1. Pain Management through
Spirituality: Pain of Cancer
and Its Relief
Dr. Bhaswat S. Chakraborty
Senior Vice President and Chairman,
R&D Core Committee, Cadila Pharmaceuticals Ltd.

2. Contents
Pain
Cancer Pain & QoL
Psychological & Spiritual Pain in Cancer
Untreated Pain and Suffering in Cancer
Psychological and Spiritual Treatments of
Cancer Pain
Mind-Body (Spiritual) Medicine for Cancer
Patients
Concluding Remarks

3. Pain
 Untreated 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.

4. Cancer Pain & QoL
 Cancer 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).

5. Somatic, Visceral & Neuropathic
Pain
 Somatic 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.

6. Breakthrough Pain
 Unexpected 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.
 Usuallytreated 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)

7. Psychological & Spiritual Pain in
Cancer
 Suffering in cancer includes psychological and spiritual pain.
 Thepatient 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.

8. Different Interpretations of
Suffering
Theory Example
Punishment My pain is the results of my sins
Testing God is testing my loyalty to Him
Bad luck The odds are against me
Submission to be laws of It’s nature taking here course, and I’ve got to grin and bear it
nature
Resignation to the will of God willed it – even though I don’t know why, so there is no
God way that I can avoid it
Acceptance of the human Pain is a part of life
condition
Personal growth This suffering is making me a better person
Defensiveness and denial I just don’t think about it
Minimization It could be worse
Divine perspective If I could see things from God’s perspective, I know I’d see a
reason for this pain
Redemption There is joy in my suffering because it has increased my
appreciation for Christ’s suffering
Foley (1988) Journal of Religion and Health, 27, 321-328

9. Pain Management: WHO Guide

10. Untreated Pain and Suffering in
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.

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

12. Confounding the Treatment –
Patient & 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

13. Physician’s Attitude:
A South Korean Study
Kim et al., (2011). Jpn J Clin Oncol,41, 783-791

14. Psychological and Spiritual
Treatments of Cancer Pain
Psychoeducational 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

15. Clinical assessment of the Need
for [Structured] Pastoral Services
Clinical
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.

16. Pastoral 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

17. Satsang Services to a Patient
 “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)

18. Gurbani & 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 Bhardwaj
Journalist, Science Writer,
Corporate Analyst

19. Meditation
Stage 1
◦ Removes lethargy
◦ Calms you down
◦ You become logical
Stage 2
◦ Doubts eliminated
◦ Certainty, decision making
ability increases
◦ Stamina increases
◦ Creativity is unleashed

20. Meditation
Stage 3
◦ Removes irritation, anger
◦ Feel rapture
◦ Successful and optimistic
◦ Stage 1 and stage 2
powers are intensified
Stage 4
◦ Anxiety eliminated
◦ Feel deep and full joy
(bliss)
◦ Feel very focused
whatever you engage in
◦ Tranquility is experienced

21. Mind-Body (Spiritual) Medicine for
Cancer Patients
 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,.
 Theyshould 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

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

23. Meditation-Based Stress Reduction in
Cancer Outpatients – 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.

25. Nirvichara Samadhi (Thoughtless
Concentration
Both Hindu (Patanjal) and Buddhist Shamata
support and teach this meditation
The state of awareness & concentration is
thoughtless
Itsuffuses with joy and bliss, thus transcends
the pain boundaries albeit not for ever
Regular practice enhances well being, defeats
suffering

26. Nirvikalpa Samadhi (Contrastless
Concentration)
Both Hindu (Patanjal) and Buddhist Mahayana
support and teach this meditation
Ittakes 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

27. Understanding Duality and
False Imagination
Duality 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!

28. Samskara-Upeksha Jnana (Spiritual
Composure) of Lord Buddha
 Physicality and mentality are interdependent
A 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!
 Thisstate (and higher) almost always transcends
psychological & psychosomatic Pain.
 From such neutrality, a higher life can be touched and
lived.

29. How does mindfulness 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.”

30. Concluding Remarks
 Cancer 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.
 Spiritualityis 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.

31. 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.

32. Dedicated to my Sadguru
Sri Sri Thakur Anukulchandra