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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 patient’s 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. ever, 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 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.
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 University of
Wisconsin Medical School’s "Fast Fact" article
that addresses the double
effect of morphine. The patient’s 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. (Return
to list)
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. (Return
to list)
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. (Return
to list)
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. (Return
to list)
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. (Return to list)
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. (Return
to list)
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. (Return
to list)
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. (Return to list)
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 at the end of life—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 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. (Return to list)
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. (Return
to list)
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. (Return
to list)
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. (Return to list)
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. (Return
to list)
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. (Return
to list)
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. (Return
to list)
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. (Return
to list)
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. (Return to list)
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. (Return
to list)
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.
Information
on respite care available in your area may be obtained by
calling “The Nebraska Respite Network” toll free
at 1-866-737-7483. (Return to list)
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