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Topic Contents
- Introduction
- Overview
- Assessment
- Management with Drugs
- Physical, Integrative, Behavioral, and Psychosocial Interventions
- Radiation Therapy to Relieve Pain
- Invasive Interventions to Relieve Pain
- Treating Older Patients
- Changes to This Summary (02 / 27 / 2013)
- Questions or Comments About This Summary
- Get More Information From NCI
- About PDQ
Pain (PDQ®): Supportive care - Patient Information [NCI]
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
This patient summary on pain is adapted from the summary written for health professionals by cancer experts. This and other credible information about cancer treatment, screening, prevention, supportive care, and ongoing clinical trials is available from the National Cancer Institute. Pain associated with cancer can be controlled in most patients but is frequently undertreated. This brief summary describes the management of cancer pain with the use of medication, physical methods, and psychological intervention.
This summary is about pain in adults with cancer.
Cancer pain can be managed effectively in most patients with cancer or with a history of cancer. Although cancer pain cannot always be relieved completely, therapy can lessen pain in most patients. Pain management improves the patient's quality of life throughout all stages of the disease.
Flexibility is important in managing cancer pain. As patients vary in diagnosis, stage of disease, responses to pain and treatments, and personal likes and dislikes, management of cancer pain must be individualized. Patients, their families, and their health care providers must work together closely to manage a patient's pain effectively.
To treat pain, it must be measured. The patient and the doctor should measure pain levels at regular intervals after starting cancer treatment. Checks should be done at each clinic visit, at each new report of pain, and after starting any type of treatment for pain. The cause of the pain must be identified and treated promptly.
Patient Self-Report
To help the health care provider determine the type and extent of the pain, cancer patients can describe the location and intensity of their pain, any aggravating or relieving factors, and their goals for pain control. The family/caregiver may be asked to report for a patient who has a communication problem involving speech, language, or a thinking impairment. The health care provider should help the patient describe the following:
- Pain: The patient describes the pain, when it started, how long it lasts, and whether it is worse during certain times of the day or night.
- Location: The patient shows exactly where the pain is on his or her body or on a drawing of a body and where the pain goes if it travels.
- Pattern: The patient describes if there have been changes in where the pain is, when the pain occurs, and how long it lasts, or if there is new pain.
- Intensity or severity: The patient keeps a diary of the degree or severity of pain.
- Aggravating and relieving factors: The patient identifies factors that increase or decrease the pain. The patient also identifies symptoms that are most troublesome, since they are not always the most serious or severe.
- Personal response to pain: Feelings of fear, confusion, or hopelessness about cancer, its prognosis, and the causes of pain can affect how a patient responds to and describes the pain. For example, a patient who thinks pain is caused by cancer spreading may report more severe pain or more disability from the pain.
- Behavioral response to pain: The health care provider and/or caregivers note behaviors that may suggest pain in patients who have communication problems.
- Goals for pain control: With the health care provider, the patient decides how much pain he or she can tolerate and how much improvement he or she may achieve. The patient uses a daily pain diary to increase awareness of pain, gain a sense of control of the pain, and receive guidance from health care providers on ways to manage the pain.
Physical Exam
The assessment will include an exam of the body to check general signs of health or anything that seems unusual, and to look for signs that the cancer has grown or spread. A history of the patient's health habits and past illnesses and treatments will also be taken. A neurological exam will be done. This is a series of questions and tests to check the brain, spinal cord, and nerve function. The exam checks the patient's mental status, ability to move and walk normally, and how well the muscles, senses, and reflexes work. The patient's psychological and spiritual well-being are evaluated. A personal and family history of substance abuse is taken. All of this information is taken as a whole to diagnose and treat the pain effectively.
Assessment of the Outcomes of Pain Management
The results of pain management should be measured by monitoring for a decrease in the severity of pain and improvement in thinking ability, emotional well-being, and social functioning. The results of taking pain medication should also be monitored. Drug addiction is rare in cancer patients. Developing a higher tolerance for a drug and becoming physically dependent on the drug for pain relief does not mean that the patient is addicted. Patients should take pain medication as prescribed by the doctor. Patients who have a history of drug abuse may tolerate higher doses of medication to control pain.
Management with Drugs
Basic Principles of Cancer Pain Management
The World Health Organization developed a 3-step approach for pain management based on the severity of the pain:
- For mild to moderate pain, the doctor may prescribe a Step 1 pain medication such as aspirin, acetaminophen, or a nonsteroidal anti-inflammatory drug (NSAID). Patients should be monitored for side effects, especially those caused by NSAIDs, such as kidney, heart and blood vessel, or stomach and intestinal problems.
- When pain lasts or increases, the doctor may change the prescription to a Step 2 or Step 3 pain medication. Most patients with cancer -related pain will need a Step 2 or Step 3 medication. The doctor may skip Step 1 medications if the patient initially has moderate to severe pain.
- At each step, the doctor may prescribe additional drugs or treatments (for example, radiation therapy).
- The patient should take doses regularly, "by mouth, by the clock" (at scheduled times), to maintain a constant level of the drug in the body; this will help prevent recurrence of pain. If the patient is unable to swallow, the drugs are given by other routes (for example, by infusion or injection).
- The doctor may prescribe additional doses of drug that can be taken as needed for pain that occurs between scheduled doses of drug.
- The doctor will adjust the pain medication regimen for each patient's individual circumstances and physical condition.
Acetaminophen and NSAIDs
NSAIDs are effective for relief of mild pain. They may be given with opioids for the relief of moderate to severe pain. Acetaminophen also relieves pain, although it does not have the anti-inflammatory effect that aspirin and NSAIDs do. Patients, especially older patients, who are taking acetaminophen or NSAIDs should be closely monitored for side effects. Most NSAIDs affect the blood platelets, making it take longer for blood to clot and stop bleeding. Aspirin should not be given to children to treat pain.
Opioids are very effective for the relief of moderate to severe pain. Many patients with cancer pain, however, become tolerant to opioids during long-term therapy. Therefore, increasing doses may be needed to continue to relieve pain. A patient's tolerance of an opioid or physical dependence on it is not the same as addiction (psychological dependence). Mistaken concerns about addiction can result in undertreating pain.
Types of Opioids
There are several types of opioids. Morphine is the most commonly used opioid in cancer pain management. Other commonly used opioids include hydromorphone, oxycodone, oxymorphone, methadone, fentanyl, meperidine (Demerol), tapentadol, and tramadol. The availability of several different opioids allows the doctor flexibility in prescribing a medication regimen that will meet individual patient needs.
Guidelines for Giving Opioids
Most patients with cancer pain will need to receive pain medication on a fixed schedule to manage the pain and prevent it from getting worse. The doctor will prescribe a dose of the opioid medication that can be taken as needed along with the regular fixed-schedule opioid to control pain that occurs between the scheduled doses. The amount of time between doses depends on which opioid the doctor prescribes. The correct dose is the amount of opioid that controls pain with the fewest side effects. The goal is to achieve a good balance between pain relief and side effects by gradually adjusting the dose. If opioid tolerance does occur, it can be overcome by increasing the dose or changing to another opioid, especially if higher doses are needed.
Occasionally, doses may need to be decreased or stopped. This may occur when patients become pain free because of cancer treatments such as nerve blocks or radiation therapy. The doctor may also decrease the dose when the patient experiences opioid-related sedation along with good pain control, or when kidney failure develops or worsens.
Medications for pain may be given in several ways. When the patient has a working stomach and intestines, the preferred method is by mouth, since medications given orally are convenient and usually inexpensive. When patients cannot take medications by mouth, other less invasive methods may be used, such as rectally, through medication patches placed on the skin, or in the form of a nasal spray. Intravenous methods are used only when simpler, less demanding, and less costly methods are inappropriate, ineffective, or unacceptable to the patient. Patient-controlled analgesia (PCA) pumps may be used to determine the opioid dose when starting opioid therapy. Once the pain is controlled, the doctor may prescribe regular opioid doses based on the amount the patient required when using the PCA pump. Intraspinal administration of opioids combined with a local anesthetic may be helpful for some patients who have uncontrollable pain.
Side Effects of Opioids
Patients should be watched closely for side effects of opioids. The most common side effects of opioids include nausea, sleepiness, and constipation. The doctor should discuss the side effects with patients before starting opioid treatment. Sleepiness and nausea are usually experienced when opioid treatment is started and tend to improve within a few days. Other side effects of opioid treatment include vomiting, difficulty in thinking clearly, problems with breathing, gradual overdose, and problems with sexual function. Chronic nausea and vomiting in patients receiving long-term opioid treatment may be caused by constipation.
Opioids slow down the muscle contractions and movement in the stomach and intestines resulting in hard stools. The key to effective prevention of constipation is to be sure the patient receives plenty of fluids to keep the stool soft. Unless there are problems such as a blocked bowel or diarrhea, patients will usually be given a regimen to follow to prevent constipation and information on how to manage bowel health while taking opioids.
Patients should talk to their doctor about side effects that become too bothersome or severe. Because there are differences between individual patients in the degree to which opioids may cause side effects, severe or continuing problems should be reported to the doctor. The doctor may decrease the dose of the opioid, switch to a different opioid, or switch the way the opioid is given (for example intravenous or injection rather than by mouth) to attempt to decrease the side effects. (Refer to the PDQ summaries on Gastrointestinal Complications, Nausea and Vomiting, Nutrition in Cancer Care, and Sexuality and Reproductive Issues for more information about coping with these side effects.)
Drugs Used with Pain Medications
Other drugs may be given at the same time as the pain medication. This is done to increase the effectiveness of the pain medication, treat symptoms, and relieve specific types of pain. These drugs include antidepressants, anticonvulsants, local anesthetics, corticosteroids, bisphosphonates, and stimulants. The use of cannabinoids added to pain medicine is being studied for cancer-related pain. A monoclonal antibody called denosumab is used to prevent broken bones and other bone problems caused by solid tumors that have metastasized (spread) to bone. There are great differences in how patients respond to these drugs. Side effects are common and should be reported to the doctor.
The use of bisphosphonates may cause severe and sometimes disabling pain in the bones, joints, and/or muscles. This pain may develop after these drugs are used for days, months, or years, as compared with the fever, chills, and discomfort that may occur when intravenous bisphosphonates are first given. If severe muscle or bone pain develops, bisphosphonate therapy may need to be stopped.
The use of bisphosphonates is also linked to the risk of bisphosphonate-associated osteonecrosis (BON). See the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information on BON.
Physical, Integrative, Behavioral, and Psychosocial Interventions
Noninvasive physical, integrative, thinking and behavioral, and psychological methods can be used along with drugs and other treatments to manage pain during all phases of cancer treatment. These interventions may help with pain control both directly and indirectly, by making patients feel they have more control over events. The effectiveness of the pain interventions depends on the patient's participation in treatment and his or her ability to tell the health care provider which methods work best to relieve pain.
Physical Interventions
Weakness, muscle wasting, and muscle/bone pain may be treated with heat (a hot pack or heating pad); cold (flexible ice packs); exercise (to strengthen weak muscles, loosen stiff joints, help restore coordination and balance, and strengthen the heart); changing the position of the patient; restricting the movement of painful areas or broken bones; or controlled low-voltage electrical stimulation.
Integrative Interventions
Integrative interventions include massage therapy, acupuncture, and music.
Massage therapy
Massage therapy has been studied as part of supportive care in managing cancer-related pain. Massage may help improve relaxation and benefit mood. Preclinical and clinical trials show that massage therapy may:
- Stimulate the release of endorphins (substances that relieve pain and give a feeling of well-being).
- Increase the flow of blood and lymphatic fluid.
- Strengthen the effects of pain medications.
- Decrease inflammation and edema.
- Lower pain caused by muscle spasms and tension.
Physical methods to help relieve pain have direct effects on tissues of the body and should be used with caution in patients with cancer. Studies suggest that massage therapy may be safe in patients with cancer with the following precautions:
- Avoid massaging any open wounds, bruises, or areas with skin breakdown.
- Avoid massaging directly over the tumor site.
- Avoid massaging areas with deep vein thrombosis (blood clot in a vein). Symptoms may include pain, swelling, warmth, and redness in the affected area.
- Avoid massaging soft tissue when the skin is sensitive following radiation therapy.
(For more information on massage, see Exercise 2 in the following section.)
Acupuncture is an integrative intervention that applies needles, heat, pressure, and other treatments to one or more places on the skin called acupuncture points. Acupuncture may be used to manage pain, including cancer-related pain. See the PDQ summary on Acupuncture for more information.
Music interventions
Music interventions may help relieve pain and decrease anxiety in some patients. Music has been used to relieve pain caused by the cancer and by procedures and treatments. Studies have reported that music may work on areas of the brain that increase pleasant feelings and decrease unpleasant responses. Favorite music from the patient's own collection has been shown to help the most. Music that begins before a procedure is more effective than music that begins during or after a procedure. Music may be used along with pain medicine.
There are two main types of music intervention, music therapy and music medicine:
- Music therapy is given by a trained specialist. The music used may be live or recorded. Therapy may include music improvisation (making up music), song writing and singing, and relaxing to music. The music therapist bases treatment on the patient's needs, such as controlling pain, decreasing anxiety, or learning new coping skills.
- Music medicine is listening to music (usually recorded music) to take attention away from the pain. Music medicine is guided by a medical professional who does not have specialized training in music therapy.
The use of music for pain related to cancer is still being studied.
Music is also used in relaxation exercises. See the next section, on Thinking, Behavioral, and Psychosocial Interventions.
Thinking, Behavioral, and Psychosocial Interventions
Thinking, behavioral, and psychosocial interventions are also important in treating pain. These interventions help give patients a sense of control and help them develop coping skills to deal with the disease and its symptoms. Beginning these interventions early in the course of the disease is useful so that patients can learn and practice the skills while they have enough strength and energy. Several methods should be tried, and one or more should be used regularly.
- Relaxation and imagery: Simple relaxation techniques may be used for episodes of brief pain (for example, during cancer treatment procedures). Brief, simple techniques are suitable for periods when the patient's ability to concentrate is limited by severe pain, high anxiety, or fatigue. (See Relaxation exercises below.)
- Hypnosis: Hypnotic techniques may be used to encourage relaxation and may be combined with other thinking/behavior methods. Hypnosis is effective in relieving pain in people who are able to concentrate and use imagery and who are willing to practice the technique.
- Redirecting thinking: Focusing attention on triggers other than pain or negative emotions that come with pain may involve distractions that are internal (for example, counting, praying, or saying things like "I can cope") or external (for example, music, television, talking, listening to someone read, or looking at something specific). Patients can also learn to monitor and evaluate negative thoughts and replace them with more positive thoughts and images.
- Patient education: Health care providers can give patients and their families information and instructions about pain and pain management and assure them that most pain can be controlled effectively. Health care providers should also discuss the major barriers that interfere with effective pain management.
- Psychological support: Short-term psychological therapy helps some patients. Patients who develop clinical depression or adjustment disorder may see a psychiatrist for diagnosis.
- Support groups and religious counseling: Support groups help many patients. Religious counseling may also help by providing spiritual care and social support.
The following relaxation exercises may be helpful in relieving pain.
Exercise 1. Slow rhythmic breathing for relaxation *
|Breathe in slowly and deeply, keeping your stomach and shoulders relaxed.
|As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving your body.
|Breathe in and out slowly and regularly at a comfortable rate. Let the breath come all the way down to your stomach, as it completely relaxes.
|To help you focus on your breathing and to breathe slowly and rhythmically: Breathe in as you say silently to yourself, "in, two, three." OR Each time you breathe out, say silently to yourself a word such as "peace" or "relax."
|Do steps 1 through 4 only once or repeat steps 3 and 4 for up to 20 minutes.
|End with a slow deep breath. As you breathe out say to yourself, "I feel alert and relaxed."
Exercise 2. Simple touch, massage, or warmth for relaxation *
- Touch and massage are traditional methods of helping others relax. Some examples are:
- Brief touch or massage, such as hand holding or briefly touching or rubbing a person's shoulders.
- Soaking feet in a basin of warm water or wrapping the feet in a warm, wet towel.
- Massage (3 to 10 minutes) of the whole body or just the back, feet, or hands. If the patient is modest or cannot move or turn easily in bed, consider massage of the hands and feet.
- Use a warm lubricant. A small bowl of hand lotion may be warmed in the microwave oven or a bottle of lotion may be warmed in a sink of hot water for about 10 minutes.
- Massage for relaxation is usually done with smooth, long, slow strokes. Try several degrees of pressure along with different types of massage, such as kneading and stroking, to determine which is preferred.
Especially for the elderly person, a back rub that effectively produces relaxation may consist of no more than 3 minutes of slow, rhythmic stroking (about 60 strokes per minute) on both sides of the spine, from the crown of the head to the lower back. Continuous hand contact is maintained by starting one hand down the back as the other hand stops at the lower back and is raised. Set aside a regular time for the massage. This gives the patient something pleasant to anticipate.
Exercise 3. Peaceful past experiences *
- Something may have happened to you a while ago that brought you peace or comfort. You may be able to draw on that experience to bring you peace or comfort now. Think about these questions:
- Can you remember any situation, even when you were a child, when you felt calm, peaceful, secure, hopeful, or comfortable?
- Have you ever daydreamed about something peaceful? What were you thinking?
- Do you get a dreamy feeling when you listen to music? Do you have any favorite music?
- Do you have any favorite poetry that you find uplifting or reassuring?
- Have you ever been active religiously? Do you have favorite readings, hymns, or prayers? Even if you haven't heard or thought of them for many years, childhood religious experiences may still be very soothing.
Additional points: Some of the things that may comfort you, such as your favorite music or a prayer, can probably be recorded for you. Then you can listen to the tape whenever you wish. Or, if your memory is strong, you may simply close your eyes and recall the events or words.
Exercise 4. Active listening to recorded music *
|Obtain the following:
|Mark time to the music; for example, tap out the rhythm with your finger or nod your head. This helps you concentrate on the music rather than on your discomfort.
|Keep your eyes open and focus on a fixed spot or object. If you wish to close your eyes, picture something about the music.
|Listen to the music at a comfortable volume. If the discomfort increases, try increasing the volume; decrease the volume when the discomfort decreases.
|If this is not effective enough, try adding or changing one or more of the following: massage your body in rhythm to the music; try other music; or mark time to the music in more than one manner, such as tapping your foot and finger at the same time.
Additional points: Many patients have found this technique to be helpful. It tends to be very popular, probably because the equipment is usually readily available and is a part of daily life. Other advantages are that it is easy to learn and not physically or mentally demanding. If you are very tired, you may simply listen to the music and omit marking time or focusing on a spot.
*Adapted and reprinted with permission from McCaffery M, Beebe A: Pain: Clinical Manual for Nursing Practice. St. Louis, Mo: CV Mosby: 1989.
Radiation Therapy to Relieve Pain
Radiation therapy may be used for pain relief rather than as treatment for primary cancer in patients with cancer that has spread to the bone. Radiation may be given as local therapy directly to the tumor or to larger areas of the body. Local or whole-body radiation therapy may make pain medication and other noninvasive therapies work better by directly affecting the cause of the pain (for example, by shrinking tumor size). Radiation therapy may help patients with bone pain from cancer to move more freely with less pain.
Pain flare is an increase in pain after radiation therapy that develops before pain is relieved. Pain flare is being studied in patients receiving radiation therapy for cancer that has spread to the bone.
External Beam Radiation Therapy
External-beam radiation therapy (EBRT) is a type of radiation therapy that uses a machine to aim high-energy x-rays at the cancer from outside the body. EBRT relieves pain from cancer that has spread to the bone in many patients. Radiation therapy may be given in a single dose or divided into several smaller doses given over a period of time. Single dose schedules and multiple dose schedules of EBRT are both effective for pain relief but single dose therapy is more likely to need to be repeated. Single dose EBRT for pain relief has not been found to cause more long-term harm than multiple dose EBRT. The decision whether to have single or multiple dose EBRT may also depend on how convenient the treatments are and how much they cost.
Stereotactic Body Radiation Therapy
Stereotactic body radiation therapy (SBRT) is a type of external radiation therapy that uses special equipment to position a patient and precisely deliver radiation to tumors in the body (except the brain). This type of radiation therapy helps spare normal tissue. SBRT may be used to treat cancer that has spread to the bone, especially spinal tumors. SBRT may also be used to treat areas that have already received radiation.
Bisphosphonates with Radiation Therapy
The use of radiation therapy given together with bisphosphonates is being studied in patients with cancer that has spread to the bone. More studies are needed to find out if giving bisphosphonates with radiation therapy relieves pain better than radiation therapy alone.
Radiopharmaceuticals are drugs that contain a radioactive substance that may be used to diagnose or treat disease, including cancer. Radiopharmaceuticals may also be used to relieve pain from cancer that has spread to the bone. A single dose of a radioactive agent injected into a vein may relieve pain when cancer has spread to several areas of bone and/or when there are too many areas to treat with EBRT. Small areas of cancer may respond to radiopharmaceuticals while large areas usually do not. A second treatment may be helpful in patients whose pain does not respond to a single treatment. One study showed that more than 2 doses of a radioactive substance called samarium 153 may be safe and effective in patients who responded to their first dose. Radiopharmaceuticals have not been shown to prevent the need for EBRT in relieving pain from cancer that has spread to the bone.
Radiofrequency Ablation
Radiofrequency ablation uses a needle electrode to heat tumors and destroy them. An imaging method is used to insert the electrode through the skin and guide the needle to the right location. This procedure may relieve pain in patients who have cancer that has spread to the bone. More study is needed to learn about possible risks and benefits.
Invasive Interventions to Relieve Pain
Less invasive methods should be used for relieving pain before trying invasive treatment. Some patients, however, may need invasive therapy.
Nerve Blocks
A nerve block is the injection of either a local anesthetic or a drug that inactivates nerves to control otherwise uncontrollable pain. Nerve blocks can be used to determine the source of pain, to treat painful conditions that respond to nerve blocks, to predict how the pain will respond to long-term treatments, and to prevent pain following procedures.
Neurologic Interventions
Surgery can be performed to implant devices that deliver drugs or electrically stimulate the nerves. In rare cases, surgery may be done to destroy a nerve or nerves that are part of the pain pathway.
Management of Procedural Pain
Many diagnostic and treatment procedures are painful. Pain related to procedures may be treated before it occurs. Local anesthetics and short-acting opioids can be used to manage procedure-related pain, if enough time is allowed for the drug to work. Anti-anxiety drugs and sedatives may be used to reduce anxiety or to sedate the patient. Treatments such as imagery or relaxation are useful in managing procedure-related pain and anxiety.
Patients usually tolerate procedures better when they know what to expect. Having a relative or friend stay with the patient during the procedure may help reduce anxiety.
Patients and family members should receive written instructions for managing the pain at home. They should receive information regarding whom to contact for questions related to pain management.
Treating Older Patients
Older patients are at risk for under-treatment of pain because their sensitivity to pain may be underestimated, they may be expected to tolerate pain well, and misconceptions may exist about their ability to benefit from opioids. Issues in assessing and treating cancer pain in older patients include the following:
- Multiple chronic diseases and sources of pain: Age and complicated medication regimens put older patients at increased risk for interactions between drugs and between drugs and the chronic diseases.
- Visual, hearing, movement, and thinking impairments may require simpler tests and more frequent monitoring to determine the extent of pain in the older patient.
- Nonsteroidal anti-inflammatory drug (NSAID) side effects, such as stomach and kidney toxicity, thinking problems, constipation, and headaches, are more likely to occur in older patients.
- Opioid effectiveness: Older patients may be more sensitive to the pain-relieving and central nervous system effects of opioids resulting in longer periods of pain relief.
- Patient-controlled analgesia must be used cautiously in older patients, since drugs are slower to leave the body and older patients are more sensitive to the side effects.
- Other methods of administration, such as rectal administration, may not be useful in older patients since they may be physically unable to insert the medication.
- Pain control after surgery requires frequent direct contact with health care providers to monitor pain management.
- Reassessment of pain management and required changes should be made whenever the older patient moves (for example, from hospital to home or nursing home).
Changes to This Summary (02 / 27 / 2013)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Changes were made to this summary to match those made to the health professional version.
Questions or Comments About This Summary
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PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information database. Most of the information contained in PDQ is available online at NCI's Web site. PDQ is provided as a service of the NCI. The NCI is part of the National Institutes of Health, the federal government's focal point for biomedical research.
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Last Revised: 2013-02-27
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Stocks Crushed as Wall Street Girds for Fiscal Cliff Battle
TheStreet) -- The major U.S. stock averages were walloped Wednesday, dragged lower by persistent worries about the fiscal cliff. The selling accelerated after President Barack Obama again stressed his commitment to ending Bush-era tax cuts for the wealthiest Americans during a press conference. The president's firm stance sets the stage for a tough battle with Republicans toward compromise on the next federal budget.The release of the minutes of latest Federal Reserve policy meeting was a factor as well as the commentary showed some division among members of the central bank's open market committee about continued quantitative easing efforts in 2013. The Dow Jones Industrial Average closed down more than 185 points, or 1.45%, at 12,571. The blue-chip index, which has now lost ground in five of the past six sessions, is now up just 2.89% year-to-date. The index, which scraped a session low of 12,542, has pulled back roughly 8% since hitting its 2012 intraday high of 13,661 on Oct. 5. Breadth within the Dow was very negative with losers far outpacing winners, 29 to 1. The biggest percentage decliners -- all down more than 2% -- were Boeing (BA), Bank of America (BAC), Caterpillar (CAT), General Electric (GE), Home Depot (HD), and United Technologies (UTX). Cisco was the only blue chip to finish in the green after the networking giant posted strong quarterly earnings after Tuesday's close. The stock added nearly 5%. The S&P 500 finished off more than 19 points, or 1.39%, at 1355, while the Nasdaq lost a little more than 37 points, or 1.29%, to settle at 2847. Both indices are still up so far in 2012, 7.78% and 9.28%, respectively. Since hitting a high of 3197 on Sept. 21, the Nasdaq has now lost 11%, qualifying as a correction. The S&P 500 has fallen 8.1% since peaking for the year at 1474.51 on Sept. 15. All sectors in the broader market were in the red, with basic materials, capital goods, conglomerates, consumer cyclicals and transportation posting the biggest declines. Decliners outnumbered advancers by a nearly 9-to-1 ratio on the New York Stock Exchange and 4-to-1 ratio on the Nasdaq. Volume totaled 4.09 billion on the Big Board and 2.10 billion on the Nasdaq. "With the majority of earnings reports in (approximately 70% better than expected) and the elections complete the equity markets are searching hard for direction and the fiscal cliff is clearly the major concern of the moment and the main driver," said Mike Boyle, a senior vice president at Advisors Asset Management. "Given this we would look for the S&P 500 to tack between 1350 and 1430 through year-end as the fiscal cliff negotiations heat up, but we fully expect the cliff to be averted and the S&P 500 to post a double digit return for 2012 and again in 2013."NEW YORK (
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subset: commoncrawl


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22 U.S. Code § 2804 - Establishment of standards and criteria; publication in the Federal Register
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(a) The Secretary of Commerce is hereby authorized and directed to establish and maintain standards, definitions, and criteria which are adequate to carry out the purposes of section 2802 (a)(1) andsection 2803 (a) of this title; and
Source(Pub. L. 91–269, § 4,May 27, 1970, 84 Stat. 272.)
LII has no control over and does not endorse any external Internet site that contains links to or references LII.


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Music MP3 Downloader 126.96.36.199 | 6.8 MB
Music MP3 Downloader - is a versatile, easy-to-use software which enables you to quickly free download over 100 million MP3 from the largest networks. Music MP3 Downloader provides direct access to free music. This mp3 downloader will provide you with a long musical compositions. In the world there are thousands of bands and artists offering their works for free. Chance to find among them something for the soul is very large. To facilitate your search, the program offers top one hundred of the week and the best in fourteen genres. You can optionally pre-listen to the melody first and then save it to your hard drive.


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Log in
Do you know if there is? Do you know how much it affects your organization's ability to do your mission-driven work now or in the future?
During our First Wednesday Risk Management Series webinar, presenter Carlye Christianson of the Nonprofit Risk Management Center pointed out several critical outcomes from having 'unhappy stakeholders' (staff, volunteer, board members) in your midst. Common to all stakeholder groups: discontent diminishes commitment to mission; and, costs of replacing people are high. She recommends studying retention in departments and stakeholder groups at least annually so problems can be addressed quickly. Below are some key points she made about why people leave organizations and how to proactively address discontent-causing practices:
Board Members
Continually assessing all areas (ED, board, staff, volunteers), individually and collectively, and implementing a culture of continuous engagement and improvement will go a long way to stemming and/or reversing discontent in all stakeholder groups. The costs for your organization and, especially the constituents you serve, are too high to do otherwise.
For more information on this and many other risk management topics, visit the Nonprofit Center for Risk Management. ONEplace presents their First Wednesday Webinar Series and Third Thursday HR Webinar Series. Check our website calendar for more information and registration.
Posted by Bobbe Luce at 07/08/2011 04:00:13 PM |


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Overhead cranes – optimized to your business
Konecranes is the world's largest supplier of lifting equipment for industrial purposes. Our offer includes the most significant innovations developed for overhead crane applications. This industry leading technology is based on our innovation power in mechanical and electrical design, and the application of the most modern industrial manufacturing technology. The reliability of our industrial cranes and other lifting equipment are both the result of our experience and commitment to engineering excellence.
Efficient lifting solutions for your businesses
Konecranes has gained an extensive and diverse global customer base in lifting businesses. General manufacturing represents the largest single customer segment. Konecranes also dedicate to improving performance in all kinds of industries. We empower your lifting solutions in ports, oil & gas, mining, automotive, warehousing, entertainment, energy, steel, petrochemicals, shipyards pulp & paper and other industries.
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24 Crowd-Pleasing Recipes for the Big GameBabble Editors
24 Crowd-Pleasing Recipes for the Big Game 1 of 25
Cherry Chipotle Chicken Wings 2 of 25
Put a sweet spin on this traditional game day staple with cherry chipotle sauce! Everyone at your house will be begging for more.
Five-Alarm Meatless Chili 3 of 25
Give the vegetarians at your party something to cheer about! This meatless chili is smoky, piping hot, and packs the perfect football party kick.
Perfect Salted Caramel Corn 4 of 25
Too busy watching the commercials to prepare snacks for your guests? This salted caramel corn is big on flavor, but quick on time — you prepare it in the microwave!
2-Minute Gorgonzola Dip 5 of 25
No matter what team your guests are rooting for, everyone will agree on this fantastic Gorgonzola dip. Whip it up faster than you can say "touchdown!" and serve with tortilla chips for that extra crunch.
Chocolate Cookie Ice Cream Cake 6 of 25
There's no better way to celebrate a win (or sulk over a loss) than with an indulgent slice of chocolate cake. Combining cookies, ice cream, and chocolate, this cake is a triple threat.
Loaded Enchilada Vegan Nachos 7 of 25
It's not a sporting event until the nachos are served. This vegan recipe allows you to customize your nachos, leaving plenty of room for creativity — pile on the toppings and dig in!
Taco Baked Potato Chips with Creamy Avocado Dip 8 of 25
Score a flavor touchdown with these ridiculously good — and healthy — taco-flavored baked potato chips!
Potato Skins 9 of 25
If there was a Lombardi trophy for flavor, these skins would win.
Caramelized Onion Bacon Dip 10 of 25
Football plus this smoky dip equal the perfect tailgating companions.
Buffalo Chicken Dip 11 of 25
This spicy dip will have all your guests cheering — no matter who they''re rooting for!
Philly Cheesesteak Sliders 12 of 25
Expect these sliders to score plenty of points with your hungry guests.
Potato Nachos 13 of 25
Go refill during a time-out — these loaded potato nachos are better than the Big Game commercials anyway!
Quesadillas 14 of 25
Put a huge dish of these crowd-pleasers near the TV and even non-fans will be acting like cheerleaders.
Homemade Calzones 15 of 25
Forget ordering pizza — no restaurant could make pizza pockets this good.
Crispy, Honey Mustard Chicken Tenders 16 of 25
Watching your diet more than the score? These tenders provide Big Game satisfaction without the guilt.
One-bite Pepperoni Pizza 17 of 25
A plate of these cheesy bites will disappear faster than the losing team.
Make one-bite pepperoni pizza
Homemade Soft Pretzels 18 of 25
The taste of these doughy delights will make you feel like you're actually IN the stadium!
Make homemade soft pretzels
Baked Jalepeno Poppers 19 of 25
Baked jalapeno poppers bring more heat than a wardrobe malfunction — adults only!
Make baked jalapeno poppers
Pizza Potatoes 20 of 25
This combination of game-day favorites is something any fan can cheer for.
Make pizza potatoes
Black Bean Fiesta Dip 21 of 25
This spicy black bean dip will punt traditional salsa right off the field, er, table.
Make black bean fiesta dip
Homemade Arby's Curly Fries 22 of 25
What better side to pair with your game day sliders than these homemade curly fries? And bonus: this skinny recipe has fewer calories than traditional fast food fare.
5-Minute Chocolate Chip Cookie Cake 23 of 25
Looking for a last-minute dessert you can whip up during half-time? We've got you covered with this super-easy cookie cake that'll leave you more time to check out your favorite commercials.
Make 5-minute chocolate chip cookie cake
Cinnamon Tortilla Chips with Fruit Salsa 24 of 25
You don''t need instant replay to know this dessert will be a huge hit!
Classic Root Beer Floats 25 of 25
A universally loved dessert that requires only two ingredients and takes less than a minute to prepare? Score!
Make classic root beer floats


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A federal judge also sentenced 72-year-old Dennis Eugene Rodebaugh of Meeker on Wednesday to pay a $7,500 fine and $37,390 in restitution to the state of Colorado.
A jury convicted him last year of aiding and abetting six violations of the Lacey Act. Prosecutors say his business, D&S Guide and Outfitter, provided out-of-state customers with hunting-guide services from salt-baited tree-stands, even though it's illegal in Colorado to use bait to take big game.
Rodebaugh's assistant guide Brian Kunz was sentenced Wednesday to time served, a year of probation, and a $2,000 fine for violating the Lacey Act while working for Rodebaugh.


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Jaco Pastorius
From Uncyclopedia, the content-free encyclopedia
"He can do Anything!"
|Jaco Pastorius
John Francis "Jaco" Pastorius is known as one of the greatest bassists of all time, and others still consider him far too great for the mortal world. He is best known for his
penis canibalism insane musicianship of jazz bass guitar. Eventually God became jealous, and killed him while disguised in the form of a Bruce Lee-type douchebag.
CreationIn the 1950's scientists were developing a new form of super-sperm. An experiment to fuse the sperm of Miles Davis, Dave Brubeck, Jimmy Blanton, and Paul Chambers to create a new breed of godly jazz musicians to combat the new movement of rock 'n' roll that old people in the 50's hated so much. Products of this experiment were Jaco Pastorius as well as Stanley Clarke, John Patitucci, Will Lee, Randy Brecker, Mike Brecker, Herbie Hancock, Al DiMeola, Lenny White, Chick Corea, Victor Wooten, Marcus Miller, Victor Bailey and, unfortunately, Kenny G.
Early Life
Jaco first picked up a bass four months before he was born. Jaco overcame the fact that his fingers had barely formed and composed the song "Portrait of Tracy" that would later be featured on his self-titled solo debut. Other songs from composed he in the uterus are "The Chicken", "Okonkole Y Trompa", and "Kuru/Speak Like a Child". Jaco's mother died in child birth because of the Fender Jazz Bass that was ejected from her vagina. Of course if she had survived she would have been wheelchair-bound for the rest of her life.
Jaco's Work in the AfterlifeJaco is currently working on a jazz-funk fusion album with Jesus (Drums), James Brown (
"Bass of Doom"
Jaco's "Bass of Doom" was a Fender Jazz Bass that he plied the frets out of with a butter knife. Then he put an epoxy resin on it so his fretboard wouldn't turn into the same kind of surface Fred Flintstone created while anxious. The result was possibly the most badass instrument ever conceived by man. The exact model was reissued a little while go, however, it would be sadly noted that thousands of souls were sacrificed during the making of these basses because the essence required to make just one of these basses were so great. The leftover ashes were used for the epoxy resin coating of the fretboard.
Shortly before God killed Jaco, his Bass Of Doom vanished. Recently, a man who claimed had the Bass of Doom walked up to Will Lee's apartment but this bass was really dressed up in disguise (it wasnt really a Fender; instead, it was a Sadowsky cunningly disguised as the Bass of Doom). The real Bass of Doom looks nothing like the original Bass of Doom or the 'wannabie' Sadowsky Bass of Doom. Some say instead it is black with a white scratch plate, rather reminiscent of the bass either Chris Frangou uses to destroy universes with, and some say it was turned into a trumpet and played by Maynard Ferguson.
Life on Earth
Apart from being an amazing bass player, Jaco was pretty fucked up. He was a drug addict and diagnosed with bipolar disorder later in his life, and to top it all off, he huffed cats like a mofo. He also impregnated women for miles with his bass playing causing thousands of illegitimate "Jaco babies" to be born in the early and mid 80's. As Jaco's life began to go into a downward spiral, God saw weakness in him and began plotting his attack on Jaco.
Because of his godly bass skills, God himself became angry with Jaco. God feared Jaco would overtake him as supreme ruler of the universe. He then killed him in the most embarrassing way possible. He took the form of a bouncer at a Florida nightclub and beat the living fuck out of him. This, however, only prolonged Jaco's reign as almighty.
Life after Death
After his death Jaco now resides in Birdland with his friend and co-conspirator-against-jazz Joe Zawinul, and his pet emu, Chris Frangou.


text: Orvis Mirage Pure Fluorocarbon IGFA Approved Tippet 30 Meter Spool If you are hoping for a line class world record or if you just want to be satisfied that you actually caught a fish that would qualify, this material is for you. Orvis Mirage IGFA tippet is perfect for adding new tippet to tapered leaders or building leaders from scratch. I use Orvis Mirage fluorocarbon to make my leaders for larger gamefish and saltwater fishing. For the tippet end, I use IGFA Approved Orvis fluorocarbon. I dont plan to go through the hassle of turning in a line class record. But, I do weigh large fish and sometimes check online to see how I did.Fluorocarbon does not deteriorate over time like monofilament. I have spools in my boat bag that are several years old. This is great material and I recommend it to anyone. I do use Orvis Super Strong for fishing with poppers and dry flies because it does not sink like fluorocarbon.Byron BegleyFREE GROUND SHIPPING IN THE CONTINENTAL UNITED STATESLittle River Outfitters is a fly shop and mail order company located in Townsend, Tennessee, a gateway to Great Smoky Mountains National Park. We have been family owned since 1994.


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May 6, 2016
Police said two men and one woman were assaulted inside a Kinston nightclub.
Kinston Police said they responded to a call around 2:30AM on Sunday for a stabbing at the Platinum Club on North Queen Street. Investigators said two men and one woman had been stabbed and their injuries ranged in severity.
19-year-old Dajuquon Poole was stabbed in his abdomen and was later airlifted to Vidant Medical Center in Greenville. 21-year-old Deangelo Simmons had stab wounds to his arm and chest, and was also later transported to Vidant Medical Center. 37-year-old Shontelle Poole's wounds were treated on the spot.
Police said the investigation continues. No word yet on any suspects.
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|"Mystery of Pain"
|(ペインの謎, Pein no Nazo)
|Episode data
|"Pain vs. Kakashi"
|Naruto: Shippūden #160 (Watch Online)
|"Surname is Sarutobi, Given Name, Konohamaru"
|Invasion of Pain Arc
|Chapter #424, Chapter #425, Chapter #426
|May 13, 2010
Mystery of Pain (ペインの謎, Pein no Nazo) is episode 160 of the Naruto Shippūden anime.
Konoha continues to fight off Pain while attempting to learn his secret. The Animal Path attacks the ANBU Interrogation Corps, and the Konoha ninja present must fight off a variety of different summons. Ibiki captures Animal Path in a Summoning: Torture Chamber, and tries to extract information about the enemy but to no success. Instead, torture is turned against him as Animal Path uses Ibiki's stomach as a conduit for summoning the Giant Drill-Beaked Bird. In the end, Animal Path unleashes all of the Summons, which led to more trouble for the Konoha shinobi to handle. Meanwhile, Naruto finishes his Sage Mode training and attempts to bond with Fukasaku, so that he can move in Sage Mode, while the Toad Sage gathers Nature Energy. However, Fukasaku is rebuffed by the Nine-Tailed Fox, forcing the duo to find an alternate method for Naruto to enter Sage Mode in battle.


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Yep, you read that correctly. November 19th is indeed a global celebration of the humble toilet.
I'll admit that I've enountered a few memorable toilets over the years. First, there was the eccentric elderly neighbor who deemed certain bodily functions inappopriate for the great indoors and relegated them to a ramshackle old outhouse that had seen as many or more years than she herself had. Then there were the restrooms at a certain state park in Upstate South Carolina, made remarkable not by the fixtures but by the "natural" surroundings … complete with a six-foot long black snake that slowly began uncoiling itself from the base of "my" toilet about the time I — as a 10-year-old — became aware of its presence. A few years down the road came the pay toilets of Europe — particularly the lavatory outside Versailles. (After all, one would think the maintainers of one of the world's most gilded palaces, situated in one of the wealthiest suberbs of Paris, could provide free "accomodations" for visitors!) Then came the squat toilets of Asia — odd at first, but arguably more hygenic than their seated counterparts if properly maintained.
But World Toilet Day isn't about functional toilets, however strange or humble. It's part of the World Toilet Organization's efforts to create a healthier world by providing toilets to impoverished areas and improving sanitation worldwide. According to the World Toilet Organization, some 2.6 million people worldwide live without toilets. Your donation of even $1 can help improve sanitation in impoverished areas and reduce the spread of disease.
November 19th also marks the the anniversary of Abraham Lincoln's delivering the Gettysburg Address, the death of the Ford Edsel, the first Cold War meeting between Ronald Reagan and Mikhail Gorbachev, and the beginning of the end for lip-syncing pop group Milli Vanilli.
Finally, November 19th was the birth date of Ruby Inez White. Can't place that name in your memory of world events? That's OK. The eldest of a sharecropper's 13 children, Ruby White didn't make the history books. But she did make her way all the way through school during the Great Depression and on through nurses' training in an era when few higher education opportunities were available to women (especially poor women). Most important to me, however, she went on to marry a certain Parker Holliday, give birth to my mother, and become a beloved grandmother.
Grandmama Holliday passed away in 1989. But during the fourteen years she was a part of my life, she taught me to celebrate not just the holidays, but life itself. Thanks, Grandmama. I love you.