Living Without Cancer Pain: Three Common Pain Management Methods
Cancer pain is one of the major challenges faced by most cancer patients. It can significantly impair quality of life, and actively managing cancer pain not only improves day-to-day comfort but may also prolong survival. With advances in technology and medicine, awareness of proactive cancer pain management is increasing, and more innovative treatments are continually emerging.
The Intrathecal Drug Delivery System (ITDD) involves implanting a drug infusion pump under the skin that delivers medication directly and continuously into the subarachnoid space (located in the spine and skull). The drugs circulate in the cerebrospinal fluid (CSF) and act on spinal cord receptors to achieve pain relief.
Since Wang et al. first used morphine intrathecally in 1979, ITDD has become widely recognized worldwide for managing chronic, refractory pain. In China, refractory cancer pain is the main clinical application. Patient reports show that after ITDD treatment, pain scores decrease, and 87% of patients rate their quality of life from fair to excellent.[1]
Advantages of intrathecal over oral administration include:
ꔷ Lower doses required — only about 1/300 of the oral dose achieves the same analgesic effect.[1]
ꔷ Direct drug delivery to CSF allows targeted action and blocks pain signal transmission.
ꔷ Minimal systemic exposure, reducing overall drug concentration in the blood.
ꔷ Continuous pain relief and management of breakthrough pain.[2]
ꔷ Reduced side effects such as constipation and drowsiness for most patients.[2]
1. Preoperative assessment (Evaluate pain symptoms and psychological status)
2. Drug trial (Test efficacy and determine whether implantation is suitable)
3. Surgical implantation (minimally invasive)
The pump and catheter are implanted subcutaneously, with the catheter tip placed in the subarachnoid space and the pump in the abdominal or gluteal region. Because the medication is delivered directly to central pain receptors, very small doses can achieve the effect of high-dose oral morphine.
4. Postoperative pain management adjustment
Clinicians gradually adjust daily infusion doses and breakthrough pain doses, while tapering off oral or peripheral analgesics to achieve optimal pain control.
5. Follow-up and monitoring (The pump medication is typically replaced every 3–6 months)
Initial recovery may take 6–8 weeks, with some discomfort and activity limitations. Patients can gradually resume low-intensity activities like walking, cycling, or watching sports.
Modern ITDD pumps allow precise control of dose and infusion rate, increasing patient safety. Techniques such as microdosing and personal therapy managers (PTM) help delay tolerance, reduce total opioid consumption, and minimize adverse effects, improving pain control and patient satisfaction. Evidence also suggests that intrathecal therapy can improve prognosis, and it remains a cornerstone in managing chronic pain syndromes.[3]
Indications: Patients who cannot tolerate traditional pain therapy due to toxicity or inadequate analgesic effect; severe side effects such as nausea, vomiting, constipation, drowsiness, respiratory depression, urinary retention, itching, or dizziness; refractory pain after WHO three-step therapy; severe breakthrough pain not well controlled by medication.
Anesthesia: General anesthesia
Surgery duration: 1–2 hours
Hospitalization: 4–6 days (dose titration until optimal analgesia is achieved)
Possible adverse effects: Itching, headache, peripheral edema, tolerance, myoclonus, catheter tip granuloma
The advent of minimally invasive interventional techniques has brought new hope for managing pain in cancer patients and is regarded as the “fourth step” in cancer pain treatment. So, what exactly is the WHO three-step analgesic ladder for cancer pain, and what other pain management methods are available in clinical practice?
In 1986, the World Health Organization (WHO) introduced the cancer pain three-step ladder: Non-opioid analgesics, Weak opioids, Strong opioids. WHO guidelines recommend oral administration first[4] due to convenience, minimal pain, and stable blood drug concentrations. Other routes like intramuscular, subcutaneous, or intravenous administration can be more invasive, carry infection risks, and cause discomfort.
Indications: Pain caused directly by tumor or cancer diagnosis and treatment, covering mild, moderate, and severe cancer pain.
Possible side effects: Constipation, nausea, vomiting, drowsiness, itching, dizziness, urinary retention, delirium, cognitive impairment, respiratory depression.
Indications: Pain from bone metastases or soft tissue infiltration[6]
Side effects: Generally minimal
Cancer pain management in China is developing rapidly, with growing awareness encouraging patients to speak openly about their pain and seek individualized treatment. The ultimate goal of pain management is not simply to lower pain scores but to restore a tolerable and comfortable quality of life — helping patients sleep well, maintain appetite, and participate actively in social activities, ultimately aiding recovery.
We hope this guide on cancer pain management will be helpful to patients and caregivers.
References:
[1] Deer T, Chapple I, Classen A, et al. Intrathecal drug delivery for treatment of chronic low back pain: report from the National Outcomes Registry for Low Back Pain. Pain Med. 2004;5:6-13.
[2] Smith TJ, Staats PS, Deer T, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002;20:4040-4049.
[3] Zhang JH, Lin L, Deng S. New “four-step” model for cancer pain management. Practical Pain Medicine, 2019, 15(4):250-252.
[4] WHO. Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents. Geneva: WHO, 2018. PMID: 30776210.
[5] Arantzamendi M, Belar A, Payne S, et al. Clinical Aspects of Palliative Sedation in Prospective Studies: A Systematic Review. J Pain Symptom Manage. 2021;61(4):831-844.e10.
[6] Williams GR, Manjunath SH, Butala AA, et al. Palliative Radiotherapy for Advanced Cancers: Indications and Outcomes. Surg Oncol Clin N Am. 2021;30(3):563-580.
