Pain Management

What is pain?

Pain is unpleasant sensation, suffering or distress of the body or mind. Pain hurts and it wears you down. lt can make it hard for you to be active and make you feel tired and tense. Pain often accompanies cancer and other progressive diseases and it can affect all aspects of your life- psychological, emotional and spiritual.

Why are we afraid of pain?

Not all people living with terminal illness experience pain. However, many people living with a terminal illness are afraid of pain because they worry that pain cannot be controlled without awful side effects. Fear of pain adds to the total impact of pain. It is important to speak up about your pain and your fears about pain. Be honest and ask questions so that you can be given accurate information.

Can pain always be controlled?

Most pain can be relieved or controlled. Bringing pain under control and keeping it there means assessing each aspect of pain and monitoring it. These are core skills of palliative care doctors and nurses.

How can I help control my pain?

Good pain control requires good communication amongst patients, carers, medical and nursing staff. It is important to be open and share information so your care team knows exactly what is happening with your pain. Sometimes people report less pain than they experience because:

They value stoicism- they don’t want to appear weak

People interpret their pain according to their particular life experiences, values and beliefs. If you value stoicism for religious or cultural reasons, you may wish to discuss the matter with your religious leader or a pastoral carer. None of the major religions urges its followers to reject pain-killers {analgesics) in terminal illness. If you think that it is weak to ‘give in’ to pain, you might consider whether analgesia will free your energy for more important things.

They think increasing pain might be a sign of a worsening condition

Sharing your fears about your condition with the palliative care team can lessen your concern. Even if your situation is not good, discussing it may reduce your anxiety.

They think they will not have a say about their pain control

Control of your pain is negotiated between you and your doctor and nurses. Pain control plans are tailored to meet your particular needs and are adjusted as your needs change. You have the say as to whether you want more or less pain relief.

They are afraid that if they have strong pain-killers now, there will be nothing strong enough for them later

There is no set limit to the amount of pain relief offered. You cannot ‘run out’ and it can always be increased or decreased according to your experience.

How is pain controlled?

Medications are the foundation of pain control. There are two main groups of pain medicines ranging from mild pain relievers such as aspirin and paracetamol though to medium and strong relievers, such as morphine and related drugs (opiates). Anti-inflammatory, anti-depressant and steroid medication may also have a complementary role for some patients and some sources of pain. The right mix of medications is part of the expertise of the palliative care team.

Must I take medication?

Medication is the core treatment of pain in terminal illness. Surgery, radiation and ‘nerve block’ (like a local anaesthetic) are used to control pain in some cases.

When regular (eg: 4, 12 or 24 hourly) pain medication has been prescribed for you, you must take it on time. Do not wait to experience pain. The schedule is designed to prevent pain from occurring, not to treat it after it arrives since this type of pain tends to be with you continuously.

Other measures include:

Hot packs

• Careful positioning and repositioning appropriate exercise or support for a painful body part
• Special physiotherapy techniques, such as laser therapy and ultrasound
• Therapies such as massage, relaxation meditation, hypnosis, music therapy, aromatherapy acupuncture and acupressure
• Distraction – any activity that diverts and holds your attention will lessen your awareness of pain

Complementary measures are used as well as medical treatments. They increase the effectiveness of drug therapy and may reduce the amount of medication required.

If I take strong pain-killers (opiates), will I become addicted?

People sometimes think that opiates must be addictive because they come from the same source as heroin (opium). Heroin, injected into a vein, gives a rush of pleasure, called euphoria, which can be highly seductive. People who inject themselves in this way for no medical reason can become addicted and will need increasing quantities of the drug to remain euphoric or to avoid withdrawal symptoms.

Medically prescribed opiates are used in a very different way. The dose neutralises the pain. It does not give a ‘rush’. The chemical effect is taken up by the pain so that any feeling of euphoria is very mild or not noticed. Medication is given in the easiest way, usually by mouth (as a liquid, tablet or capsule); by injections (into skin, muscle or vein) or on the skin (in a patch quite like a nicotine patch).

Some patients will remain on the same dose even though their disease is progressing. Others need increasing doses of pain relieving medication. This is not evidence of addiction. The correct dose is the one that stops your pain and makes you comfortable. People vary, pains vary and there is no one right dose for everyone.

What are the side-effects of opiates?

Morphine and similar drugs cause ongoing constipation, which can be controlled with laxatives. Some people experience nausea, sleepiness or confusion when they first take these medications, for some people this can last up to five days. These symptoms usually clear up when the person adjusts to the medication; you can always discuss these symptoms with the doctors and nurses helping you with your care.

A few people experience continuing, unacceptable side-effects. In such cases other drugs are used or low doses of two or more drugs are combined to relieve pain without the side-effects. Palliative care physicians are specialists in pain control. If your pain control is less than perfect, seek specialist advice.

Does morphine suppress breathing?

An overdose of morphine in someone not accustomed to taking it, may suppress breathing but in most cases if the morphine has been properly prescribed this will not occur. Indeed, morphine can be used in low doses to ease difficult breathing and to suppress chronic cough.

What about breakthrough pain?

There may be times, even if you receive regular or continuous pain relief, when you will experience pain. This is called breakthrough pain and is very distressing for you and your carer. Your doctor will probably have prescribed extra medication to be taken as required. In this case take the extra medication, make a record of it, and make sure you tell the nurse or doctor. If extra medication for breakthrough pain has not been prescribed, get help from your palliative care team or General Practitioner without delay. Sometimes breakthrough pain means you need extra (or different) medication before some planned event requiring extra exertion or effort, such as showering. Often it means that your regular medication needs to be increased so that you remain comfortable. The goal of pain management is to prevent pain; it is more difficult to try to control pain once it has recurred, than to routinely treat it before you experience it.

Pain is a symptom most feared by people living with a terminal illness, but often it is not a source of worry for those receiving palliative care. Modern pain management means that patients can expect to remain virtually pain free throughout their illness