Management of pain
Pain management should be tailored to the individual and for myeloma patients, this usually requires a multidisciplinary approach and pharmacological and non-pharmacological interventions. Treatment of the myeloma is a key component of pain management as this can be the underlying cause of the pain.
Pain arising in bone as a result of myeloma bone disease may be alleviated to some degree by regular bisphosphonate treatment. Radiotherapy can also be effective in treating bone pain. There are two minimally invasive surgical procedures known as Balloon Kyphoplasty and Percutaneous Vertebroplasty which can offer effective pain relief in cases where there is vertebral collapse. In addition, fractures of unstable bones may require orthopaedic fixation with plate or rod insertions.
The management of pain related to myeloma bone disease is described in more detail in Module 9. You can read more about how to manage this complication in our Myeloma Nurse Guide: Myeloma Bone Disease.
The type of pain relief given is directed by the severity, type and cause of the pain.
Recommendations for pain control:
- For mild pain
Over-the-counter analgesics such as paracetamol can be very effective. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen should generally be avoided for myeloma patients as they can cause or exacerbate renal damage and have an anti-platelet effect. Occasionally NSAIDs are prescribed for short-term (maximum of 3 – 5 days) for acute severe pain e.g. bone fracture. NSAIDS should only be used in this way when prescribed by the patient’s myeloma team and under careful medical supervision. - For mild to moderate pain (<6 on a 0 – 10 scale)
For pain that is no longer controlled by paracetamol, co-codamol or codeine are the next options (caution required in patients with renal impairment) - For chronic moderate-severe pain (>4 on a 0 – 10 scale)
High-dose tramadol, oxycodone, fentanyl (as patches, tablets, lozenges or nasal spray), buprenorphine (BuTrans or Transtec patches), morphine - For acute severe pain (>6 on a 0 – 10 scale)
Subcutaneous opioid therapy can achieve quicker pain control using oxycodone (alternatively use morphine)
A reduction of 2 or greater on a 0-10 point scale is accepted as a clinically significant response to treatment. Patients who do not attain this, or have increasing pain levels, should be referred to a pain or palliative medicine specialist. Occupational and physiotherapy can also help support patients in safely adapting and managing everyday activities.
Patients with neuropathic pain, e.g. due to peripheral neuropathy, may benefit from a calcium channel blocker (e.g. gabapentin or pregabalin), a sodium channel blocker (e.g. carbamazepine) and/or a serotonin-norepinephrine reuptake inhibitor (SNRI) (e.g. duloxetine or amitriptyline).
Nurses play a central and highly skilled role in supporting effective pain management for people living with myeloma. It is important that patients are given clear information and instruction about pain and its management and encouraged to be open and honest about the level of pain they have and how much it is affecting them. This helps ensure that the most appropriate pain management plan can be initiated.
Patients should also be encouraged to take an active role in managing their pain e.g. to continue to document their pain using a symptom diary, and to explore the potential benefits of non-medical interventions, such as:
- Topical creams to help alleviate pain or burning sensations in the hands or feet caused by peripheral neuropathy
- Hot water bottles, microwavable wheat bags, electric heat pads and ice packs for short term pain relief
- Transcutaneous electrical nerve stimulation (TENS) machines which deliver small electrical pulses to the body via electrodes placed on the skin. The electrical impulses can reduce the pain signals going to the spinal cord and the brain
- Meditation, visualisation, mindfulness and relaxation therapies
As well as pain resulting from myeloma disease or drug side effects, myeloma patients may have to undergo painful investigations during the course of their treatment. Patients often consider bone marrow biopsies for example to be one of the most painful medical procedures they experience, and studies have found that the level of pain experienced is often underestimated by healthcare professionals. There are many ways that pain during this procedure can be managed:
- Powered bone marrow biopsy system
- Distraction through music and conversation
- Nitrous oxide
- Local anaesthesia
- HCP technique
- Pre-medication with paracetamol or tramadol
- Consideration for pre procedure benzodiazepines