Pain is a dreaded feature of serious/advanced disease and the dying process. It is always a subjective experience, not what anyone else thinks it should be. Physical pain is not isolated from other forms of suffering; there is an interaction between physical distress and other issues such as psychological, social, financial or spiritual concerns. Pain does not necessarily relate to the extent of the illness, and some people with advanced disease may have no pain. It is important to know that 1 in 3 people with cancer do not have pain directly caused by their illness.
People with severe chronic disease may have variety of different pains, such as the body aching due to inactivity; ulcers due to continuous pressure on parts of the body eg heels, sacrum; constipation; old injury; and a host of other causes. These may need treatment along with the disease process itself.
Contrary to popular mythology, dying is not in itself a painful process. There may be pain caused by the situation causing death, eg chest pain due to heart attack. In peacetime, the majority of people can expect death to be without physical pain.
Pain is worsened by factors such as anxiety and tension, fear of the unknown, isolation, lack of sleep, spiritual concerns, and others.
The aim of pain management is to prevent the experience of pain. It is therefore important that you tell your medical care givers of any pain you may have, so that an individualized plan may be made to keep you comfortable.
Pain may also be a sign of advancing disease or complications of treatment, so it is essential to discuss it.
With good pain management strategies, over 90% of pain can be relieved. Pain is considered a vital sign in some institutions, along with pulse and blood pressure. You have a right to live and die free of pain.
Pain Management Strategies
There are many different strategies to reduce the experience of pain. Different therapies work for different people, varied types of pain, and at different times. Non medical strategies and complementary therapies should be exhausted prior to the use of analgesics (pain medications).
Instinctual responses to alleviate pain include reassurance, touch, rest, and the application of cold or heat. Relaxation may be by whatever method is helpful, such as music, meditation, imagery, visualization, hypnosis, laughter, movies. Physical strategies may involve massage, biofeedback or physiotherapy, and other methods. Herbal therapies may include arnica, ginko, kava, valerian, willow, dong quai, devil’s claw, lavender, St John’s wort or others. Some benefit may be obtained from homeopathic or naturopathic remedies. Medical marijuana works well for some people.
It is only when all avenues have been unsuccessful that medication should be used. Medications, street drugs, naturopathic remedies and herbs can all damage organs and should be used with caution.
Mild pain should be treated with mild analgesics, such as the over-the-counter medications including ASA, acetameniphen, NSAIDs, and various combinations with low doses of codeine.
When regular doses of these medications do not relieve the pain, a prescription will be needed for stronger medications. These are usually of the opioid (morphine based) group, of which there are many varieties and methods of delivery.
In some types of pain, medications usually used for other purposes may be very effective, eg anticonvulsant medication for nerve pain.
In the past, the word Narcotic referred to the opioid group of medications. Now Narcotic is often used to refer to street drugs. Morphine and related drugs are more accurately described as opioids.
When used appropriately, the opioid family of drugs are safe and extremely effective. Many people fear them or have mistaken beliefs concerning their use in medical situations. Discussion of these Morphine Myths applies to all members of the morphine group of medications.
Common misperceptions about morphine:
Addiction is inevitable. Morphine can be addicting when taken irregularly and in uncontrolled doses, allowing a sudden drop in blood level which leads to craving for the next dose. This rarely occurs in the medical setting where doses are given regularly to prevent the experience of pain.
Sedation and loss of awareness. Somnolence is a common side effect of morphine, but it nearly always disappears in 3-4 days after commencing therapy. Following this time, sleepiness and level of awareness return to normal levels.
Allergy is often confused with side effects. Since other opioids have slightly different chemical structure, they can be used for analgesia in the rare instances when morphine produces the hives and breathing difficulty of true allergy.
Morphine is an end-stage drug. However morphine is given to prevent the experience of severe pain, regardless of life expectancy. Its use does not mean that the person has ‘given up’ and will soon die. Due to persistent severe pain, some people are on regular doses of opioids for months or even years.
Tolerance is inevitable meaning that if you take morphine now, it will not be effective in the future. Fortunately this is not the case and the opioids remain effective over long periods of time.
Euphoria Morphine ‘high’ is rare when opioids are given in a specific manner to prevent the experience of pain.
Morphine causes respiratory depression. This can happen in cases of overdose, but is avoided in the medical setting by increasing the dose gradually to the level where pain is relieved.
Addicts cannot use morphine. Many addicts believe morphine will not be effective for pain relief. However, the right drug in the right dose can nearly always be found.
New Age concepts suggest that dying is a natural process and you should not take drugs for it. But morphine is given for severe, unrelenting, excruciating and exhausting pain; to deny a person relief from this is cruel, ignorant and unkind. Pain relief allows a person to put their attention where they would benefit, such as family connections or spiritual issues.
All opioids are illegal. Morphine is legal when prescribed in the medical setting.
Side Effects of Morphine:
Always: Constipation. This should be prevented proactive, in the same way that morphine is given to prevent the experience of severe pain.
Often: Nausea and vomiting clears in 4-5 days
Often: Sedation/ lack of awareness clears in 3-4 days
Sometimes: Itching, hallucinations, muscle twitching, difficulty emptying the bladder.
Side effects in the often/sometimes groups are often relieved by switching to another member of the morphine family.
This Hospice Net article addresses some common myths about pain control:
Pain Control: A Guide for People with Cancer and Their Families:
BC Cancer Agency patient information including items on pain:
Canadian Cancer Society patient information about pain:
Cancer Supportive Care has good information about pain:
Cancer Links provides descriptions to several good links on pain issues:
Booklets to help parents understand pain and teach them how they can help their child deal with pain from cancer:
Pain, Pain Go Away: Helping Children with Pain and Making Cancer Less Painful: A Handbook for Parents
The “Handbook for Mortals” includes a good section about pain.
An excellent on-line brochure outlining resources that are available
- On Line Publications made available through the Living Lessons Program of the Canadian Hospice Palliative Care Association entitled You are Not Alone living-lessons.org
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