PAIN, PAIN GO AWAY

We've Made Advances, but There's Room for Improvement

People with advanced cancer pray that their pain be well-controlled.

But despite the advances in pain management over the years,
significant cancer pain is still present in more than 70% of
patients. "In good centres, pain is well managed," says Dr. Allan
Gordon, director of the Wasser Pain Management Centre at Mount Sinai
Hospital in Toronto. "But there is still room for improvement." Lots, it seems.

As the population ages, the number of new cases of cancer will
steadily rise. In 2007, an estimated 159,900 new cases of cancer will
be diagnosed in Canada, an increase of 4% over the previous year.
Surveys have suggested that cancer pain is under-recognized and
under-treated in up to 50% of patients.

That's why pain, pain, go away is not just a patient's wish, it's
also on the minds of people like Gordon and others who work in the
area of palliative care.

Cancer pain is not as well controlled as it could be, adds Dr. Yvon
Beauchamp, family medicine-chief of palliative care at the Hopital du
Sacre-Coeur de Montreal: "The reasons include everything from
physicians not being educated adequately in pain management to
physicians not having the right medicines."

Pain is complicated, Beauchamp explains: "In pain there are at least
15 different mechanisms at work. Each of the various classes of
medication available to us only acts on one mechanism of the pain.
That's why when you deal with pain you have to use different
classes," he says, referring to various drug categories.

According to the World Health Organization, pain is a scale and pain
relief is like a ladder.

"We refer to pain as mild, moderate or severe," Gordon explains.
"Severe is seven to 10 on a scale of one to 10." Opioids (drugs like
codeine and morphine) have been key to treating the strongest pain,
and when they don't work on their own non-opioid analgesics have been added.

But a couple of weeks ago, pain experts welcomed another class of
drugs when Health Canada approved Sativex, a mouth spray derived from
marijuana. The controversial drug, which contains two ingredients
used to treat pain, has been used in the past for the symptomatic
relief of neuropathic pain in multiple sclerosis.

Neuropathic pain can also be a feature of cancer, Gordon says.

"This is pain that occurs because of damage to the nerves themselves.
It could be because the nerves are being stretched or pressed by the
cancer surgery or the cancer itself, or it could be as a result of
remote nerve inflammation." Neuropathic pain can be severe, adds
Beauchamp, and does not always respond well to opiates such as
morphine: "All pains are not alike. There is not really one class of
medication that can take care of one pain, or excruciating pain. In
cancer, most of the pain comes from the cancer itself, but as much as
25% of it may come from the treatment -- from the surgery, the
chemotherapy, the radiation. All those kinds of pains are neuropathic
pains. We are trying to help the patient, but sometimes we are
creating more problems than we are solving."

"Better education at all levels of care is really needed," says
Gordon, who believes that most pain patients can be treated well in
the community by an informed team that includes a doctor, a nurse and
a pharmacist. "There's still a gap in the education of the average
practitioner in using these kinds of medications."

Beauchamp adds that many physicians still wrongly fear that using
morphine or a drug like Sativex will make their patients addicted:
"You have doctors who have the wrong idea because of lack of
information and old knowledge."

This new class of drugs is not recreational: Unlike marijuana, the
effect is not immediate, explains Dr. Gordon who describes the drug
as "an add-on, another drug in the arsenal, part of a brave new world
of pain management."

But pain management first requires a proper pain assessment that
looks at the diagnosis, what's causing the pain, the kind of and
severity of the pain, the risks of treatment, and the side effects.

"You can't just blindly give medication," Gordon explains. "Pain
isn't on the radar screen in as many constituencies as it should be.
We have to fight to get pain management as a priority."