Pain Management in Palliative Care

Pain is a complex symptom; there are several types of pain and numerous potential causes. Pain is also extremely personal and unique to the person experiencing it. For these reasons, pain management is also complex and deeply personal.

Management of pain in the palliative care setting has evolved a great deal in recent years. Physicians and patients often choose to take a multidirectional approach, using more than one type of treatment to alleviate pain.

What is Pain?

Pain is a multifaceted experience; which holds six different aspects:

Sensory: The actual pain sensation, gathered by our nerves and carried up our spine to our brain for interpretation. 

Cognitive: The way we explain pain to ourselves. For instance; "This is the normal pain of delivering my child" versus "This is pain from my cancer coming back." These two types of pain can be carried by the same nerve fibers and reach the same parts of our brain, but this interpretation makes them dramatically different. 

Emotional: Pain is largely affected by emotion. Depressed and anxious patients have much worse pain issues that are usually harder to control. On the upside, when these patients have appropriate treatment of the underlying emotional issues, pain becomes more manageable. 

Social: Pain is part of family and community communication. "Mom has a migraine." "I don't want to go to school because I have a belly ache." "Grandma suffered a lot to get us where we are." We learn to validate and invalidate different forms of pain in our particular culture from a very early age. 

Functional: Pain usually holds our functionality hostage. Back pain alone is one of the largest culprits of work absenteeism in the United States, costing the economy billions of dollars. This is a big aspect of pain, since ultimately the goal of treating any pain syndrome will be to restore that patient back to their normal functionality.

Spiritual: Many faiths base a lot of their teachings on the fact that a deity "suffered physical pain" for humankind. Finding meaning in pain is at the core of many individual and collective forms of spirituality. 

It is due to this rich nature of the pain experience that the reductionist view of treating pain solely as a biological phenomenon will usually fall short of actually helping people.

Pain Assessment Basics

Over the past 20 years, physicians have learned to incorporate pain assessment as the fifth vital sign. Many providers now ask patients if they have any pain at this time and to rate that pain on a 1-10 scale. Even though this is a great improvement in terms of providing better care for patients, the complexities and personal nature of the pain experience will have this solely numeric assessment fall short.

Understanding how pain impacts someone's life and their functionality—and how it particularly affects quality of life—is a nuanced process.

It starts with understanding the onset, frequency, location, radiation, triggers and soothers of a particular pain in a particular patient. Also, doctors and nurses should try to understand any previous intervention including physical therapy, procedures and medications and whether they have benefited pain or not.

Afterwards, asking questions about how pain has impacted movement, daily activities and overall functionality is also important to gauge the best pain recovery plan. Finally, every single person has a different way of thinking about their pain, and a different set of emotions around their pain experience.

Some patients feel particularly helpless against pain, others fear that pain is a sign of serious underlying "undiagnosed" medical issues, which further makes pain harder to control. Exploring pain in a broad way including all these factors is key to developing a plan for recovery.

Finally, there are some patients that, due to stroke, advanced disease (i.e. at the end of life), or other limitations, are incapable of transmitting the nature and characteristics of their pain with words. In these situations we rely on nonverbal cues like grimacing, moaning, or other signs of unrest to diagnose underlying pain.

How Palliative Care Approaches Pain

The palliative-care approach to pain is multifaceted and it explores physical, psychological, behavioral and social aspects of pain.

If pain stems from advanced cancer or another serious illness, the treatment plan will usually include an opioid.

Opioids are pain medications that either come directly from the poppy seed or manmade chemicals that resemble them.

Opioids provide pain relief by acting directly on the brain.

They are very effective medications for pain control, however they have serious side effects. When used in inappropriate doses, opioids can lead to excessive sleepiness and even unresponsiveness. In this unresponsiveness, patients might stop breathing, which is how opioids can cause death.

Used in proper dosages and under the supervision of a medical team, opioids are usually considered safe.

Risk of Opioid Addiction

This is a common concern of patients receiving opioids for pain control.

First, it is important to distinguish dependency from addiction:

Dependency is defined as "biological attachment" of your body to any substance. It happens frequently with everyday opioid therapy, and it can also happen with antidepressants, seizure medications and even blood pressure medications: if you stop any of these medications abruptly after being on them for a while, your body will "miss them" and you might experience symptoms of withdrawal.

However, an addiction is a different concept. When addiction is present, besides the biological dependency, there is a toxic behavior on the part of the patient which is what ultimately can affect well-being and put the patient at risk. For instance, it is different to feel the natural need for your next dose of your opioid pain medication (dependency) than to try and help the medication get a "kickstart" by crushing and snorting it (addiction).

Although patients cannot help and are even sometimes expected to develop dependency to medications that they've been on for a long time, addictive behavior should be expressed to your doctor as soon as it manifests since this might require the help of a specialist.

If you happen to grow dependent on your opioid pain medications, and you have reached a point in your health where you want to come off from them, this can be done in a progressive fashion. This way you might spare yourself withdrawal symptoms and comfortably come off your medications.

That being said, oftentimes in palliative care the culprit for pain (i.e. cancer tumors causing pain) continues to be present and it is both warranted and expected that the need for the opioid pain medication persists, and your doctor should continue to prescribe it as you navigate this complex phase of your life.

Baseline versus Breakthrough Opioid Pain Medications

Your baseline opioid pain medication is meant to prevent your pain, by giving your body a constant yet relatively low dose of pain medication. The idea is for this dose to keep the pain "at bay."

Baseline opioid pain medications usually come in the form of a long-acting tablet (a tablet that dissolves slowly in your stomach over 12 to 24 hours), or in the form of a patch (which slowly releases opioid pain medication into your body over the course of several days).

Your breakthrough opioid pain medication is meant to treat any flares of your pain, and help you deal with unexpected episodes of "extra" pain.

If your doctor has prescribed them appropriately for your medical condition(s) and other factors, it is usually safe to use the breakthrough opioid pain medication on top of your baseline opioid medication, if you feel you need it.

What to Expect Regarding Pain Control with Opioids

If you have a serious medical condition and your palliative medicine physician or hospice team have prescribed you opioids, it is with the intention of helping you preserve your quality of life as you endure this phase of your life.

That being said, the goal is usually not to have zero pain. However, the goal is for the pain to stop interrupting your everyday life (including sleep!) and not allowing do the things that you find most meaningful.

Tailored opioid pain medication regimens allow patients to complete the goals they had for their life as they are living with a life-limiting illness, and hopefully allow enough comfort to connect with loved ones, sleep peacefully, wander in nature, eat food they enjoy, etc.

A well-thought-out opioid pain plan should not prove to be dangerous, but actually seamless and safe; allowing you to have the highest quality of life and focus on the things that matter most to you.

Pain Medications Other Than Opioids

A number of other pain medications could be prescribed by your doctor. They include:

  • Anti-inflammatories and Tylenol: These over-the-counter medications are usually overlooked, but they could surprise you with how effective they can be. In palliative care, anti-inflammatories (like Ibuprofen or Naproxen) are frequently used for bone pain and it usually proves to be useful.
  • Anti-seizure medications: Drugs like gabapentin or Lyrica (pregabalin) are usually very helpful for pain from nerve injury (so called neuropathic pain).
  • Cannabis: More and more American states are legalizing and promoting the use of medical marijuana (cannabis). If you live in one of those states, talk to your provider about starting you on a formulation of cannabis that you can tolerate (experienced cannabis users versus inexperienced users need to be prescribed different forms and/or doses to avoid excessive sedation, confusion, or agitation). THC—one of the thousands of chemicals in cannabis that has an effect on human brains—has proven to be a powerful analgesic.

Finally, besides medications, a thorough assessment by your palliative care team will explore how your pain is affecting you—not only physically—but psychologically, functionally, and spiritually. Also, a palliative care team will help your loved ones understand how to better support you when you suffer with pain, as well as keep an eye on your caregiver's burden, making sure your support system stays strong and available to you.

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