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Things a patient can do:
Medications
Using medicines is the most common strategy for
relieving pain. Over-the-counter choices include aspirin, ibuprofen, or acetaminophen;
doctors also prescribe stronger pain medications such as morphine. These stronger
types of medication, known as opioids, are available in several forms: pills,
liquids, patches, suppositories, pumps that inject a small quantity under the
skin, and fluids that are delivered through an IV.
Although prescription medicines are very effective,
they may cause side effects. (See also "Myths and facts about
pain medicine" below.) Consulting with the patient’s doctor will
help identify the type of medication and dosage that will work best, but pinpointing
what is best for you may take some work. Following is a list of the most prevalent
side effects caused by opioids and things you can do to help the patient relieve
them:
Constipation is quite common, as is nausea.
However, some medications and home remedies help relieve these problems. (See
our article about Caregiving Tips.)
Many patients feel very sleepy, especially
during the first few days after starting a new pain medication or an increase
in dosage. Once the body adjusts to the new level, the patient usually becomes
more alert and this feeling passes. If this does not happen, you may wish to
talk to the doctor about trying a different medication or perhaps prescribing
a mild stimulant to counteract the patient’s drowsiness. Similarly, some
patients respond to pain medication with symptoms of mental fuzziness, confusion,
or delirium. If these responses do not resolve in a few days, the patient
may want to try a different medicine.
A less common side effect is involuntary twitching
of the muscles. This condition can be more distressing to the family members
than it is to the patient. If this becomes a troublesome side effect, there are
some medications that can offset this response, or a different version of the
opioid can be investigated. (Return to list)
Things a patient can do: Complementary
therapies
A good pain management plan consists not only of
medicines but also of non-medical therapies that will work together to more effectively
relieve the patient’s pain. Here are some complimentary therapies you may
find helpful.
Heat or cold. If a particular area of the
patient’s body is painful, hot or cold compresses may help relieve the discomfort.
Ask your doctor which is most likely to be beneficial. A hot bath can help, but
heat can also be applied through electric heating pads, hot water bottles, microwavable
pillows, or gel packs. Be sure that the heat source is wrapped in a way that
will protect the patient from leakage and burns. Heat therapy is best if it is
applied for 20 minutes at a time. If the person you are caring for is undergoing
radiation therapy, do not apply heat to that part of the body. By the same token,
do not apply heat to areas over an open wound or tumor.
For some types of pain, 15 minutes of cold is a
better source of comfort. Ice packs, gel packs, towels soaked in ice water, or
a bag of frozen peas all make excellent cold compresses. As with heat therapy,
be sure the source of the cold is wrapped to protect the patient against leakage
or skin irritation.
Massage. The healing power of touch has
been recognized for millennia. Massage stimulates blood flow, encourages relaxation,
and increases the recipient’s feeling of well being. Great benefits can
be obtained by light stroking, kneading, and rubbing. Seriously ill individuals
may need the massage to be gentle and restricted to areas that are not red or
inflamed. Use lotion to reduce friction on the skin.
Relaxation techniques. With techniques such
as deep breathing or progressive relaxation, the patient can interrupt the cycle
of pain–fear–tension–more pain. Deep breathing is simply slow,
deliberate inhalation and exhalation of air, with an emphasis on the release
of tension with each exhale. In progressive relaxation, the patient tenses and
then releases various muscle groups along the body. By contracting muscles and
then relaxing them, the patient experiences the contrast and learns to identify
and deliberately release tension in the body.
Meditation and guided imagery for pain relief.
Like massage, meditation has long been recognized around the world as a method
of releasing tension and easing pain. There are several types of meditation.
Some forms focus on expanding the mind’s awareness beyond the level of the
individual. Others concentrate the mind’s awareness on the internal functioning
of the body, which, surprising as it may seem, reduces pain by placing the focus
directly upon it. Either method seems to be helpful.
For those who are not inclined to meditation, guided
imagery is an effective way to draw upon the mind’s ability to transform
the perception of pain. Guided imagery usually entails someone giving the patient
instructions in a calm, low voice, describing images and sensations such as a
sunny day on the beach, with the gentle suggestion that each wave is washing
the tension and pain out to sea. A slow, detailed narration of this type can
help the patient by focusing attention away from the pain and onto pleasant and
relaxing images.
Adjusting our attitudes. The experience
of pain involves the mind’s perception of a physical sensation. Our mind,
including our attitudes and the focus of our "inner voice," can deeply
influence our perception of that sensation and the degree of hopelessness we
may feel about it. By using the technique of "reframing," a patient
can maximize the ability to cope with pain by altering any limiting or destructive
messages to the self. For instance, "Nothing has worked. This pain is never
going way," can be reframed to "I wish I were not in pain. I guess
I need to keep experimenting so I can find the right combination of approaches."
Reframing includes the practice of intentionally
shifting the awareness from what isn’t working to focusing on whatever positives
do exist in the situation. It challenges all-or-nothing thinking. Thus, another
way to respond to hopelessness about pain would be to transform "This is
useless, nothing has worked" to "This isn’t working as well as
I had hoped, but ‘X’ has helped a little, and that’s a start." Difficult
as it may be, if the patient concentrates on what truly is working and gives
him or herself encouragement to move forward, it will ultimately be more productive
than focusing on disappointments. Focusing on defeats causes a person to be more
aware of pain than if the focus is directed to victories or what might be possible.
Counseling. Although pain itself is very
real, our perception of it and our confidence in our ability to cope with it
have a significant impact on how much we suffer. People in chronic pain are not
able to be themselves. They are constantly distracted, often irritable, and frequently
discouraged. Relationships can become strained, and the person’s self esteem
can plummet. Physical pain often brings with it emotional, spiritual, and social
pain. Some patients find it helpful to work with a counselor trained in pain
management techniques. These professionals can help not only with coping strategies
to offset the physical pain of illness, but also with suggestions for handling
the complicated feelings and dynamics that often arise when a person in pain
is dependent on others for help and support.
Distraction. In the context of childbirth,
Dr. Ferdinand Lamaze discovered that the nerve pathway that sends messages of
pain to the brain can be filled with other nerve messages, effectively distracting
or blocking the brain from fully registering the negative sensation. The Lamaze
method uses unusual breathing patterns coupled with intense concentration to
distract a laboring woman from the pain of contractions.
Although "labor breathing" may be helpful
for short term, stabbing, or shooting pains, it is not generally a long-term
solution for chronic pain. Nevertheless, the distraction principle is a useful
one. Certainly a patient with nothing else to focus on is more likely to be fully
aware of his or her pain than is a patient whose attention is drawn to a specific
activity.
Depending on the patient’s energy level and
mental capacity, useful distractions can include singing, playing cards, listening
to music, watching television, talking with friends, reading, or having a story
or magazine article read to them. Be aware that when distraction helps, it does
not mean the pain was not real to begin with. Distraction simply blocks the pathway
of the nerves leading to the brain and, thankfully, keeps the brain from registering
discomfort.
Prayer or spiritual support. In times of
pain many people turn to prayer or spiritual pursuits and find it a source of
great solace. Because physical, emotional, and spiritual well-being are interrelated,
if the person you care for is spiritually inclined, the use of prayer, the reading
of spiritual works, or talking with members of the clergy may indeed result in
feelings of reduced pain or anxiety.
Acupuncture. The Chinese have a long history
of using acupuncture very successfully as a method to block pain. This ancient
method of healing is based on a concept of "meridians" or pathways
that circulate vital energy, called chi, throughout the body. In the Chinese
approach, pain and illness are caused by blockages in these meridians. To relieve
pain or illness, an acupuncturist inserts very thin, sterile needles into specific
junctures on the pathways and twirls the needles to release the blockages and
restore the balanced flow of chi. (Return to list)
Myths and facts about pain medicine
Many patients and families have inaccurate notions
about prescription drugs that relieve pain. "Palliative care"—the
medical discipline of making comfort a priority, especially when experiencing
a serious illness—is a relatively new field. As a consequence, people often
make medication decisions on the basis of an incomplete understanding of the
issues. Following are some of the most common myths about the use of opioids
for pain relief:
Fear of addiction or dependency. Addiction
is a physical and psychological dependency on a substance. When people worry
about addictions, they often conjure images of desperate, hedonistic individuals
who behave in irrational and illegal ways in order to get a "fix." People
who take morphine for pain rarely become addicted; they don’t fit this picture.
For instance, patients in hospitals who are given unlimited access to a morphine
pump following surgery typically undermedicate themselves. It is extremely unlikely
that a patient in the advanced stages of a serious illness will develop that
type of desperate physical/psychological dependence. Unfortunately, a fear of
addiction often results in family caregivers not giving the patient enough medication,
which leads to the patient experiencing unnecessarily high levels of pain.
Fear of developing a tolerance. Some people
are concerned that if the patient takes pain medication too early, the body will
adjust (i.e., develop a tolerance) and need increasing dosages to get the same
effect. Although it is true that dosages may be increased, this fear is based
on an assumption that there is a ceiling on the amount of medication a person
can take.
Fortunately, there is no ceiling, so there is no
need to endure pain in the present in order to save the medicine for some future
need. If the symptoms increase, whether from tolerance or increased intensity
of the disease, the dosage of the medicine can be increased indefinitely. Typically,
if current dosages are no longer effective, then the amount must be increased
by 25 to 50 percent.
To say there is no ceiling does not mean there
are no side effects, however. Increased dosages may well increase the number
or severity of side effects. But if a seriously ill patient wants to be pain
free, there is no need to put off relief early in the disease as an investment
against potential pain in the future.
Concern that increased pain means the disease
is getting worse. A person might experience increased or decreased pain for
a variety of reasons. In the case of a tumor, it may simply have shifted and
is now pressing on a different set of nerves. Or, psychological circumstances
may have changed and altered the person’s perception of pain. For instance,
relatives who were visiting have had to return home. Without the pleasant distraction
of their company, the patient is more aware of physical pain and discomfort.
No matter the reason for increased pain, if the patient does not communicate
this change to the physician or family caregivers, he or she is not likely to
experience relief from the symptom.
For more information about addiction
and tolerance as well as other guidelines for giving pain medications,
check out the "Fast Fact" briefs
written for physicians by the End of Life
Palliative Educational Resource Center of the University of Wisconsin
Medical School. (Return to list)
Tips for working with medications
Stick to a regular schedule. In an effort
to minimize the amount of medicine they take, some people try to extend the interval
between dosages. Unfortunately, it is much harder to bring pain back under control
than it is to prevent it from flaring up in the first place. Deviating from the
schedule suggested by the doctor can result in a need for more medicine to keep
the pain in check than if each dose had been taken when prescribed. If you are
having trouble remembering to give a dosage, use an alarm clock or the oven timer
to help remind you.
Get instructions about breakthrough pain.
Sometimes a patient will begin to feel pain before the next dosage is due. Generally
it is better to administer a smaller dosage in the middle than wait until the
next scheduled time. Again, it is easier to stop a buildup of pain than it is
to correct it after the fact.
Ask your doctor what to do if the patient vomits
up the medicine. Some medications can be re-administered if they were given
only a few minutes beforehand. Others require that you wait a specific interval
of time before it is safe to give them again.
Consider alternate forms of the medicine.
If the patient is having trouble with middle-of-the-night doses, a long acting
pain medicine might be a better choice to prevent having to wake at night to
take a pill. If the patient is having trouble swallowing or is throwing up the
medicine, a patch or rectal suppository might be a preferable delivery method.
Check with your doctor before you crush a pill and put it in applesauce. Some
medications do not work as intended if they have been crushed or altered.
Use a pill box. Many people with a serious
illness take an overwhelming number of medicines. To help keep track of the patient’s
treatment schedule, purchase a pill box that has compartments for morning, noon,
evening, and night. Because many boxes hold up to seven days’ worth of medication,
choose a time when you can fill the tray without distraction. Once the tray is
full, simply give the medicines one compartment at a time. You will find that
using a pill box also helps verify when the patient last took his or her medication.
Call several days in advance for refills.
It often takes a doctor a few days to get a refill prescription to the pharmacy.
When the patient gets down to five days’ worth of medication, call the doctor
for a refill. It’s better to be safe than sorry!
Use the same pharmacy for all the patient’s
prescriptions. Many patients have several doctors. It is difficult for these
physicians to know what their colleagues have prescribed. Let the pharmacist
help you avoid negative drug interactions. If all the patient’s prescriptions
are filled at the same pharmacy, the druggist can alert you about combinations
that are known to present problems.
Help monitor the pain. Keep a chart of the
types of pain the patient is experiencing and when during the day the pain occurs.
Help the patient rate the pain using a 0-to-10 rating system and record these
numbers. The more information you can give the doctor about your loved one’s
condition, the more likely it is that your health provider will be able to combat
the pain.
Take periodic time away for yourself. It’s
not selfish, it’s essential! Caring for a person in chronic pain can be
very draining. If you do not take breaks now and then, you are likely to burn
out and will not be able to give the best care possible. Check with community
agencies, friends, family, or your congregation for help with respite. A simple
walk around the block or lunch with a friend can do wonders for your mood and
your ability to keep giving optimum care. You need to keep your strength up,
if not for yourself, then for the sake of the patient. (Return
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