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Medications
Using medicines is the most
common strategy for relieving pain. Over-the-counter choices
include aspirin, ibuprofen, or acetaminophen; doctors also prescribe pain killers
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 often cause side effects. (See also "Myths and facts about pain medicine"
below.) Consulting with the patientís doctor will help identify
the type of medication and dosage that will work best, but
pinpointing the best solution may take some trial and error.
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.)
Another side effect is involuntary twitching of muscles. This condition seems to be more
distressing to family caregivers than it is to the patient.
However, some medications can offset this response, or a different
version of the morphine could be investigated.
Many patients feel very sleepy,
especially during the first few days after an increase in
dosage. Once the body adjusts to the new level, the patient usually becomes more
alert and able to interact. 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 patientís 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.
Just as morphine slows down
many other bodily functions (e.g., digestion), it also slows
the patientís breathing. If a patient is near death,
slowed breathing may to a small degree hasten the moment
when he or she stops breathing altogether. Some physicians
feel uncomfortable about this unintended side effect of
morphine and therefore hesitate to prescribe it. If this
is the case for your physician, he or she may want to
read the Medical College of Wisconsin's Fast Facts Article
#8 which addresses the double
effect of morphine. The patientís wishes are of
prime importance. For this reason, it is important to
talk to family members and the doctor to let them know
if keeping the patient pain free is more important than
helping him or her live a few hours or days longer. (Return
to list)
Non-pharmacological approaches
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.
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. You
may want to 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.
Mental techniques 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"óthe medical discipline of making comfort
a priority, especially at the end of lifeóis 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 donít
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 terminal 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 must 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 terminally 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 personís 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 Mdical College of Wisconsin. (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.
Do not skip middle-of-the-night
doses. Because the body needs a constant level of medication
in the system, skipping a middle-of-the-night dose is likely
to result in unnecessary pain. If getting up is too difficult
for the patient, shift the schedule so the late-night and
early-morning doses are closer to times when he or she is
more likely to be awake.
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 patch might be a better way for
the medication to be administered. 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 tray. 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 tray 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 tray 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 to list)
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