A GUIDE FOR FAMILY AND
Pain may be a problem with progressing illness.
It can be well controlled to permit quality living. Hospice
wants to help you learn the basic principles of pain control so you
can apply them to your own situation.
Pain is an
intensely unpleasant feeling that only the person experiencing it
can know. The causes of pain include bodily change from the physical
effects of disease, pressure on sensitive structures, swelling from
inflammation, and irritation produced by chemicals. Pain
almost always causes anxiety or fear at first. When it lasts
for a long time, many people become depressed and have sleeping
difficulties. Pain is worsened by anxiety and tension,
depression and sleeplessness. A comprehensive plan for pain relief
should always include ways to relieve emotional distress and promote
relaxation. The Hospice team can provide guidance on the use
of these approaches. This guide will help you to understand
the use of medication to control
1) When pain is
constant, drugs need to be taken around the clock at regular
intervals, even if it means waking up the patient. This keeps
enough medication in the blood at all times so that pain is always
controlled. If a person waits until the pain comes back before
taking the drug, he or she will need a larger dose to ease the
pain. Just as the diabetic does not wait for signs of coma
before taking insulin, the hospice patient does not wait for pain to
take drugs to control it. In both situations, the purpose is
prevention of symptoms by keeping a constant level of drug active in
preferred way of giving medications is by mouth. When
necessary, there are other ways of giving medicines other than by
injections. Some medicines last longer than
3) The amount of
narcotic needs to be carefully adjusted and readjusted in order to
prevent suffering. Be sure to let the Hospice staff know about
any pain, discomfort, or side effects that are new or
medications require special prescriptions, which cannot be phones in
and may be difficult to refill on weekends or holidays. Please
always count medication to be certain you do not run out over the
5) The amount of
narcotic should be just enough to ease the pain, but not so much as
to cloud the mind.
When people first start taking a narcotic regularly they may become
sleepy or feel their thinking is foggy. If the drug is right
to control the level of pain, the mid will clear in 2 to 3
days. Waiting or the fog to clear is difficult but
people worry about becoming addicted to medications. This is
not a problem, but if it concerns you, please discuss this with the
Sometimes a person will be comfortable on narcotic drugs for a long
time and then start feeling confused. Confusion may be due to
chemical or physical changes in the body but drugs should also be
reviewed. Too much medication may be in the body, or the pain
itself may be less. Drug dosage can be dropped back for a few
days to see if the mind clears. Discuss any changes with your
d) When pain
reappears after a period of comfort, the amount of narcotic can be
increased or other medications or approaches can be added to balance
with the increasing pain.
Pain Control: Dispelling the
By Joel Potash, M.D.
Hospice strongly advocates good pain control for terminally
ill patients, even to the point of using narcotic drugs (we call
them opiates) such as morphine as they are needed. With all the concern about
drug abuse, patients and their families and friends sometimes
question this use of narcotics. Are we pushing ďdopeĒ? Or
are we practicing good medicine? Letís explore some of the myths
about the use of narcotics for pain control.
#1: Morphine is offered to patients only when death is
It is not the stage of a terminal illness, but the
degree of pain that dictates which medicine to use. We start
with the mildest medicine and if it works, stop there. If it
doesnít we move on, to morphine when itís appropriate. Some
people never need morphine, while others will require it for quite a
while. You can live for a long time on morphine.
#2: People who take morphine will become addicted.
Drug addicts are people who are driven by their needs for
narcotics; they may commit crimes or harm others to get their needs
met. Hospice patients
usually donít have drug-seeking behavior. When their pain is in good
control, they donít desire more opiates. Sometimes we can never
decrease the dosage. If
patients take morphine for a while, their body does become used to
it and it should not be suddenly stopped, because side effects could
occur. However, hospice
patients on morphine are not considered to be addicts.
#3: People who take morphine will become so sedated (sleepy) that
they canít function.
When patients start to take drugs like morphine, they often
feel drowsy for a few days.
But their bodies usually will very quickly build up a
resistance to the sedating effects. Most patients whose pain is
well controlled on morphine are not bothered by unusual
people, however, notice a difference in their alertness and might
choose somewhat less than perfect pain control as a
#4: People who take morphine die sooner because morphine causes them
to stop breathing.
Fortunately, patients quickly adjust to any effect that
morphine may have on their breathing. We prescribe a small initial
dose, gradually increasing it if needed. So rarely do breathing
problems occur, they are usually not even listed as side
effects. In fact
morphine is a drug of choice for breathing distress in people with
end-stage heart or lung disease; it makes their breathing more
#5: Iím allergic to morphine: once I had a shot of morphine
after an operation and I felt very strange.
Of course you can be allergic to morphine just like any other
medicine. But feeling
strange is not a sign of morphine allergy usually. Some people may have
unpleasant mental sensations temporarily when they start to take
morphine. But that is
not an allergy: and it might never recur. There are other opiates
available for those people who are truly allergic to
#6: Morphine must be give by injection.
We used to think that opiates were not effective unless
administered by injection. But Hospice has been a leader in
demonstrating the effectiveness of morphine and other opiates taken
orally. Even people who
required injections of morphine in the hospital (the most common way
of giving morphine there) will probably be able to well control on
oral morphine at home.
There are also long-acting preparations of morphine which can
be given every twelve hours, or opiate skin patches which can be
applied every 72 hours, to simplify the routine of pain
#7: People should wait until their pain is bad to take morphine so
it will be effective when itís really needed.
There is no upper dose limit to the use of morphine or other
opiates. If pain
increases we can increase the dose; this is true of very few other
medications. Using it
when itís needed early in the course of a terminal illness does not
mean that it wonít continue to work later in the disease.
Morphine, one of the oldest drugs in existence, has found a
well-deserved place in the new field of palliative care; the relief
of pain and other symptoms. We recommend opiates for pain
control only if they are needed. When they are needed, they
are often successful in controlling the pain and suffering of