An Interview with
Kathleen M. Foley "In recent years, the most important change for patients is that pain is now recognized as another vital sign" 
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Multiple myeloma is a complex disease that can cause a range of symptoms, including varying degrees of pain. About 70 to 80 percent of patients with multiple myeloma report that they experience pain related to the disease.
Over the past several years, physicians and researchers have made strides in understanding the biologic basis of pain. With that knowledge, they are better able to target pain medications and techniques than they were in the past. Doctors and nurses who treat patients with cancer make pain control a priority.
At Memorial Sloan-Kettering, pain specialists work to ensure that patients who are experiencing pain are continuously monitored and that their pain is treated.
Pain Related to Myeloma
Back pain is often the first symptom of myeloma, but because it is such a common condition, it might not be initially associated with myeloma.
A backache that lasts for months can be a signal that bones in the spine and ribs are weakening in spots because of myeloma. Sudden, severe back pain can be a sign of a fracture or of the collapse of a vertebra in the spine. Shooting pains in the arms and legs can also indicate that a tumor in the spinal column is pressing on nerves in that area. Another common, painful condition related to multiple myeloma is peripheral neuropathy, which is a burning pain sensation, weakness, and numbness in the feet and lower legs. Myeloma patients may also develop carpal tunnel syndrome, which can result as protein deposits accumulate in the hands.
The most severe pain reported by patients with myeloma, however, comes from bone lesions. Those that begin inside the bone can cause a dull, aching pain. If the lesion expands, it can reach the periosteum -- the sensitive, nerve-rich membrane that covers the bone -- causing a periodic shooting, burning sensation.
Bisphosphonates
Over the past ten years, physicians have begun to use a group of drugs called bisphosphonates to treat myeloma. Bisphosphonates are commonly used to treat osteoporosis (thinning of the bones). At higher doses, potent bisphosphonates such as pamidronate (Aredia®) and zoledronic acid (Zometa®) can halt the progression of bone lesions in myeloma and other cancers. By preventing the growth of lesions, these agents also provide pain relief. Bisphosphonate therapy for myeloma is given intravenously (through the vein) on a monthly basis. Unlike analgesics, which start working immediately, bisphosphonates may take some time before they provide pain relief.
In rare cases, bisphosphonate therapy can cause kidney damage or jawbone damage, which results in open sores in the mouth (osteonecrosis of the jaw). Memorial Sloan-Kettering doctors review the side effects of bisphosphonates with each patient before they prescribe drugs. Our physicians provide detailed information and guidance for patients to talk over with their dentists. Patients are instructed not to take bisphosphonates if they are undergoing invasive dental procedures such as extractions, and to wait until the mouth has totally healed before resuming bisphosphonates.
Controlling Pain
Before beginning a pain management program, a physician will carefully evaluate a patient to determine the exact cause and location of the pain. For example, the doctor will need to find out if a bone lesion is pinching nerves or compressing the spinal cord, as this can lead to serious or permanent damage. Physicians use x-rays, computed tomographic (CT) scans, and magnetic resonance imaging (MRI) to pinpoint the location and number of lesions or tumors, and to put together a pain control plan that is tailored to each patient.
Approaches to pain control for patients with multiple myeloma have improved in recent years, giving physicians and patients many more options to effectively target pain. Analgesics, drugs that reduce pain, remain the mainstay of bone pain treatment. The strongest analgesics are called opioids or narcotics, and these are often prescribed to control pain in patients with myeloma. The most commonly prescribed drugs are codeine, morphine, and morphine-like synthetic compounds. Physicians prescribe the specific painkillers that are most effective and best-tolerated for each patient at different stages of their disease. For example, physicians may prescribe methadone for patients with advanced disease because it is less likely than other opioids to build up and become toxic in those whose kidneys are affected by myeloma.
There are a few different ways that pain medications can be taken. For example, patients can take fentanyl (a fast-acting and short-lived opioid that is especially beneficial for those who cannot tolerate other narcotics) through a patch applied directly to the skin. This patch supplies a steady stream of medication and needs to be changed once every few days. Several other opioids now come in a sustained-release form, so patients don't need to take frequent doses of medication. Patients with severe chronic pain can also carry a small, portable pump that dispenses pain medication intravenously and continuously.
Fentanyl is also available in the form of a lozenge on a stick or lollipop. As patients suck on the lozenge, the medication is absorbed through the mucosal membrane (the moist membrane that lines the mouth) and can provide rapid pain relief. This form of medication is especially useful for patients who experience pain on movement or breakthrough pain (a sudden, temporary flare of pain).
To alleviate pain that arises mainly from nerve damage, physicians sometimes prescribe anticonvulsant (anti-seizure) and antidepressant drugs. Some of these medications can slow or stop neurons -- the specialized cells that transmit signals throughout the body -- from sending pain signals along nerve pathways to the brain.
Physicians sometimes use radiation therapy and surgery to control myeloma pain. Radiation therapy can relieve pain by shrinking tumors that are growing toward nerves and pressing on them. Fractures that result from weakened bones are usually treated surgically. Physicians can insert plates and rods to support these fragile bones. Doctors often suggest that patients also wear a back brace or a neck brace to support bones and relieve pain.
Some patients find that complementary pain control techniques such as relaxation and imagery can reduce the intensity of pain when used along with pain medication and treatment agents. Massage and acupuncture can also reduce pain, and currently researchers at Memorial Sloan-Kettering are studying the effectiveness of these techniques in patients with multiple myeloma and other cancers. Our Integrative Medicine Service offers patients, their families, and the public a range of complementary therapies that have been shown to have real benefits.
Memorial Sloan-Kettering's pain experts are available 24 hours a day in the clinic or in the urgent care setting. These specialized pain physicians also continue to oversee myeloma patients who are being cared for at home in collaboration with local infusion companies, visiting nurses, and hospice workers.
