What to Expect in Pain Management

Food and water represent life. But what does pain management represent? Pain is your body's way of letting you know something is wrong. When your loved one is in pain, it forces you to realize something is really wrong. And, as the strength of the pain medication increases, you realize that their condition is getting worse.

The desire to withhold the heavy narcotics from your loved one is not uncommon. There is a sort of magical thinking of "if they are not on pain medication, then they are not sick."

Other reasons you may have for wanting to withhold pain management could include: worries of your friend or family member becoming addicted, fear of over-sedation, or the fear that, if your loved one takes the heavy narcotics now, they won't have anything to help them if their pain gets worse.

You are right in thinking that if your friend or family member requires pain management with appropriate medication, there is something wrong. But, withholding their medication will not make the problem go away. In fact, it could make the problem worse. Without the proper medication the pain reaches a point where it is out of control.

As the result of the pain, your loved one will have difficulty sleeping. They may also feel depressed and have a decrease in their appetite or desire to do things they once enjoyed, as the quality of their life becomes compromised from the severe pain. Trying desperately to pretend the problem doesn't exist, doesn't make it go away. Allowing your loved one to take the pain medication will actually give quality to the time they have.

If your loved one has reached the point where their pain is out of control, it may take several doses before they finally find relief. Remember, while they are in pain, they are not able to get adequate sleep. Think back to when you may have had a horrible headache or back ache. You were so focused on the pain you weren't able to think of anything else; you weren't able to eat or sleep. Pain management allows for more normal sleeping, eating, and quality of life.

The same thing is true for your friend or family member. Once they are able to sleep, they will be playing catch-up with all the sleep they have lost over the past days or weeks. It is understandable how you may think they are over-sedated and you may even be tempted to withhold their medication to prevent this "over-sedation” from occurring again. But, try and resist this temptation.

When your friend or family member begins a new pain medication routine, there may be a period of adjustment. Once their body finds relief from the pain, they may finally have a chance to relax and get some desperately needed sleep. After this period of adjustment they will be more refreshed and able to enjoy your company.

As the disease progresses, your loved will become more tired. They will sleep longer. It is easy to misinterpret the end-phase of an illness with over-sedation; but, before you blame the narcotic and make changes to your friend or family member's pain management routine, it is always wise to consult with the physician first! The last thing you want is for your loved one to be awake and in pain.

Another common misconception is that your friend or family member will become addicted to painkillers. If your loved one was not addicted to drugs or alcohol prior to their illness, the likelihood of their becoming "addicted" to painkillers now is very slight.

Even if your friend or family member had a prior history of addiction, now is not the time to think about preventing them from becoming addicted again. Don't lose sight of the goal. The goal is for your loved one to have quality to their lives. Part of this quality involves effective pain management in terminal illness.

Let's look at some of the narcotics used to control pain:

Fentanyl comes in several forms. In the home setting, typically, children are prescribed Fentanyl in lollipop form while adults are prescribed a time-released patch form (Duragesic patch). The advantage of the patch is that it only has to be changed every three days (72 hours). This can also its short-fall.

While the patch lasts three days, it also takes about two to three days for the effects of the medication to be noticeable. And, about two to three applications (six to nine days) before there is a fairly consistent concentration in the bloodstream. Your loved one will need to continue taking short-acting narcotics until the Duragesic reaches its peaked effectiveness.

Duragesic also has a 17 hour half-life. This means that it takes 17 hours for half of the dose of the Duragesic to be eliminated from a relatively healthy body. If your loved one has to be switched from Duragesic to another narcotic, this half-life has to be taken into consideration as part of the pain management program.

While the patches can be convenient, you and your loved one will have to remember when to change the patches, to remove the old patch first before replacing it with the new patch and to rotate where you place the patch. The patch can also be affected by heat or cold. If your loved one takes a hot tub or shower or if their skin surface is cool (circulation is impaired) the absorption of the drug can be altered.

In the home setting, Dilaudid (Hydromorphone) is given either in oral or intravenous form (via a patient-controlled analgesic/PCA pump). The oral dose is given every 4 to 6 hours. It takes about thirty minutes to an hour for Dilaudid to reach its peak and it lasts about 5 hours.

Morphine comes in multiple forms. The time-released, long-acting form of morphine is commonly known as MS Contin, Oramorph SR or Morphine SR. Long-acting morphine is released over a 12 hour period. Because it is a sustained release (SR) formula, the pills cannot be crushed or split. An immediate form of morphine comes in liquid and tablet. It begins to work in 30 minutes but only lasts for 4 hours. Like Dilaudid, Morphine can be given in the home via a PCA pump intravenously.

Morphine, Fentynal and Dilaudid are used for more severe pain. Narcotics such as Vicodin , Codeine or Darvocet are used for moderate pain or pain that may breakthrough the pain-relief abilities of Dilaudid, Morphine or Fentynal.

The positive news is, as the level of pain increases, Dilaudid, Morphine and Fentynal are narcotics that can be increased (titrated) to meet the needs of your loved one for pain management. If, for any reason, your friend or family member has to switch from morphine to dilaudid, or Fentynal to morphine (etc.), there are conversion charts that allow this to occur.

With so many choices in medications, the route the medication can be given (oral, topical or intravenous), and with doses that can be tapered up as needed, pain control should not be an issue for your loved one.

Return to What to Expect in the Final Days


Continue to Terminal Agitation from Pain Management

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