, shooting,
etc.)

Stabbing pain in right side

under my arm

2 Percocet at
7:45 a.m.

Name, time,
and amount of
medicine taken

Deep
breathing

Non-drug
techniques
I tried

About
35 min.

How long
the pain
lasted

Pain came down

to a 3, and I
was able to get
up and shower at
8:30.

Other notes

Heres an example of how you might set up your pain diary:

You can also print out a Pain Diary from our website, or call
us to have a copy mailed to you.

Medicines used to relieve pain

The type of medicine and the way the medicine is
given depend on the type and cause of pain. For
example, chronic pain is best relieved by methods
that deliver a steady dose of pain medicine over a long
period of time, such as a patch that releases medicine
through the skin or slow (extended)-release pills. On
the other hand, breakthrough pain is best treated
with medicines that work fast (quick release), and stay
in the body only for a short time. Below is an overview
of the types of medicines used to relieve pain.

For mild to moderate pain

Non-opioids: Acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs), such as
aspirin and ibuprofen (Advil, Motrin), are often used.
You can buy many of these over the counter
(without a prescription). For others, you need a
prescription. Check with your doctor before using
these medicines. NSAIDs can slow blood clotting. This
may be a problem if youre having surgery or getting

Opioids or
narcotics are the
strongest pain
relievers available.
25

chemotherapy. NSAIDs and acetaminophen may also

affect other parts of the body and may interact with
other medicines.

For moderate to severe pain

Opioids (also known as narcotics): Morphine,
fentanyl, hydromorphone, oxycodone, codeine
and others
You need a written prescription for these medicines.
Non-opioids may be used along with opioids for
moderate to severe pain.

For breakthrough pain

Rapid-onset opioids: Fast-acting oral morphine;
fentanyl in a lozenge, sucker, or under-the-tongue
spray (These forms of fentanyl are absorbed from your
mouth they are not swallowed.)
You need a written prescription for these medicines. A
short-acting opioid, which relieves breakthrough pain
quickly, is often used with a long-acting opioid.

Many times the same opioid drug is used to treat both

the chronic and the breakthrough pain, so be sure you
know what youre taking. For example, hydrocodone
ER (Zohydro ER) may be for your chronic pain and
hydrocodone with acetaminophen (Lortab) is for your
breakthrough pain. Do not mix them up!
26

For tingling and burning pain

Antidepressants: Amitriptyline, nortriptyline,
venlafaxine, and others
You need a prescription for these medicines.
Antidepressants are prescribed to relieve certain
types of pain. Taking an antidepressant does not
mean that youre depressed or have a mental illness.
Anti-convulsants (anti-seizure medicines):
Carbamazepine, gabapentin, and others
You need a prescription for these medicines. Despite
the name, anti-convulsants are not only used for
convulsions (seizures), but also to control burning
and tingling (nerve) pain.

For pain caused by swelling or pressure

Steroids: Prednisone, dexamethasone
You need a prescription for these medicines. Theyre
most often used to lessen swelling, which often causes
pressure and pain.
27

How is pain medicine given?

Some people think that if their pain becomes severe,
theyll need to get injections or shots of pain
medicine. In fact, shots are rarely given to relieve
cancer pain. There are many other ways you can take
pain medicine.
Oral means the drug is taken by mouth, either by
being swallowed or absorbed in the mouth. Medicine
is given as a liquid, pill, capsule, or in transmucosal
form (the drug is in a lozenge, sucker, or spray and
absorbs directly through the tissues of the mouth).
Skin patch a clear, sticky patch placed on the skin.
It slowly but constantly releases medicine through the
skin for 2 to 3 days.
Rectal suppositories medicine that dissolves in the
rectum and is absorbed by the body
Injections
Subcutaneous (SC) injection Medicine is put just

under the skin using a small needle.

Intravenous (IV) injection Medicine goes right

into a vein through a needle, port, or catheter.

28

 Intrathecal and epidural injections Medicine

is put into the fluid around the spinal cord

(intrathecal) or into the space around the spinal
cord (epidural).
Pump, or patient-controlled analgesia (PCA)
With this method, you have control over the amount
of pain medicine you take. When you need pain
relief, you press a button to get a pre-set dose of pain
medicine through a computerized pump. (The pump
carefully controls how much you can get at a time,
so you cant take too much.) The pump is connected
to a small tube going into your body. The medicine
goes into a vein, just under the skin, or into the area
around the spine.

Never crush, break, or open extended-release pills

or capsules. Talk to your doctor if you have trouble
swallowing your pain medicines. There are many
different ways to take them.

29

Different ways to treat chronic

and breakthrough pain

Treating chronic pain

Drugs used to treat chronic or persistent pain need
to work for a long time. Theyre called long-acting or
extended-release drugs and are taken at regular times.
Theyre slowly released into the body and keep pain at
a lower level over a long period of time.
You take these pain medicines on a schedule even
if youre not having pain at the time the medicine is
due. By taking these drugs on a schedule, you can
maintain a fairly constant level of pain relief through
the day and night. These drugs may be given in the
form of tablets or capsules taken every 8 to 12 hours
or as a skin patch thats worn for several days. Again,
these drugs are taken on a schedule and not just when
youre in pain.

Treating breakthrough pain

Breakthrough pain is best treated with pain
medicines that work quickly and for a short period
of time. Theyre usually taken as needed, which
means that they should be taken as soon as you

30

You may want

to take a dose of
your breakthrough
medicine to prevent
pain before it starts
if you know that
youre likely to have
breakthrough pain
during or after a
certain activity.

notice breakthrough pain. These short-acting drugs

(sometimes called rescue medicines) work faster than
those used for chronic pain. They also stay in your
body for a shorter time and tend to cause fewer
side effects.
You should take your short-acting medicine when you
first notice pain, so that it can start to work to relieve
your pain right away. Do not let the pain build up and
become too severe it will be much harder to get
under control. Follow the directions given to you. If
the usual dose doesnt relieve your breakthrough pain,
or if you think youre having breakthrough pain too
often, tell your cancer care team. They may need to
adjust the dose or frequency of the medicine you take
for chronic pain.

31

Common questions
about breakthrough pain
If I have breakthrough pain, does it mean that
the pain medicine Im using regularly for my
chronic pain isnt working?
No. Breakthrough pain is an intense flare-up of
pain thats usually more severe than chronic pain.
Remember, breakthrough pain is common in people
with cancer pain. It can happen even when a person
is taking the right dose of pain medicine on a regular
schedule for their chronic pain.
Still, let your cancer care team know if youre having
more breakthrough flare-ups than usual, and just
how often you need your breakthrough medicine. You
may need a larger dose of your chronic pain medicine.
How can I be sure that Im getting the right
dose of breakthrough pain medicine?
Your breakthrough pain medicine should relieve
most of your breakthrough pain without causing
unacceptable side effects, such as extreme
drowsiness. If your breakthrough pain medicine
doesnt relieve the breakthrough pain or if you have
breakthrough pain more than 4 times a day, contact
your cancer care team. They may need to adjust your
dose or type of pain medicines to help you get the best
pain relief.

32

Can I take my chronic pain medicine and my

breakthrough pain medicine at the same time?
Yes, if you need to. You may have breakthrough pain
just before or after taking your regular (chronic)
pain medicine. At such times, you should take your
breakthrough pain medicine and keep taking your
chronic pain medicine on schedule. Always follow the
directions given to you by your cancer care team.
If you notice that you often have breakthrough pain
right before your usual dose of chronic pain medicine,
talk to your team. They may need to adjust the dose,
timing, or frequency of your chronic pain medicine.
If you have any questions about when to take either
your chronic or breakthrough pain medicines,
contact your team to discuss your pain medicine
schedule.
What if I need a different pain medicine?
If one medicine or treatment doesnt work, theres
almost always another one that can be tried. If the
schedule or way that youre taking medicine doesnt
work for you, it can be changed, too. Some pain
medicines cost more than others, and this may also
be an issue. Talk to your cancer care team about
finding the pain medicine and/or method that works
best for you.
You may need a different pain medicine, a
combination of pain medicines, or a change in the
dose or timing of your pain medicines if:
Your pain is not relieved.
33

 Your pain medicine doesnt start working within

the time your doctor said it would.

Your pain medicine doesnt work for the length of

time your doctor said it would.

You have breakthrough pain more than 4 times a

day, its getting worse, or its not relieved with the

short-acting medicine youre taking for it.
You have side effects. Side effects such as sleepiness,

nausea, and itching usually go away as your body

adjusts to the medicine. Let your cancer care team
know if these bother you.
You have serious side effects such as trouble

breathing, dizziness, and/or rashes. Call your

cancer care team right away if any of these start.
The schedule or the way youre taking the medicine

doesnt work for you.

Pain interferes with your normal activities, such as

eating, sleeping, working, and sex.

To help make the most of your pain control plan:
Take your pain medicine on a regular schedule

(around the clock) to help control chronic pain.

Take it when its time to take it even if youre not
having pain.
Do not skip doses of your scheduled medicine. The

more pain you have, the harder it is to control.

34

 If you have breakthrough pain, use your short-

acting medicine as instructed. Dont wait for the

pain to get worse if you do, it can be harder to
control.
Be sure only one doctor prescribes your pain

medicine. If another doctor changes your medicine,

the two doctors should discuss your treatment with
each other.
Dont run out of pain medicine. Remember that

prescriptions are needed for opioid pain medicines

they cant be called in and drugstores dont always
have them in stock. It can take a few days to get the
medicine, so give yourself time for delays.
Store pain medicines safely away from children,

pets, and others who might take them.

Never take someone elses medicine. Medicines that

helped a friend or relative may not be right for you.

Do not use old pain medicine or medicine left over

from other problems. Drugs that worked for you in

the past may not be right for you now.
Pain medicines affect different people in different

ways. A very small dose may work for you, while

someone else may need to take a much larger dose
to get pain relief.
Remember, your pain control plan can be changed

at any time.

35

Non-opioid pain medicines

Non-opioids control mild to moderate pain. Some
can be bought without a prescription. In many cases,
non-opioids are all youll need to relieve your pain,
especially if you stay on top of the pain by taking
them regularly. These medicines are stronger pain
relievers than most people realize.

Brand-name drugs and generic drugs

Drugs may have as many as 3 different names: brand,
generic, and chemical. Drug companies give their
products brand names, and some products have more
than one brand name. You should also know that the
same brand name may be used on different drugs,
since the name belongs to the company. Read the
labels to see what ingredients are in each medicine.
Chemical names are long and tend to be hard to
pronounce. The Food and Drug Administration (FDA)
approves the generic, shortened names by which
drugs are usually known. Heres an example:
Brand names: Tylenol, Tempra, Liquiprin,
Anacin, Paramol (and many more)
Generic name: acetaminophen
Chemical name: N-(4-hydroxyphenyl)
acetamide
36

Table 1. Common non-opioids Acetaminophen and NSAIDs and

their side effects
Type

Action

Side effects

Acetaminophen (Tylenol)

Reduces pain
and fever

Large doses (more than 4 grams in

24 hours) can damage the liver and/
or kidneys.
Use by people who have 3 or more
alcoholic drinks per day may cause
liver damage.
Acetaminophen reduces fever, so ask
your doctor what to do if your body
temperature is higher than normal
(98.6F or 37C) while you are taking
this medicine.

NSAIDs (Non-steroidal
anti-inflammatory drugs)
Over the counter:
Aspirin*
Ibuprofen (Motrin)
Naproxen sodium (Aleve or
Naprosyn)
Prescription:
Diclofenac (Voltaren)
Etodolac (Lodine)
Fenoprofen calcium (Nalfon)
Indomethacin (Indocin)
Ketorolac (Toradol)
Meclofenamate Nabumetone
(Relafen)
Naproxen (Naprosyn or
Anaprox)
Oxaprozin (Daypro)
Piroxicam (Feldene)
Sulindac (Clinoril)

Reduce pain,
inflammation,
and fever

Can irritate the stomach

Can cause bleeding of the stomach
lining, especially if combined with
alcohol or if you smoke
Can cause kidney problems
Avoid these drugs if you are on anticancer drugs that may cause bleeding,
or if you are taking blood thinners,
steroids, blood pressure medicines,
or lithium.
Aspirin and NSAIDs reduce fever, so
ask your doctor what to do if your
body temperature is higher than
normal (98.6F or 37C) while you are
taking one of these medicines.
NSAIDs may increase your risk of
stroke or heart attack.

* Children and teens should NOT take

aspirin or products that contain it.

37

Many pain relievers are available under both generic

and brand names. We have included some of the more
common generic names with their common brand
names in parentheses in Table 1. Your doctor, nurse,
or pharmacist can tell you the generic and common
brand names of any medicines youre taking. Its
always good to know both because you may hear
either name when talking about your medicines.
Knowing both names can also keep you from getting
confused when keeping track of prescriptions and pill
bottles. It can also keep you from taking too much of
the same medicine if its prescribed using 2 different
names.
Generic drugs usually cost less than brand-name
ones. Sometimes medicines can have the same generic
name, but are made by different companies. Because
the companies may produce the medicines differently,
they may differ slightly in the way theyre absorbed by
the body. For this reason, your doctor may sometimes
prefer that you take a brand-name drug. Ask your
doctor, nurse, or pharmacist if you can use a cheaper
generic medicine. Pharmacists are careful to get
high-quality generic products, so its often possible to
substitute a generic.
Along with the main substance (for example aspirin,
acetaminophen, or ibuprofen), some brands contain
substances called additives. Common additives
include:

38

 Buffers (such as magnesium carbonate or

aluminum hydroxide) to decrease stomach upset

Caffeine to act as a stimulant and help improve the

effect of some pain medicines

Antihistamines (such as diphenhydramine or

pyrilamine) to help you relax or sleep

Medicines with additives can cause side effects you
wouldnt expect from the main drug. For example,
antihistamines sometimes cause drowsiness. This
may be all right at bedtime, but it could be a problem
during the day. Also, additives tend to increase the
cost of non-prescription pain relievers. They can also
change the action of other medicines you may be
taking or even keep your body from absorbing the
other drug. When you start a new drug, even one you
can get over the counter, always talk with your doctor
or pharmacist about what youre already taking to see
if the combination can cause harmful effects.
Plain aspirin, acetaminophen, or ibuprofen probably
works as well as the same medicines with additives.
But if you find that a brand with certain additives
is a better pain reliever, ask your doctor, nurse, or
pharmacist if the additives are safe for you. Talk
with them about any concerns you may have about
the drugs contained in your non-prescription pain
medicines.

39

Non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs)
work a lot like aspirin (see list in Table 1 on page 37).
Either alone or used with other medicines, NSAIDs
can help control pain. Before you take any NSAIDs
or other non-opioids, ask your doctor, pharmacist,
or nurse if its safe for you to take it with your other
medicines, and how long you can take it.
Precautions when taking NSAIDs
Some people are at increased risk of complications
related to NSAIDS. In general, NSAIDs should be
avoided by people who:
Are allergic to aspirin or any other NSAIDs
Are on chemotherapy
Are taking steroids
Are taking blood pressure medicines
Have stomach ulcers or a history of ulcers, gout, or

bleeding disorders
Are taking oral medicine (drugs by mouth) for

diabetes or gout
Have kidney problems
Will have surgery within a week

40

Talk to your doctor, nurse, or pharmacist about

how to take your medicine.

Are taking blood-thinning medicine

Are taking lithium

Be careful about mixing NSAIDs with alcohol

taking NSAIDs and drinking alcohol can cause
stomach upset and raise the risk of bleeding in
the stomach. Smoking may also increase this risk.
NSAIDs may also raise your risk of heart attack or
stroke, especially if you take them a long time.
Children and teens should not take aspirin or
products that contain it.

41

Side effects of NSAIDs

The most common side effect from NSAIDs is upset
stomach, especially in older people. Taking NSAIDs
with a snack or just after a meal may lessen your
chance of stomach problems. Ask your pharmacist to
tell you which NSAID products are less likely to upset
your stomach.
NSAIDs also keep platelets from working the way they
should. Platelets are the blood cells that help blood
clot after an injury. When platelets dont work like
they should, it takes a longer time to stop bleeding.
If your stools become darker than normal or if you
notice unusual bruising both signs of bleeding tell
your doctor or nurse.
Other side effects include kidney problems and
stomach ulcers. NSAIDs can sometimes cause people
to retain fluids and worsen heart failure. They also
can affect the actions of other drugs. There are
other less common side effects of many NSAIDs that
happen in some people.

Acetaminophen
This medicine relieves pain much the same way
NSAIDs do, but it doesnt reduce inflammation as well
as NSAIDs. People rarely have side effects from the
usual dose of acetaminophen. But liver and kidney
damage may result if you use large doses of this
medicine every day for a long time or drink alcohol

42

with the usual dose. Even moderate amounts of

alcohol (3 drinks per day) can lead to liver damage
in people taking acetaminophen. You also need to
be careful about taking other drugs with added
acetaminophen. See Aspirin, acetaminophen, and
ibuprofen in other medicines.
Your doctor may not want you to take acetaminophen
regularly if youre getting chemotherapy because it
can cover up a fever. Your doctor needs to know about
any fever because it may be a sign of infection, which
needs to be treated.

Aspirin, acetaminophen,
and ibuprofen in other medicines
Some opioid medicines also contain aspirin or
acetaminophen (Tylenol) in the same pill. A few also
contain ibuprofen. This can pose dangers for people
who take these drugs without knowing about the
extra medicine.
If one of your doctors tells you not to take aspirin
or ibuprofen, or if you cant take NSAIDs for some
reason, be sure to check your medicine labels
carefully.
If one of your prescription medicines has
acetaminophen in it, and you also take over-thecounter acetaminophen for pain, you can get too
much without knowing it. Too much acetaminophen
can damage your liver.
43

If youre not sure if a medicine contains aspirin,

acetaminophen, or ibuprofen, ask your pharmacist.
If you take any non-prescription medicine for a cold,
sinus pain, or menstrual symptoms while youre
taking pain medicines, read the label carefully. Most
of these drugs are combination products that contain
aspirin, ibuprofen, or acetaminophen. Check with a
pharmacist to find out what you can safely take with
your pain medicines.

44

Opioid pain medicines

These medicines are used alone or with non-opioids
to treat moderate to severe pain. Opioids are much
like natural substances (called endorphins) made by
the body to control pain. These medicines were once
made from the opium poppy, but today many are
synthetic, that is, theyre man-made in a lab.

Common opioids by generic name

Here are some of the opioids used in cancer care.
The more common brand names are added in
parentheses. An ER behind the name of any of
these drug names stands for extended release, and
is a sign that the drug is taken on a regular schedule
to treat chronic pain.
Codeine*
Hydromorphone (Dilaudid)
Levorphanol (Levo-Dromoran)
Methadone (Dolophine, Methadose)
Morphine (Apokyn, Avinza, Kadian, MS-Contin,

and others)
Oxycodone* (OxyContin, OxyIR, Roxicodone)
Hydrocodone*
Oxymorphone (Opana)

45

 Fentanyl (Duragesic, Actiq, Fentora, Lazanda, and

others)
*Common combination opioid and
acetaminophen or NSAID drugs:
Codeine may be added to aspirin or

acetaminophen. For instance, Fiorinal with codeine

has aspirin; Fioricet with codeine, Tylenol #3, and
Tylenol #4 all contain acetaminophen.
Oxycodone may be added to aspirin,

acetaminophen, or ibuprofen. For instance,

Percodan has aspirin in it; Percocet, Roxicet,
Roxilox, Oxycet, and Tylox all have acetaminophen;
Combunox has ibuprofen.
Hydrocodone may be added to acetaminophen

or ibuprofen. For instance, Zydone, Norco, and

Lortab all contain acetaminophen; Vicoprofen and
Reprexain have ibuprofen

Opioid tolerance
People who take opioids for pain sometimes find that
over time they need to take larger doses. This may be
due to an increase in the pain or the development of
drug tolerance. Drug tolerance is when your body gets
used to the opioid youre taking, and it takes more
medicine to relieve the pain as well as it once did.
Many people do not develop a tolerance to opioids.
But if tolerance does develop, usually small increases
in the dose or a change in the kind of medicine will
help relieve the pain.
46

If youre taking
a combination
pain medicine,
be sure you know
what drugs are in
each pill.

Increasing the doses of opioids to relieve increasing

pain or to overcome drug tolerance does NOT mean
that a person is addicted.

How to get proper pain relief

with opioids
When a medicine doesnt give you the pain relief you
need, your doctor may prescribe a higher dose or tell
you to take it more often. When your cancer care
team is working closely with you, doses of strong
opioids can be raised safely to ease severe pain. Do
not increase the dose of your pain medicine on your
own. If dose changes dont work, your doctor may
prescribe a different drug or add a new drug to the
one youre taking.
If your pain relief isnt lasting long enough, ask your
doctor about extended-release medicines that come
47

in pills and patches. These can control your pain for a

longer period of time.
If your pain is controlled most of the time, but you
sometimes have breakthrough pain, your doctor may
prescribe a fast-acting medicine or immediate-release
opioid that will give you faster pain relief right when
its needed.

Be safe when taking opioids.

Doctors carefully watch you and adjust the doses of
pain medicine so you dont take too much. For this
reason, its important that only one doctor prescribe
your pain medicines. If youre working with 2 or more
doctors, be sure that one does not prescribe opioids
for you without talking to the others about it.
If you drink alcohol or take tranquilizers, sleeping
pills, antidepressants, antihistamines, or any other
medicines that make you sleepy, tell your doctor
how much and how often you do this. Combinations
of opioids with alcohol or tranquilizers can be
dangerous. Even small doses may cause problems.
Using such combinations can lead to overdoses and
symptoms such as weakness, trouble breathing,
confusion, anxiety, or more severe drowsiness or
dizziness.

48

Side effects of opioids

Not everyone has side effects from opioids. The
most common side effects are usually drowsiness,
constipation, nausea, and vomiting. Some people
might also have dizziness, itching, mental effects
(such as nightmares, confusion, and hallucinations),
slow or shallow breathing, or trouble passing urine.
Many side effects from opioid pain medicine can be
prevented. Some of the mild ones such as nausea,
itching, or drowsiness, often go away without
treatment after a few days, as your body adjusts to the
medicine. Let your cancer care team know if youre
having any side effects and ask for help in managing
them.
Here are a few of the more common side effects:
Drowsiness
When you first start taking them, opioids may cause
drowsiness, but this usually goes away after a few
days. If your pain has kept you from sleeping, you
may sleep more for a few days after starting opioids
while you catch up on your sleep. Drowsiness will
also lessen as your body gets used to the medicine.
Call your cancer care team if you still feel too sleepy
for your normal activities after youve been taking the
medicine for a week.

49

Sometimes it may be unsafe for you to drive a car,

or even to walk up and down stairs alone. Do not do
anything that requires you to be alert until you know
how the medicine affects you.
Here are some ways to handle drowsiness:
Wait a few days and see if it goes away.
Check to see if other medicines youre taking can

also cause drowsiness.

Ask the doctor if you can take a smaller dose more

often or an extended-release opioid.

If the opioid is not relieving the pain, the pain itself

may be tiring you out. In this case, better pain relief

may lead to less drowsiness. Ask your cancer care
team what you can do to get better pain relief.
Sometimes a small decrease in the dose of an

opioid will still relieve your pain without causing

drowsiness. If the drowsiness is very bad, you may
be taking more medicine than you need. Talk to
your doctor about lowering the amount youre
taking.
Ask your doctor about changing to a different

medicine.
Ask your doctor if you can take a mild stimulant

such as caffeine during the day.

50

 If drowsiness is bad or if it suddenly starts to be a

problem after youve been taking opioids for a while,

call your cancer care team right away.
Constipation
Opioids cause constipation in most people. This is
because opioids slow the movement of stool through
the intestinal tract, which allows more time for water
to be absorbed by the body. The stool then becomes
hard. Its best to start a laxative, stool softener, or
other treatment to keep your bowels moving when
you start taking opioids. Constipation can often be
prevented or controlled.
After checking with your cancer care team, try the
following to prevent constipation:
Talk with your team about stool softeners and

laxatives. Ask how often and how much you should

take.
Drink plenty of liquids. Eight to 10 8-ounce glasses

of fluid each day can help keep your stools soft. This
is a very important step if your stool is dry, it will
be hard to pass.
Eat foods high in fiber or roughage such as

uncooked fruits (with the skin on), vegetables, and

100% whole-grain breads and cereals.
Add 1 or 2 tablespoons of unprocessed bran to

your food. This adds bulk and promotes bowel

movements. Keep a shaker of bran handy at
51

mealtimes to make it easy to sprinkle on foods. Be

sure to drink plenty of water when you eat bran so
that it softens in the bowel.
Exercise as much as you can. Talk with your doctor

about what kind of exercise is best for you. Walking

is often a good start if you havent exercised
recently.
Eat foods that have helped you relieve constipation

in the past.
If you havent been getting out of bed, try to use the

toilet or bedside commode when you have a bowel

movement, even if thats the only time you get out
of bed.
If youre still constipated after trying all the above
measures, ask your doctor about changing your stool
softener or laxative. Check with your cancer care
team before taking any laxative or stool softener on
your own. If you havent had a bowel movement for 2
days or more, call your team.
Nausea and vomiting
Nausea and vomiting caused by opioids will usually
go away after a few days of taking the medicine. These
tips may help:
If you have more nausea when youre up or walking

around but not when youre lying down, stay in bed

for an hour or so after you take your pain medicine.
This type of nausea is like motion sickness.

52

Sometimes over-the-counter medicines such as

meclizine (Bonine or Antivert) or dimenhydrinate
(Dramamine) help this type of nausea. Check with
your cancer care team before taking these medicines,
since they can cause problems for some people.
If pain itself is causing the nausea, using opioids to

relieve the pain usually makes the nausea go away.

Medicines that relieve nausea can be prescribed if

you need them. Talk with your cancer care team if

you cant hold down foods or liquids for a full day, or
if nausea lasts more than a few days.
Ask your team if the cancer, another medical

problem, steroids, chemo, or other medicines might

be causing your nausea. Constipation may also
worsen nausea.
Some people think theyre allergic if they have nausea
after they take an opioid. Nausea and vomiting alone
usually are not allergic reactions. But a rash or itching
along with nausea and vomiting may be an allergic
reaction. If this happens, stop taking the medicine
and call your cancer care team right away. If you have
swelling in your throat, hives (itchy welts on the skin),
and/or trouble breathing, get help right away.

When you no longer need opioids

You should not suddenly stop taking opioids. People
who stop taking opioids are usually tapered off
the medicine slowly so that their bodies have time

53

to adjust. If you stop taking opioids suddenly and

develop a flu-like illness, excessive sweating, diarrhea,
or any other unusual reaction, tell your cancer care
team. These symptoms can be treated and tend to
go away in a few days to a few weeks. Again, slowly
decreasing your opioid dose over time usually keeps
these kinds of symptoms from happening. Check with
your doctor about the best dose schedule for tapering
off your pain medicines.

54

Other types of pain medicine

Many different types of medicines can be used along

with (or instead of) opioids to help relieve cancer
pain. Some of these medicines relieve pain or increase
the effect of opioids. Others lessen the side effects of
opioids. These drugs are often started at low doses
and increased over time. Table 2 on page 56 shows the
classes of non-opioid drugs that your doctor might
prescribe to help you get the best pain relief with as
few side effects as possible.

55

Table 2. Other medicines commonly used to relieve cancer pain

56

Drug class

Generic (brand)
name

Action

Side effects

Antidepressants

aamitriptyline
(Elavil),
imipramine
(Tofranil),
nortriptyline
(Pamelor),
desipramine,
duloxetine
(Cymbalta),
venlafaxine
(Effexor)

Used to treat tingling

or burning pain from
damaged nerves.
Nerve injury (and nerve
pain) can be caused
by surgery, radiation,
chemo, or the cancer
itself.

Dry mouth, blurred vision,

trouble passing urine,
sleepiness, constipation
Drop in blood pressure
with dizziness or fainting
when standing. May
cause irregular heartbeat,
especially in patients with
heart disease.

Antihistamines

hydroxyzine
(Atarax, Vistaril),
diphenhydramine
(Benadryl)

Can help control

nausea and help people
sleep. Can help control
itching.

Drowsiness, dry mouth

and nose, irritability,
restlessness, nervousness,
trouble passing urine

Anti-anxiety
drugs

diazepam (Valium),
lorazepam (Ativan)

Used to treat muscle

spasms that may go
along with severe pain.
Also lessens anxiety.

Drowsiness. May cause

urinary incontinence (loss
of bladder control).

Stimulants and
amphetamines

caffeine, dextro
amphetamine
(Dexedrine),
methylphenidate
(Ritalin), modafinil
(Provigil)

Increase the painrelieving action of

opioids and reduce the
drowsiness they cause

Irritability, rapid
heartbeat, decreased
appetite

Anticonvulsants

carbamazepine
(Tegretol),
clonazepam
(Klonopin),
gabapentin
(Neurontin),
pregabalin (Lyrica)

Help to control tingling

or burning from
nerve pain caused by
the cancer or cancer
treatment

Liver problems, low red

and white blood cell
counts. Some may cause
sleepiness and dizziness.

Steroids

dexamethasone
(Decadron),
prednisone

Help relieve bone pain,

pain caused by spinal
cord and brain tumors,
and pain caused by
inflammation

Increased appetite and

thirst. Fluid build-up in
the body, increased blood
sugar, stomach irritation,
confusion. Changes
in behavior, trouble
sleeping.

Other medical methods

to relieve pain
Some people have pain thats not relieved by drugs
or non-medical methods. When this happens, other
treatments can often be used to help reduce pain.

Stopping pain impulses from going

through the nerves
Surgery
Pain cant be felt if the nerve pathways that carry
pain impulses or signals to the brain are interrupted.
To block these pathways, a neurosurgeon may cut
nerves, usually near the spinal cord. When the nerves
that relay pain are cut, feelings of pain, pressure, and
temperature can no longer be felt the area becomes
numb. Only surgeons with special skills, who are also
experts in pain management, should do this kind of
surgery. These surgeons normally work with other
pain specialists to explore other methods of pain
control before they cut nerves this treatment cant be
reversed.
Nerve block
A nerve block is a procedure where a local anesthetic
(a numbing drug), often combined with a steroid,
is injected into or around a nerve or into the space
around the spinal cord to block pain. After the
injection, the nerve is no longer able to relay pain so the
pain is relieved for some time. For longer-lasting pain
relief, phenol or alcohol can be injected. A nerve block
57

may cause muscle paralysis or a loss of all feeling in the

affected area.
Spinal analgesia
Low doses of pain medicine may be injected into the
fluid around the spine (called intrathecal injection). If this
works, a tube and a pump may be used to deliver the pain
medicine right into the spinal fluid to control the pain.
Morphine is often used for this purpose, and you can still
have side effects like itching and constipation. Surgery is
done to put the small pump and tube into your body.
Epidural
Certain kinds of pain may respond to pain medicine
thats injected into the space around the layers of
the spine. If this works, a pump can be implanted
so that you can get pain medicines right around the
nerves. This may cause numbness or weakness of the
treated area.

More cancer treatment may be given

to shrink the tumor.
Sometimes, even when cancer treatment cant cure the
cancer, it can shrink the size of a tumor thats pressing
on nerves and organs and causing pain. Chemo,
hormone therapy, or radiation may be used in this way.
Radioactive injections are sometimes used when the
cancer has spread to many places in the bone the
radioactive drug settles in the bones near the cancer
and helps to stop its growth and relieve pain. In a few
cases, other treatments like radiofrequency ablation can
58

be used in certain areas of the body. In this treatment,

electrodes are put in near the tumor to heat and destroy
the cancer.
Call us or go to our website if youd like to learn more
about any of these pain treatments.

59

Non-medical treatments
for pain
Non-medical treatments may be used along with pain
medicine, though they can also be used alone for mild
pain or discomfort. Some people find they can take a
lower dose of pain medicine when they also use nonmedical treatments. These methods include things
like relaxation, biofeedback, imagery, distraction,
hypnosis, skin stimulation, transcutaneous electric
nerve stimulation (TENS), acupuncture, exercise
or physical therapy, and emotional support and
counseling.
We give you some basic tips here, but you may need
the help of health professionals social workers,
physical therapists, psychologists, nurses, or others
to learn to use these techniques. Family and friends
can also help. To find someone who specializes in
these techniques or learn more about them:
Talk with your doctor or nurse.
Contact a local hospice, cancer treatment center, or

pain clinic.
Visit your local bookstores or library.

You can also contact the National Center for

Complementary and Alternative Medicine
Clearinghouse to learn more about these techniques.
(See the To learn more about cancer pain section on
page 78 for contact information.)
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Pain may be a sign that the cancer has spread, an

infection has started, or there are problems caused
by the cancer treatment. Because of this, you should
report any new pain problems to your cancer care
team before trying any medical or non-medical
treatments to relieve the pain on your own.
Some general guidelines for managing pain with nonmedical methods include:
Try using a non-medical method along with your

regular pain medicines. For instance, you might use

a relaxation technique (to lessen tension, reduce
anxiety, and manage pain) at the same time you
take medicine.
Know yourself and what you can do. Often when

people are rested and alert, they can use a method

that demands more attention and energy. When
tired, people may need to use a method that
requires less effort. For example, try distraction
when you are rested and alert; use hot or cold packs
when youre tired.
Try different methods to learn which ones work for

you. Be open-minded, and keep a record of what

makes you feel better and what doesnt help.

Relaxation
Relaxation helps relieve pain and/or keep it from
getting worse by reducing muscle tension. It can help
you fall asleep, give you more energy, make you less

61

tired, reduce your anxiety, and help other pain-relief

methods work better.
How to use relaxation
Relaxation may be done sitting up or lying down.
Choose a quiet place whenever possible. Close your
eyes. Do not cross your arms and legs because
that may cut off circulation and cause numbness
or tingling. If youre lying down, be sure you are
comfortable. Put a small pillow under your neck and
under your knees or use a low stool to support your
lower legs.
You can also ask your cancer care team to recommend
relaxation CDs for you. These recordings provide stepby-step instructions in relaxation techniques.
There are many relaxation methods. Here are some
for you to try:
Visual concentration and rhythmic massage:
Open your eyes and stare at an object, or close your

eyes and think of a peaceful, calm scene.

With the palm of your hand, firmly massage near

the area of pain in a circular movement. Avoid red,

raw, or swollen areas. A family member or friend
can do this for you.
Inhale/tense, exhale/relax:
Breathe in deeply. At the same time, tense your

muscles or a group of muscles. For example, you can

squeeze your eyes shut, frown, clench your teeth,
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make a fist, stiffen your arms and legs, or draw up

your arms and legs as tightly as you can.
Hold your breath and keep your muscles tense for a

second or two.
Let go. Breathe out and let your body go limp.

Slow, rhythmic breathing:

Stare at an object or close your eyes and focus on

your breathing or on a peaceful scene.

Take a slow, deep breath and, as you breathe in,

tense your muscles (such as your arms).

As you breathe out, relax your muscles and feel the

tension draining.
Now stay relaxed and begin breathing slowly and

comfortably. Focus on your breathing, taking about

9 to 12 breaths a minute. Breathing too fast or too
deeply can cause dizziness or other symptoms.
To keep a slow, even rhythm as you breathe out,

you can say silently to yourself, In, 1, 2; out, 1, 2. It

may be helpful at first if someone counts out loud
for you. If you ever feel out of breath, take a deep
breath and then continue the slow breathing. Each
time you breathe out, feel yourself relaxing and
going limp. If some muscles, such as your shoulder
muscles, arent relaxed, tense them as you breathe
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in and relax them as you breathe out. Do this only

once or twice for each muscle group.
Continue slow, rhythmic breathing for a few

seconds up to 10 minutes, depending on your need.

To end your slow, rhythmic breathing, count silently

and slowly from 1 to 3. Open your eyes. Say silently

to yourself, I feel alert and relaxed. Begin moving
about slowly.
Precautions
Some people who have used relaxation for pain relief
have noticed some common problems and have made
these suggestions:
Relaxation may be hard to use when you have

severe pain. Try quick and easy relaxation methods

such as rhythmic massage or breathe in/tense,
breathe out/relax. Or you can wait until your pain
medicine starts working before you start with the
relaxation methods.
Sometimes breathing too deeply for a while can

make you feel short of breath. If this happens, take

shallow breaths and/or breathe more slowly.
You may fall asleep. This can be a good thing if

youre ready to go to bed. If you dont want to fall

asleep, sit in a hard chair while doing the relaxation
exercise or set a timer or alarm.

64

If you have trouble using these methods, ask your

cancer care team to refer you to someone experienced
in relaxation techniques. Do not keep using any
technique that increases your pain, makes you feel
uneasy, or causes unpleasant effects.

Biofeedback
Youll need the help of a licensed biofeedback
technician to learn this technique. With the help of
special machines that give you instant feedback on
the state of your body, you can learn to control certain
body functions such as heart rate, blood pressure,
and muscle tension. Biofeedback is sometimes used
to help people learn to relax and cope with pain.
This technique is usually used with other pain-relief
methods.

Imagery
Imagery is using your imagination to create mental
pictures or situations. The way imagery relieves pain
is not fully understood, although it may be simply a
combination of relaxation and distraction. Imagery
can be thought of as a deliberate daydream that uses
all of your senses sight, touch, hearing, smell, and
taste. Some people believe that imagery is a form of
self-hypnosis.
Certain images may reduce your pain both during
imagery and for hours afterward. If you must stay
in bed or cant leave the house, you may find that
imagery helps you feel less closed in you can
65

imagine and revisit your favorite spots in your mind.

Imagery can help you relax, relieve boredom, decrease
anxiety, and help you sleep.
How to use imagery
Imagery usually works best with your eyes closed. The
image can be something like a ball of healing energy
moving through your body, or a picture drawn in
your mind of yourself as a person without pain. (For
example, imagine that youre cutting the wires that
send pain signals from each part of your body to your
brain.) Or think of a pleasant, safe, relaxing place or
activity that has made you happy. Exploring this place
or activity in your mind can help you feel calm.
Heres an exercise with the ball of energy.
Close your eyes. Breathe slowly and feel yourself

relax.
Focus on your breathing. Breathe slowly and

comfortably from your abdomen (belly). As you

breathe in, say silently and slowly to yourself, In,
1, 2. As you breathe out, say, Out, 1, 2. Breathe in
this slow rhythm for a few minutes.
Imagine a ball of healing energy forming in your

lungs or on your chest. It may be like a white light.

It can be vague it doesnt have to be clear or vivid.
Imagine this ball forming, taking shape.
When youre ready, imagine that the air you breathe

in blows this healing ball of energy to the area of

66

your pain. Once there, the ball heals and relaxes

you.
When you breathe out, imagine the air blows the

ball away from your body. As it goes, the ball takes

your pain with it.
Repeat the last 2 steps each time you breathe in and

out.
You may imagine that the ball gets bigger and

bigger as it takes more and more discomfort away

from your body.
To end the imagery, count slowly to 3, breathe in

deeply, open your eyes, and say silently to yourself,

I feel alert and relaxed. Begin moving about
slowly.
Problems that may occur with imagery are much like
the ones that occur with the relaxation techniques.

Distraction
Distraction means turning your attention to
something other than the pain. People often use
this method without realizing it when they watch
television or listen to music to take their minds off
a worry.
Distraction may be used alone to manage mild pain
or used with medicine to manage brief bouts of severe
pain, such as pain related to procedures. Distraction

67

is useful when youre waiting for pain medicine to

start working.
How to use distraction
Any activity that you must focus on can be used for
distraction. Distractions can be internal, such as
counting, singing to yourself, praying, or repeating
statements in your head such as I can cope. Or
distractions can be external, such as needlework,
model building, or painting. Losing yourself in a good
book might divert your mind from pain. Watching
TV and listening to music are also good distractions.
Slow, rhythmic breathing can be used along with
distraction to help you relax. Visiting with friends or
family is another useful distraction technique.
You may find it helpful to listen to rather fast music
through a headset or earphones. To help keep your
attention on the music, tap out the rhythm. This
technique doesnt require much energy, so it may be
useful when youre tired.
After using some distraction techniques, people have
reported feeling tired, irritable, and in more pain. If
this happens to you, try different techniques, and use
them only when you have mild pain.

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Hypnosis
Hypnosis is the trance-like state of high concentration
in which you are awake but calm and still. In this
relaxed state, people might become more open
to suggestion. Hypnosis can be used to blunt the
awareness of pain, to substitute another feeling for
the pain, or to change the feeling to one thats less
painful. You can be hypnotized by a person trained in
hypnosis, often a psychologist, psychiatrist, or other
mental health therapist. You can also be taught to
hypnotize yourself.
During hypnosis, many people feel much like we
do when we begin to wake up in the morning. Even
with our eyes closed, we are very aware. We can hear
sounds inside or outside our house. We may feel as
though we either cant or dont want to wake up and
open our eyes.
A trained hypnotherapist can teach people to
put themselves in a hypnotic state, make positive
suggestions to themselves, and leave the hypnotic
state when theyre ready.
Choose a hypnotherapist whos licensed in the healing
arts or who works under the supervision of someone
who is licensed. To find a therapist skilled in hypnosis,
ask your cancer care team, or contact a large cancer
center near you.

69

Massage can lessen or block the feeling of pain.

Skin stimulation
In this series of techniques, pressure, warmth, or cold is
used on the skin, while the feeling of pain is lessened or
blocked. Massage, pressure, vibration, heat, cold, and
menthol preparations can also be used to stimulate
the skin. These techniques also change the flow of
blood to the area thats stimulated. Sometimes skin
stimulation will get rid of pain or lessen pain during
the stimulation and for hours after its finished.
Skin stimulation is done either on or near the area
of pain. You can also use skin stimulation on the
side of the body opposite the pain. For example, you
might stimulate the left knee to decrease pain in the
right knee.
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What you should know about skin stimulation

If youre getting radiation therapy, check with your
cancer care team before using skin stimulation. You
shouldnt put ointments, salves, menthol, or liniments
on the treatment area, and you shouldnt use heat
or extreme cold on treated areas. If youre getting
chemotherapy, check with your team before using hot
or cold packs.
Massage: Using a slow, steady, circular motion,
massage over or near the area of pain with just your
bare hand or with any substance that feels good,
such as talcum powder, warm oil, or hand lotion.
Depending on where your pain is, you may do it
yourself or get help from a family member, friend, or
a massage therapist. Some people find brushing or
stroking lightly feels better than deep massage. Use
whatever works best for you.
Precautions: If youre getting radiation therapy,
avoid massage in the treatment area as well as in
any red, raw, tender, or swollen areas.
Pressure: To use pressure, press on various areas over
and near your pain with your entire hand, the heel of
your hand, your fingertip or knuckle, the ball of your
thumb, or by using one or both hands to encircle your
arm or leg. You can test this by applying pressure for
about 10 seconds to see if it helps. You can also feel
around your pain and outward to see if you can find
trigger points, small areas under the skin that are
71

very sensitive or that cause more pain. Sometimes

gradual pressure on the trigger points helps to relieve
pain. Pressure usually works best if its applied as
firmly as possible without causing more pain. You can
use pressure for up to 1 minute. This often will relieve
pain for several minutes to many hours after the
pressure is released.
Vibration: Vibration over and near the area of the
pain may bring short-term relief. For example, the
scalp attachment of a hand-held vibrator often
relieves a headache. For low back pain, a long, slender
battery-operated vibrator placed at the small of the
back may be helpful. You can use a vibrating device
such as a small battery-operated vibrator, a hand-held
electric vibrator, or a large heat-massage electric pad.
Precautions: If youre getting radiation therapy,
avoid vibration in the treatment area. Do not use a
vibrator on the stomach or over red, raw, tender, or
swollen areas.
Cold or heat: Heat often relieves sore muscles. Cold
can lessen the feeling of pain by partly numbing the
painful area. You can also switch back and forth
between heat and cold for added relief in some cases.
For cold, try gel packs that are sealed in plastic and
stay soft and flexible even when frozen. You can get
them at drugstores and medical supply stores. They
can be stored in the freezer and reused. You may
want to wrap the pack in a towel to make it more
72

comfortable. An ice pack, ice cubes wrapped in a towel,

frozen peas, or water frozen in a paper cup also works.
Precautions: If you start to shiver when using
cold, stop right away. Do not use cold so intense or
for so long that the cold itself causes more pain.
Avoid cold over any area where you are getting
radiation treatments and for 6 months after it has
ended.
If youre getting chemotherapy, check with your
cancer care team before using a cold pack.
Do not use cold over any area where your
circulation or sensation is poor.
Do not apply cold for more than 5 to 10 minutes at
a time.
To use heat for pain relief, a heating pad with a
moisture option is handy. You can also try gel packs
warmed in hot water; hot water bottles; a hot, moist
towel; a regular heating pad; or a hot bath or shower.
You might want to try one of the heat patches you can
buy at the drugstore. For aching joints, such as elbows
and knees, wrap the joint in a lightweight plastic
wrap (tape the plastic to itself). This retains body heat
and moisture.

73

Precautions: Do not use a heating pad on bare

skin. Do not fall asleep with the heating pad
turned on. Be very careful if you are taking
medicines that make you sleepy or if you dont
have much feeling in the area.
Do not use heat over a new injury because heat
can increase bleeding.
Avoid heat over any area where youre getting
radiation treatments and for 6 months after
treatment has ended.
Do not use heat over any area where your
circulation or sensation is poor.
Do not apply heat for more than 5 to 10 minutes at
a time.
Menthol: Many menthol preparations creams,
lotions, or gels are available for pain relief. When
theyre rubbed into the skin, they increase blood
circulation to the affected area and produce a warm
(or sometimes cool) soothing feeling that lasts for
several hours.
To use menthol, test your skin by rubbing a small
amount of the substance in a circle about the size of a
quarter in the area you want to treat. This will let you
know if menthol is uncomfortable to you or irritates
your skin. If the menthol doesnt cause a problem, rub

74

some more into the area. The feeling from the menthol
slowly increases and lasts up to several hours.
Precautions: Do not rub menthol near your
eyes, or over broken skin, a skin rash, or mucous
membranes (such as inside your nose or mouth, or
around your genitals and rectum).
Make sure you do not get menthol in your eyes.
Wash your hands well with soap and warm water
after using menthol.
Do not use menthol on the skin of the treatment
area during radiation therapy.
Transcutaneous electric nerve stimulation
(TENS): This is a technique in which mild electric
currents are applied to some areas of the skin through
electrodes attached to a small power pack. The feeling
is described as a buzzing, tingling, or tapping feeling.
The small electric impulses seem to interfere with
pain sensations for some people. The current can be
adjusted so that the sensation is comfortable or even
pleasant. Your doctor or a physical therapist can tell
you where to get a TENS unit, and how to use it.

Acupuncture
In acupuncture, very thin needles are put into the
body at certain points and at various depths and
angles. Each point is thought to control the feeling of
pain in a different part of the body. When the needle
75

In support groups,
people meet and
share their feelings
about how they
cope with cancer.

is put in, some people feel a slight ache, dull pain,

tingling, or electrical sensation for a few seconds.
Once the needles are in place, they shouldnt hurt.
The needles are usually left in for 15 to 30 minutes.
It doesnt hurt when the needles are removed.
Acupuncture is now widely available, but it should
only be done by a licensed, certified acupuncturist.
Ask your cancer care team where to get acupuncture.
Precaution: If you are getting chemotherapy, talk
to your doctor before starting acupuncture.

Emotional support and counseling

If you feel anxious or depressed, your pain may
feel worse. Pain also can make you feel worried,
depressed, or easily discouraged. Some people feel
hopeless or helpless. Others may feel embarrassed,
inadequate, angry, frightened, lonely, or frantic. These
are all normal feelings.

76

Finding support
Try to talk about your feelings with someone you feel
comfortable with doctors, nurses, social workers,
family or friends, a member of the clergy, or other
people with cancer. You may also wish to talk to
a counselor or a mental health professional. Your
cancer care team can help you find a counselor who is
specially trained to help people with chronic illnesses.
You may want to try a support group where people
with cancer meet and share their feelings. Support
groups can be face-to-face meetings, or you can meet
in a group online. For information about support
groups in your community and online, ask your
cancer care team or call us at 1-800-227-2345. Also,
many newspapers carry a special health supplement
with information about where to find local support
groups.

77

To learn more about cancer pain

More information from your
American Cancer Society
Here is more information you might find helpful. You
can read these on our website, www.cancer.org, or
order free copies from our toll-free number at 1-800227-2345.
Pain Diary
Peripheral Neuropathy Caused by Chemotherapy
Coping With Cancer in Everyday Life (also in Spanish)
Caring for The Patient With Cancer At Home: A Guide
for Patients and Families (also in Spanish)
Bone Metastasis (also in Spanish)
Advanced Cancer (also in Spanish)
Health Professionals Associated With Cancer Care

78

National organizations and websites*

Along with the American Cancer Society, there are
many other sources of information about cancer and
pain, including those listed here.
American Academy of Pain Medicine (AAPM)
Telephone: 847-375-4731
Website: www.painmed.org
Offers free general pain information and the Find
a Physician tool to help find pain specialists by
city and state.
City of Hope Pain/Palliative Care Resource Center
(COHPPRC)
Website: http://prc.coh.org
Has many articles and materials focused on
quality pain management, as well as pain
assessment tools and information on non-drug
pain relief measures
National Cancer Institute
Toll-free number: 1-800-422-6237 (1-800-4-CANCER)
TTY: 1-800-332-8615
Website: www.cancer.gov
Provides accurate, up-to-date information on
cancer to patients, their families, and the general
public. Information specialists translate the
latest scientific information into understandable
79

language and respond in English, Spanish, or on

TTY equipment.
National Center for Complementary and
Integrative Health (NCCIH)
Toll-free number: 1-888-644-6226
TTY: 1-866-464-3615
Website: http://nccam.nih.gov
Part of the National Institutes of Health (NIH),
NCCIH facilitates research and evaluation of
complementary and alternative medicine (CAM)
healing practices and shares this information with
the public. Also lists CAM-related clinical trials.
*Inclusion on this list does not imply endorsement by
the American Cancer Society.
No matter who you are, we can help. Contact us
anytime, day or night, for information and support.
Visit www.cancer.org, or call us at 1-800-227-2345.

80

Notes

81

Written June 2015

This booklet is to help people with cancer learn

about pain control. Reading it can help you:

Work with your doctors, nurses, and

pharmacists to find the best ways to control
your pain.

Know about different types of pain and how

each type is treated.

Learn about different types of pain medicines.

Know about other ways to help manage pain.
Take your medicines safely.
Talk with your cancer care team about your pain
and how well your treatment is working.
Having cancer doesnt mean you will have pain,
but if you do, there are treatments that can help.
Work with your cancer care team to get the pain
control you need. You have the right to be treated
for your pain, and you should insist on it.

2009 American Cancer Society, Inc.

No. 942600 - Rev. 6/15
Models used for illustrative purposes only.