Pain Management
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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 pain.
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 the blood.
2)      The 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 other.
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 unusual.
4)      Some 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 weekend.
5)      The amount of narcotic should be just enough to ease the pain, but not so much as to cloud the mind.
a)      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 worthwhile.
b)      Some people worry about becoming addicted to medications.  This is not a problem, but if it concerns you, please discuss this with the Hospice nurse.
c)      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 nurse first.
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 Myths

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.


Myth #1: Morphine is offered to patients only when death is imminent.


 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.


Myth #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.


Myth #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 sleepiness.  Some people, however, notice a difference in their alertness and might choose somewhat less than perfect pain control as a tradeoff


Myth #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 comfortable.



Myth #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 morphine.


Myth #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 control.


Myth #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 terminal illness.

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