Understanding Primary and Secondary Pain: A Crucial Perspective for Oncology Professionals

In oncology, managing pain is a central aspect of patient care. Cancer patients frequently experience pain due to the disease itself, treatments, or related complications.

However, not all pain is the same, and a key distinction - rooted in Buddhist philosophy, Chinese medical theory, and modern psychology - can help oncology professionals provide more effective, patient-centered care.

Primary vs. Secondary Pain: A Critical Distinction

Primary pain is the actual physical sensation caused by disease, treatment side effects, or complications. It is the direct physiological experience of pain.
Secondary pain refers to the emotional and mental suffering that arises in response to primary pain. It includes distress, fear, frustration, and catastrophic thoughts about what the pain might mean. Unlike primary pain, secondary pain is influenced by perception and can be alleviated through psychological and emotional support.

For oncology professionals, recognizing the difference between these two types of pain is crucial because it affects how they approach patient distress and symptom management.

Why This Matters in Oncology Care

1. Patients Often Present with Significant Distress About Their Symptoms

When patients report pain, it is not always the physical sensation itself that is most distressing. Often, their distress stems from the fear that their pain indicates:

Disease progression
A lack of response to treatment
A loss of control over their body and future
A sense of frustration that their symptoms persist

If an oncology professional interprets this distress solely as physical pain, they may prescribe medications to address the symptoms. However, if they take the time to differentiate with the patient which aspect - physical pain or emotional suffering - is causing the greatest distress, they may find that the patient is more troubled by the fear and frustration surrounding the pain than by the physical sensation itself.

2. More Precise and Effective Pain Management

If a patient can tolerate their pain but is struggling with their emotional response to it, the most appropriate intervention is not necessarily increased pain medication but rather a conversation about the pain's relationship to their treatment, psychosocial support, counseling, or coping strategies. Differentiating between primary and secondary pain allows for tailored care that directly addresses the patient's true needs.

3. Preventing Unnecessary Pain Medication Prescriptions

When secondary pain (suffering) is misinterpreted as primary pain (or not recognized at all), it often leads to unnecessary prescriptions of painkillers, particularly opioids. This can contribute to:

Increased risk of medication side effects
Potential for medication dependency
A missed opportunity to address the root of the patient’s suffering

By recognizing when emotional distress - not physical pain - is the primary concern, oncology professionals can avoid overprescribing pain medications and instead focus on interventions that genuinely relieve the mental/emotional distress.

4. A Simple Conversation Can Ease Distress

For many patients, the real distress comes from not knowing whether their symptoms mean their condition is worsening or their treatment is failing. The fear of the unknown can magnify their suffering. Taking the time to have a conversation about the meaning of their symptoms - clarifying whether or not the pain is a sign of progression - can often significantly reduce distress.

This conversation might include:

Explaining the possible causes of their symptoms (e.g., treatment side effects, nerve irritation, inflammation, or healing processes rather than disease progression).
Providing reassurance when appropriate (e.g., “This type of pain is common with your treatment and does not necessarily mean the cancer is spreading.”).
Encouraging open discussion of fears so patients feel heard and supported.

For many patients, simply understanding that their pain is not necessarily a sign of worsening disease is enough to reduce their suffering without the need for additional medications.

5. Empowering Patients with Effective Coping Strategies

Once secondary pain is identified, patients can be introduced to strategies that help them manage their distress, such as:

Mindfulness and Acceptance Techniques: Encouraging patients to observe pain without judgment can help separate physical sensations from suffering.
Cognitive Behavioral Therapy (CBT) Approaches: Teaching patients to reframe distressing thoughts about their pain can reduce fear and anxiety.
Relaxation Techniques and Guided Imagery: These can help patients regulate their nervous system and improve their tolerance for discomfort.

By integrating these approaches, oncology professionals can help patients regain a sense of control over their experience, reducing unnecessary distress and improving their overall well-being.

The Positive Impact on Patient Outcomes

By incorporating an understanding of primary and secondary pain into patient assessments, oncology professionals can:

Provide more precise, individualized pain management
Reduce unnecessary medication use and potential side effects
Help patients develop resilience in the face of discomfort
Strengthen patient-provider communication and trust
Improve emotional well-being and overall quality of life

When oncology professionals take the time to differentiate between pain and suffering, they empower patients to navigate their experience with greater clarity, comfort, and control. Recognizing that suffering is not an inevitable consequence of pain, but something that can be transformed, is one of the most compassionate and effective approaches to cancer care.

Wayne's Note: I frequently reviewed this perspective with patients and their care teams during my 20 years at Abramson Cancer Center (Penn Medicine). Often, the result was a decrease in fear and anxiety and the decision that pain medication was not needed.

Patient Handout: