 | Jerry Old MD is chief consulting medical officer with Hospice Care of Kansas and an associate professor at the University of Kansas School of Medicine-Wichita. He is a nationally recognized author and speaker on end-of-life issues. You may contact Dr. Old by phone at 1-800-HOSPICE. |
Hospice
2011-06-01 11:08:00
Myths in pain management
Question: What can you tell me about pain management?
Answer: When it comes to treating persistent pain, the medical profession often feels that we are “doomed if we do and doomed if we don’t!” On the one hand, almost all studies done since the 1950’s show that medical practitioners tend to under treat pain, especially in the elderly and in end-of-life situations. There is good evidence that 40% of cancer patients are undertreated, and that 45-80% of all nursing home patients reports some pain every day.
Yet, on the other hand, diversion of pain medications to those that use them for recreational purposes is on the rise. The question is “how do we treat pain in those patients that have legitimate pain, but avoid narcotic medications from being abused and adding to the drug problem in this country?” Just like most things in life, balance seems to be the key. Dispelling myths about pain medications is the first step.
First, we have to define pain. One national guideline states that “Any pain that has an impact on physical function, psychosocial function, or other aspects of quality of life should be recognized as a significant problem.”
Pain is divided into basically two types. Acute pain and chronic pain. Acute pain is what we are all familiar with like a sprained ankle or accidently hitting your thumb with a hammer. The cause is known and the duration is limited. It will eventually get better, with or without treatment. Chronic pain is different. The cause may not always be clear and it persists without improvement for months or years. Treatment of chronic pain is of greatest concern because it is going to require long-term treatment.
The World Health Organization has devised a very practical approach to treating pain, called the “pain ladder.” Essentially, the ladder starts with mild pain medications such as acetaminophen (Tylenol) and then goes up the ladder to opioids such as morphine. The lowest dose of medication is used that will adequately control the level of pain.
The greatest myths in pain control come from treatment requiring opioid pain medications, such as morphine and its other derivatives. Morphine was available without a prescription in this country in the 1800’s, and was used extensively during the American Civil War for pain treatment. Modern examples of morphine compounds include hydrocodone (Lortab, Vicodin Norco), oxycodone (Oxycotin, OxyFast, Percocet, Tylox, Roxicet) and hydromorphone (Dilaudid), to name a few. Since these medications are sometimes abused, their legitimate use for pain has become stigmatized.
Patients and physicians both have bought into several myths about narcotic pain medications. Patients often feel that reporting pain to their physician is a sign of weakness—after all, John Wayne would have never shown pain, even after being shot several times! Sometimes pain is seen as a punishment for previous transgressions—perhaps a punishment from God that is to be endured. In my geriatrics practice, older adults often withhold telling the doctor about their pain because of fear of unwanted medical testing or loss of independence (“If you are having that much pain we may need to think about nursing home placement”). Another myth that patients have, shared by many physicians, is that adequate pain control is just not possible.
Physicians are worried about legal ramifications of prescribing narcotic pain medications and share the patients concerns about addiction and side effects. In truth, addiction and serious side effects (i.e. stopping breathing) are extremely rare in treating pain. Likewise, a physician getting into legal problems for treating pain is extremely rare (but highly publicized) and generally involves inappropriate prescribing.
Many of the myths about pain management evaporate when we understand the difference between tolerance, dependence, and addiction.
Tolerance means that one has to increase the dose of a substance to keep getting the same effect. This is common if medications are used to get a “high.” Even alcohol is in this category. Each time you drink to get a “buzz” you have to drink a little more to get the same “buzz!” But this is uncommon in medications used for pain control. If we find the correct dosage of pain medication, the patient may stay on that dose for months or years.
Dependence simply means that withdrawal can happen if the medication is stopped suddenly. Again, this is not addiction. A number of medications produce dependence. There are a number of blood pressure medications that should not be stopped suddenly. Steroids such as prednisone are giving in a tapering dose. Dependence is also rare when pain medications are being used for legitimate pain control. In hospice, I have seen patients stop large amounts of narcotics when the pain goes away, and not experience withdrawal.
Think of it this way: Pain acts as an antidote to the narcotics. When pain is present, it soaks up the opioid and addiction, tolerance and withdrawal are rare. If pain is not present and the medication is used for that euphoric buzz then all three will become a problem, addiction, tolerance and dependenceny.
Psychological addiction is simply anything that is ruining your life and you keep doing it, drugs, porn, food, etc. If the pain medication is making your life better, particularly in function, then it does not fit this definition.
Opioids are physiologically very safe medications. The American Geriatric Society has determined that opioids are safer for the elderly that ibuprofen! Opioids do not seem to damage the body and have no warnings for liver, kidney or lung disease.
What about side effects? Everyone knows that morphine can stop respirations—right? Actually that is another myth. With increasingly large doses of opioids, people go through predictable stages of sedation. They do not go from awake and talking, to dead with one appropriate dose of medication. Significant stages of coma are noted before respirations are affected.
In summary, there are several myths about medications used for severe pain control. However, chronic pain can be treated safely and adequately. The risks of addiction and respiratory depression are rare in proper pain management. The myths discussed here should not be barriers to patients receiving proper pain control.
