Pain management through spirituality – pain of cancer

Pain Management Pain Management through Spirituality: through Spirituality: Pain of Cancer Pain of Cancer and Its Reliefand Its Relief

Dr. Bhaswat S. ChakrabortySenior Vice President and Chairman, R&D Core Committee, Cadila Pharmaceuticals Ltd.

ContentsContentsPainCancer Pain & QoLPsychological & Spiritual Pain in CancerUntreated Pain and Suffering in CancerPsychological and Spiritual Treatments

of Cancer PainMind-Body (Spiritual) Medicine for

Cancer PatientsConcluding Remarks

PainPainUntreated pain: devastating for an individual,

his family and his relations.The cost burden of untreated pain is huge to

an individual as well as to the society.Chronic pain has different characteristics

from those of acute pain.Chronic pain associated with diseases and

their treatment can be so severe that patient may prefer to die.

Chronic pain induces psychological fear and distortion of reality.

In all chronic pain, addressing the spiritual, existential and religious aspects are not only crucial but seems to be ethically mandatory.

Cancer Pain & QoLCancer Pain & QoLCancer patients have diverse symptoms,

◦ Impairments in physical and psychological functioning◦ Low quality of life.◦ Compromised relations.

Functional Assessment of Cancer Therapy (FACT) instrument◦ Impairments in the abilities of physical, social/family,

emotional, and functional well-being have been observed in all varieties of cancers

◦ Pain increases with the advancement and metastasis of the disease.

Prevalence of chronic pain: ◦ 30–50% (patients undergoing active treatment for a

solid tumor) ◦ 70–90% (among those with advanced disease).

Somatic, Visceral & Somatic, Visceral & Neuropathic PainNeuropathic PainSomatic pain is deep or shallow sensation of pain by

the tissues. ◦ Deep pain: cancer spreading to the bone (dull, achy feeling)◦ Surface pain: surgical incision (sharp, burning)

Visceral pain is activity of pain receptors in viscera.◦ Activation of pain receptors caused by a tumor putting

pressure on one or more of the organs, the stretching of the viscera, or general invasion of cancer (throbbing, pressured sensation).

Neuropathic pain is the most severe of pain types.◦ Caused by injury to the nervous system (burning or tingling) ◦ Tumor putting pressure on the spinal cord or nerves. ◦ Chemotherapy or radiation induced damage of nervous

system.

Breakthrough PainBreakthrough PainUnexpected pain that occurs between doses of

pain medicine (called a pain flare).

Pain gets very bad in 3-5 minutes.

Pain flares may last about 30 minutes.

◦ By doing something or without any obvious cause

Pain flares are not always the same each time you have one.

Usually treated with a pain medicine that acts very quickly and doesn’t last for long

Usually means pain medicine needs to be adjusted (may need more medicine)

Psychological & Spiritual Pain Psychological & Spiritual Pain in Cancerin Cancer

Suffering in cancer includes psychological and spiritual pain.

The patient develops severe distress that threatens his emotional coping mechanisms and “intactness.”

He also begins to ask profound existential questions about meaning of life and interprets the suffering in his unique spiritual way

Terminally ill patients attributed more positive meaning of suffering than they had before.

Even those who are unable to find a positive meaning in their suffering adjust better when

Ferrell et.al.(1993). Cancer Pract 1, 185-194.

Different Interpretations of Different Interpretations of SufferingSuffering

Foley (1988) Journal of Religion and Health, 27, 321-328

Theory ExamplePunishment My pain is the results of my sinsTesting God is testing my loyalty to HimBad luck The odds are against meSubmission to be laws of nature

It’s nature taking here course, and I’ve got to grin and bear it

Resignation to the will of God

God willed it – even though I don’t know why, so there is no way that I can avoid it

Acceptance of the human condition

Pain is a part of life

Personal growth This suffering is making me a better personDefensiveness and denial

I just don’t think about it

Minimization It could be worseDivine perspective If I could see things from God’s perspective, I know

I’d see a reason for this painRedemption There is joy in my suffering because it has

increased my appreciation for Christ’s suffering

Pain Management: WHO Pain Management: WHO GuideGuide

Untreated Pain and Suffering Untreated Pain and Suffering in Cancerin Cancer

Even strong opioids do not relieve pain in all patients with severe pain

This is further complicated by the broad potential for addiction and abuse.

Untreated pain is an ethical problem for all caregivers as it produces hopelessness

Since ethical questions lead to spiritual questions, because physical pain can contribute to spiritual pain, therefore, ethical care requires spiritual care.

Thus, the issue of spirituality is highly valid in cancer pain management.

Lisson E.(1987). Nurs Clin North Am, 22, 649-659.

WHO RecommendsWHO Recommends

Palliative Care (Cancer control : knowledge into action : WHO guide for effective programmes ; module 5.)

Confounding the Treatment – Confounding the Treatment – Patient & Physician AttitudesPatient & Physician Attitudes

Patients’ attitude◦ Negative attitude of patients about taking opioids

(11.2%).◦ Patients’ passive to cancer pain (9.4%). ◦ Fear of legal, government regulation (8.2%). ◦ Poor general image of opioids (8.5%).

Physician’s attitude towards patients◦ When patients complained about pain, patients

usually exaggerated it (47.5%).◦ Other half (51.4%) of the physicians thought that

patients exaggerated the pain for getting the attention of medical personnel.

Kim et al., (2011). Jpn J Clin Oncol,41, 783-791

Kim et al., (2011). Jpn J Clin Oncol,41, 783-791

Physician’s Attitude: Physician’s Attitude: A South Korean StudyA South Korean Study

Psychological and Spiritual Psychological and Spiritual Treatments of Cancer PainTreatments of Cancer PainPsychoeducational interventions

◦Cognitive behavioural therapy◦Relaxation therapy, guided imagery,

other types of stress management◦Other forms of psychotherapy

Spiritual Interventions◦Pastoral or Satsang services◦Shabad Kirtan◦Meditation◦End of Life Spiritual Counseling

Clinical assessment of the Clinical assessment of the Need for [Structured] Need for [Structured] Pastoral ServicesPastoral ServicesClinical assessment of spiritual and

pastoral needs of a cancer patient includes◦ Taking spiritual history◦ Recommendations and physicians’ practice

patterns.◦ Clinical assessment of spiritual needs.◦ Conceptual Considerations and Research

Instruments.◦ Closeness To and Knowledge of God.◦ Engagement with everyday life and orienting

force.◦ Relationship and support and religious and

spiritual struggles. Okon T (2005). J Pall Med, 8, 392-414.

Pastoral ServicesPastoral Services Cancer patients often receive regular visits by clergy over

the course of illness, making the clergyman a potential resource in attaining satisfatory cancer pain management.

In a survey to assess the knowledge and beliefs of clergy about cancer pain management was administered before (PI) and after (POI) an educational intervention on cancer pain control.

Participants were asked to rate their support for series of statements reflecting positive and negative perspectives on cancer pain and its management in each survey.

The intervention resulted in less support for the punitive religious statement and more positive outlook. It also decreased the notion that narcotics be reserved for the dying and that reliance on drugs is an escape from reality,.

The findings suggest that cancer pain management education for clergy can improve knowledge among clergymen and potentially improve counseling provided to cancer patients.

Stark et al.(2004). Journal of Clinical Oncology, 22, 8179

Satsang Services to a Satsang Services to a PatientPatient

“He would make both Deepak and me sit in his meditation room and pass on such aura around us that would calm our nerves and take away our fears of still unknown.”

“He would speak to me for hours till late into the night and urge me to speak to my pains internally to go away. He would urge me to take strength from the universe and to fight what I was fighting with Him for. Recharge me and my spirit through his own spirit that emitted love and understanding. This helped me recover fast and forget my pains.”

Neetima Babbar (had crcinoma of tongue)

In the book “Back to Life”Neeyati Publishers (2007)

Gurbani & ShabadGurbani & Shabad It was April 27th 2002 when three different teams of

oncologists and hematologists from Mumbai, Surat and Ahmedabad … unanimous findings, …my life is going to end in a few days as the deadly cancer called multiple myeloma.

…the moment the Granthi started reciting the Akhand Paath , I began to feel streams of energy entering and flowing thru my body. It rose majestically from the pages of Shri Guru Granth Sahib like a serene cool flame of light … After 48 hours, I got up on my own two feet and began to feel and enjoy such vibrant health that I almost ran with joy towards Sri Arjan Dev Niwas…

Mr. Vasu BhardwajJournalist, Science Writer,

Corporate Analyst

MeditationMeditationStage 1

◦ Removes lethargy◦ Calms you down◦ You become logical

Stage 2◦ Doubts eliminated◦ Certainty, decision

making ability increases

◦ Stamina increases◦ Creativity is unleashed

MeditationMeditation

Stage 3◦ Removes irritation,

anger◦ Feel rapture◦ Successful and optimistic◦ Stage 1 and stage 2

powers are intensifiedStage 4

◦ Anxiety eliminated◦ Feel deep and full joy

(bliss)◦ Feel very focused

whatever you engage in◦ Tranquility is

experienced

Mind-Body (Spiritual) Mind-Body (Spiritual) Medicine for Cancer Medicine for Cancer PatientsPatients

Among the most useful are the so-called mind-body approaches, which are classified as both psychological and integrative interventions.

Some of these treatments can be offered by the physicians or nurses who provide cancer care if access to a specially trained health professional is restricted,.

They should be regarded as mainstream adjunctive treatments intended to reduce pain and anxiety, improve coping, and increase self-efficacy.

– Russell K Portenoy (2011). Lancet, 377, 2236–47

Kabat-Zinn J. (1982). Gen Hosp Psych, 4, 33-47

Meditation-Based Stress Meditation-Based Stress Reduction in Cancer Reduction in Cancer Outpatients – an RCTOutpatients – an RCT“These results provide evidence that a

relatively brief mindfulness meditation–based stress reduction program can effectively reduce mood disturbance, fatigue, and a broad spectrum of stress-related symptoms in cancer patients, consistent with other investigations of similar interventions with different populations.”

•Speca M. et al. (2000) Psychosomatic Medicine 62, 613–622•Kabat-Zinn J, et al. (1992) Am J Psychiatry;149, 936–43.•Kabat-Zinn J, et al. (1986). Clin J Pain, 2,159–73.•Kabat-Zinn J, et al. (1998) Psychosom Med, 60, 625–32.

Nirvichara Samadhi Nirvichara Samadhi (Thoughtless Concentration(Thoughtless ConcentrationBoth Hindu (Patanjal) and Buddhist

Shamata support and teach this meditation

The state of awareness & concentration is thoughtless

It suffuses with joy and bliss, thus transcends the pain boundaries albeit not for ever

Regular practice enhances well being, defeats suffering

Nirvikalpa Samadhi Nirvikalpa Samadhi (Contrastless Concentration)(Contrastless Concentration)Both Hindu (Patanjal) and Buddhist

Mahayana support and teach this meditation

It takes a higher concentration where perceptions and mind’s contrasting dualities (Vikalpa) have to be transcended

Highly blissful state of self realization

Sri Sri Ramakrishna Paramhamsa demonstrated this even with his cancer

Understanding Duality andUnderstanding Duality andFalse ImaginationFalse ImaginationDuality is possibility or manifestation of a

second reality!◦ E.g., good-bad, association-dissociation,

spontaneous-learned, samsara-moksha ◦ Indecision, feeling of separation, I and you,

anger, infatuation, me and the world are also duality

Duality is a product of underdeveloped consciousness

Non-duality or oneness of reality is REAL!Nirvikalpa Meditation allows to experience

this supreme, non-dual reality!

Samskara-Upeksha Jnana Samskara-Upeksha Jnana (Spiritual Composure) of Lord (Spiritual Composure) of Lord BuddhaBuddhaPhysicality and mentality are interdependentA diseased body will have mental formations

that are scary and will induce hopelessness If the meditator has strong desire for release

and is neither excited about prognosis nor fearful of the diagnosis, she can compose herself to a neutrality which is liberating!

This state (and higher) almost always transcends psychological & psychosomatic Pain.

From such neutrality, a higher life can be touched and lived.

How does mindfulness How does mindfulness meditation work?meditation work?Non-attached observation – an uncoupling of

sensory dimension of the pain experience from the affective and evaluative alarm reaction

It reduces the experience of the suffering either by cognitive re-appraisal or neutralizing the mind states.

By coupling calmness and knowledge together.

There is even a potential for Highest realization

Generalization: Pain is a truth of life but is not as great a truth as “pain can be treated or cured.”

Concluding RemarksConcluding RemarksCancer patients experience severe pain – both

from the disease as well as from some of the treatments.

Human beings, including cancer patients, are spiritual beings for their spirituality pervades their whole Being and integrates and transcends their bodily and psychosocial nature.

Spirituality is also their super-human aspect which does not get tainted by disease, birth and death.

Unfortunately very pronounced and sustained pain like that of a cancer can bring to question the very foundation of a man’s spirituality.

Concluding Remarks..Concluding Remarks..Thus, understanding the epidemiological

aspects of religiosity and spirituality of cancer pain would include general trends of expressed attitudes in the general population, patients and physicians.

Therapeutic options of religious or pastoral consultation and their boundaries must be considered in giving spiritual services to cancer patients.

A priest or otherwise spiritually competent person can address the spiritual issues whereas an onco-physician can look after the palliative drug and radiation therapy.

Dedicated to my SadguruDedicated to my SadguruSri Sri Thakur Sri Sri Thakur

AnukulchandraAnukulchandra