Multiple Myeloma Pain

Multiple myeloma pain is an unfortunate and frequent component of having the disease. Prevention and management of pain are essential to patients' quality of life. Be proactive about reporting your discomfort; it can interfere with your sleep, mood, and general activity level.

Sources of Pain

Bone Disease

• Osteoporosis, lytic bone lesions, pathologic fractures, and/or vertebral compression fractures are common painful occurrences at diagnosis and throughout the disease course.

Neuropathic Pain

• Vertebral compression fractures that impinge on the spinal cord may cause sudden sharp or chronic nerve pain.
• Painful neuropathy can be caused by monoclonal protein's effect on nerve tissue as early as the MGUS stage of disease development.
• Neuropathic pain may also be treatment-related: Thalomid® (thalidomide), Velcade® (bortezomib), Ninlaro® (ixazomib), and Pomalyst® can all cause painful peripheral neuropathy; Revlimid® may make pre-existing neuropathy worse.
• Patients may have postherpetic neuralgia (enduring pain caused by a shingles infection). Shingles, a reactivation of the chicken pox virus, may occur as a result of treatment with the proteasome inhibitors Velcade, Kyprolis, and Ninlaro. Patients who are receiving treatment with these proteasome inhibitors should also receive an anti-viral therapy to prevent shingles.

Prevention and Management of Pain

Managing Bone Pain

• Detection of early bone disease with sensitive imaging studies such as MRI and PET followed by early treatment is the best way to prevent bone damage and resultant pain.
• Pain-relief medications may be prescribed to help manage bone pain and allow for improved mobility. These include narcotics (opioids such as Fentanyl® and Oxycodone® and opioid-containing medications such as Vicodin®) and such non-opioid drugs as acetaminophen (Tylenol®), aspirin, and non-steroidal anti-inflammatories (NSAIDs such as Advil® and Motrin®). Cautions with NSAIDs include possible injury to the kidneys and stomach. Opioid medications may be effective, but can also cause sedation and constipation.
• Balloon kyphoplasty or vertebroplasty is used to treat painful vertebral compression fractures. Learn more with this IMF publication: Understanding Treatment of Myeloma-Induced Vertebral Compression Fractures.
• External beam radiation therapy provides tumor control and pain relief in areas of bone disease. However, radiation therapy can compromise the bone marrow, where all new blood cells are made, and can severely damage the blood-making stem cells needed for autologous stem cell transplant.
• Bracing the back can sometimes provide relief from back pain.
• Injection with a steroid and an anesthetic at the facet joint (where the bones of the spinal column meet) may provide relief from lower back pain.

Managing Neuropathic Pain

• Most nerve-related pain in multiple myeloma does not respond as well to opioids as it does to other classes of medication. Opioids are rarely used for painful neuropathy unless other treatments fail.
• Other classes of drugs that are used to treat painful peripheral neuropathy include anti-seizure medications (such as Neurontin®, Lyrica®) and anti-depressants (such as Pamelor®, Effexor®, and Cymbalta®). All of these medications have their own potential side effects.
• Topical treatments include capsaicin cream, which contains a substance in hot peppers, and lidocaine patches.
• If pain is caused by pressure on a nerve, surgery may be necessary.
• If peripheral neuropathy is caused by anti-myeloma treatments, your doctor may recommend stopping treatment for a period of time or changing the dose and/or schedule of your treatment. Velcade should be administered by subcutaneous (under the skin) injection rather than by intravenous (in to the vein) infusion to reduce the occurrence of peripheral neuropathy. Administering Velcade once a week rather than twice a week may also help prevent or reduce symptoms of neuropathy.

Other Approaches to Improving Neuropathic Pain

• Transcutaneous electric nerve stimulation (TENS) can be helpful.
• Regular exercise, such as walking, swimming, or gentle yoga or tai chi, can improve circulation and help reduce pain from neuropathy.
• Cigarette smoking and excessive alcohol consumption can worsen neuropathy. Avoid both.
• Good nutrition will ensure you are taking in the essential vitamins and minerals necessary for nerve protection and tissue repair. Discuss supplementing your diet with B vitamins; amino acids such as acetyl-L-carnitine; alpha lipoic acid; and folic acid with a member of your health-care team.
• Gentle massage with cocoa butter can provide some pain relief.
• Acupuncture is safe when performed by a certified practitioner using sterile needles, and may provide some relief.