JAOA • Vol 107 • No suppl_4 • June 2007 • 28-31
My Wits About Me Patient Education and the Effective Use of Opiates
Nicholas G. Parise, DO, MS
Dr Parise is assistant professor of medicine at Mid-western
University/Chicago College of Osteopathic Medicine in Downers Grove,
Ill.
Address correspondence to Nicholas G. Parise, DO, MS, FACOI, Diplomate, ABHPM,
Director, Internal Medicine Residency Program, Swedish Covenant Hospital, 5145
N California Ave, Chicago, IL 60625. E-mail:
nparise{at}schosp.org
Managing symptoms at end of life can be one of the more challenging and
rewarding aspects of medical care. Pain management in particular can be made
difficult from an unlikely source. Surrounded by myth, misconception, and
cultural bias, opiates remain the mainstay of treatment. Frequently, patients
themselves may be the most formidable barrier to their effective use.
Presentation of a reality-based case serves as the basis for exploring some of
these attitudes and beliefs that may be a stumbling block to opiate use in
effective pain management.
The inhibiting fear associated with prescribing drugs classified as
"narcotic" is illustrated through 10 common misconceptions
regarding their use and is characterized by the term Opiophobia. Not
all the misconceptions originate from patients, but also from family members,
cultural and regulatory agency norms, and even physicians themselves. A brief
discussion follows each of such flawed concepts as "morphine use
indicates death is imminent," "enduring pain enhances
character," hospitalization is required for effective pain
management," and "opiate use always leads to addiction."
Regarding the hot button issue of addiction, a glossary is provided to help in
distinguishing nonaddiction etiologies that explain the frequent need for
dosing increases.
The formal recognition of hospice and palliative medicine as a certified
sub-specialty confirms the notion that it is the duty of physicians to provide
optimal care through the dying process. Undoubtedly, evidence-based guidelines
will lead to new standards of practice improving end-of-life care. This
article adds perspective to past practices and opens the door to adding
perspective to new ones.
The representative couple referred to in this vignette as Fred and
Audrey could not be more in love. Fred, a former US Navy pilot, and his blonde
beauty could not wait to be in each other's arms, and it is no surprise that
it fueled their passion for dancing all these years. In fact, through most of
the nearly 20 years that I cared for them, every Saturday night was
"Swing Night." I can only imagine how effortlessly they glided and
twirled across the floor as I had seen so many of that "Greatest
Generation" do as I grew up. In fact, it was not until Audrey's
Alzheimer disease was quite advanced that Fred stopped taking her to the dance
hall. He was quite the stalwart in his commitment to Audrey. He was totally
devoted to her care. They never had children, and their closest relative was a
niece who lived 2000 miles away. Fred was there for Audrey 24/7. As her
condition deteriorated, he learned to do it all—cook for her, feed her,
clothe her, walk her, and diaper her. He knew he was her only world, and she
was his. I often wondered if he would be totally devastated after her death,
or if there would be a sense of relief and some motivation for him to move on.
Only he was more surprised than I to realize it would be Audrey living on
without him.
Fred had been ignoring his symptoms of abdominal pain, weakness, and
weight loss, chalking them up to the stress of dealing with Audrey's
progressive decline. How could he possibly get sick when Audrey needed him so
badly? He was finally coaxed into updating some blood tests as it had been
some time since he had scheduled a visit for himself. His pallor and weight
loss suggested that more than stress was at work.
Fred was found to have metastatic liver disease and an unidentified
primary tumor. His decline was very rapid, and it seemed sudden that I found
myself seeing him in my role as a hospice clinician. The hospice nurse had
reported that Fred had increasing severe pain and had been steadfastly
refusing to take any of the "dope" that had been prescribed in
spite of his obvious suffering. "I can't be doped up. Who is going to
take care of Audrey? I gotta keep my wits about me."
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Opiophobia
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Few modalities used in standard medical practice can rival the legacy that
opium and its derivatives has built since its first mention as an analgesic by
Theophrastus in the third century
BC.1 The history
that has accompanied the cultivation, trade, uses, and the legal, political,
and profitability status of the unripe seed pod of the poppy plant,
Papaver somniferum, is a significant part of world history. It has
been romanticized and vilified, from Broadway plays to outright wars, from
billions in illegal trade to bloody murders—all of it tied to its
distribution and control. It is no surprise that with such a notorious
history, many myths and preconceived notions have developed around opium, not
only in the United States, but also in most all other cultures.
Morphine is a daughter of opium, and in the eyes of many, she cannot escape
the sins of her mother. It is a purified derivative of opium and commonly
indicated for analgesia in a variety of circumstances, not the least of which
is suffering frequently associated with symptoms accompanying end-stage
disease. Despite its checkered past, morphine sulfate has the efficacy,
safety, side effect, and cost profile that is at least comparable to those of
other high-quality pharmaceuticals used routinely in medical practice. All
available drugs classified as opiates generally share these characteristics.
Reference resources reviewed for this article are consistent in their
recommendation for morphine as a standard in pain and symptom management.
Although several barriers (eg, fear of governmental regulatory policies,
physician education and experience) to appropriate opiate use in chronic and
progressive pain syndromes of end-stage disease may complicate efforts to
provide quality end-of-life care, it is the reluctance of patients and
caregivers that is most likely to be encountered with regularity. Success in
improving patient and caregiver compliance has been shown to improve quality
of living for those with a life-limiting
prognosis.2 An
effective way to improve compliance is for physicians to upgrade their own
education and understanding and to use their communication skills to identify
and dispel patient and caregiver fears based on the mythical history of these
drugs.
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Ten Common Misconceptions About Pain and Opiate Use at End of Life
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- "Once you start taking morphine, the end is always
near."—As opiates, particularly morphine, are commonly used in
end-of-life care, many patients and families who make the association take it
as a powerful symbol that hope is lost. They need to be made aware that
morphine does not initiate the final phase of life or lead directly to death.
For patients with life-limiting illness and chronic pain, morphine can provide
the type of comfort that may permit improvement in activity (eg, deep
breathing, ambulation, or tolerance for sitting upright), nutritional intake,
and social interaction, all of which may delay complications and lengthen
their lives with improved
quality.
- "Enduring pain and suffering can enhance one's
character."—Before the advent of scientific research to
explain the physical processes of pain and modern analgesic interventions, the
explanation for the existence of pain was strongly attached to the spiritual
realm. For example, in the Judeo-Christian tradition, pain is a consequence of
man's disobedience to God in the Garden of Eden. Every religion and school of
philosophy has confronted the problem of pain. Coping with such discomfort
through a belief system (eg, "I will earn a higher place in the
after-life") was the only mechanism available for centuries. While
suffering in the spiritual realm can and does exist, treatment of the physical
element can lessen distractions from reflection, meditation, prayer, and
participation in religious rites and traditions, helping to ease existential
concern and anguish.
- "People have to be in a hospital in order to receive effective
pain management."—Compared with the average acute care
hospital, it is much more efficient and safer to provide effective pain
management in a home setting. No competition for the attention of nurses or
caregivers exists, and administration of medication can more accurately follow
dosage schedules or be customized around patient need or preference. Having
one or just a few caregivers offers an advantage for noticing nuances or more
substantial changes that may reflect problems with dosing, efficacy, or side
effects, and for reporting them in a timely manner so that appropriate
interventions can be instituted. Technologic advancements make multiple
modalities of pain control available in the home setting, (eg, peripherally
inserted central catheter [PICC] lines, continuous infusion pumps,
transcutaneous electrical nerve stimulation [TENS] units).
- "To get good pain relief, you have to take
injections."—Until the mid-1970s, it was believed that
morphine was not an effective analgesic when given by mouth, and it became
standard practice to administer it by injection. Since then, effective oral
preparations, both long-acting, (up to 12 hours) and immediate-release, rectal
suppositories, and transdermal preparations have been developed. Oral morphine
in high-concentration, low-volume preparations can be used and are effective
even when the patient does not have an intact swallowing mechanism by
installing a dose for mucosal absorption sublingually or in the buccal space
between cheek and gum.
- "Pain medications always cause heavy
sedation."—Most patients in chronic pain have been deprived of
sleep and rest as a consequence, and relief is often met with a period of
well-needed rest. In most patients, any sedative effects begin to wane in the
first 72 hours, allowing a return to baseline mental status. Short-term memory
can be compromised in some individuals, and they should be encouraged or
helped to keep a log or journal for important instructions or information.
Persistent sedation may be due to drug interactions with concurrent
medications, especially anxiolytics and sleep aids, which may no longer be
necessary if uncontrolled pain was the cause for those needs.
- "It is best to save the stronger pain relievers until the very
end."—The objective is to bring the pain under continuous
control from the outset so that each day could be the best one possible for
the patient, and the highest quality of life can be realized for the duration
of the patient's life. Partially or occasionally controlled pain tends to
increase in severity, leading to two mistaken assumptions:
- Patients mistakenly fear that the pain is so severe that it can never be
controlled; anxiety may accompany this assumption, possibly increasing the
severity of suffering and complicating further management through diminished
trust.
- Physicians mistakenly believing that the patient is becoming addicted or
developing tolerance to the analgesic; this could lead to further reservation
in providing effective dosages in the case of presuming addiction, or
overtitration's producing intolerable adverse effects in the case of presuming
tolerance.
- "Some types of pain cannot be relieved."—Solely
relying on opiates for pain control can have limitations, and neuropathic pain
may be a classic example. However, "multimodality" or combined
approaches, including adjuvant medications such as neuroleptics, chemotherapy,
radiation therapy, nerve block, or ablation techniques, cannot be overlooked,
and in nearly all circumstances are effective. Addressing psychological,
spiritual, and social aspects of the patient's suffering through intervention
of professionals from those disciplines can also act as an effective adjunct
to physical pain control.
- "Patients often develop tolerance to pain medications like
morphine."—Tolerance is certainly a phenomenon related to
opiates; however, dosage levels effective for continuous control of pain in
cases of life-limiting progressive diseases rarely need to be increased
because of tolerance, but rather for increased pain associated with the
progression of the disease process.
- "Once you start administering pain medicines, you always have to
increase the dose."—In many instances, once pain is under
control and the dose of opioid holds at a steady level for several days, the
opioid dose can be lowered gradually to a point that meets the patient's
needs. The ability to lower the effective dose once control has been
established seems paradoxical and is associated with severe chronic pain. In
theory, it may be a phenomenon associated with relief of the emotional and
psychological influences that may accompany fear that the pain will be
permanent for the remainder of the patient's life.
- "Pain medications always lead to
addiction."—3,4There
is no empirically based evidence that opioids, when prescribed on a regular
basis in a dose necessary to relieve pain, lead to addiction.
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Tolerance, Addiction, or Something In-Between
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The last misconception permeates the culture of both physicians and society
in general, and as such, it can be the toughest misconception to overcome. It
is not unusual for some physicians to underprescribe or for family and
care-takers to take it upon themselves to hold doses or discard prescribed
opiates for the sake of fears surrounding addiction and the legality of their
activity. Understanding and explaining the nature of opioids and the frequent
need for titration and at end of life may provide the confidence and trust
necessary to ensure compliance and offer quality for the remainder of a
patient's life.
The following
definitions5,6
may be useful to clarify patients' status and allow for better understanding
of their needs and the rationale for changes that may be necessary.
Tolerance: A state of adaptation in which exposure to a
drug induces changes that result in a diminution of one or more of the drug's
effects over time.
Pseudotolerance: The need to increase dosage that is
not due to tolerance, but due to other factors such as disease
progression, new disease, increased physical activity, lack of compliance,
change in medication formulation, drug interaction, addiction, and deviant
behavior. When a once-fixed opioid dose is no longer effective, the foregoing
listed conditions should be reviewed to exclude pseudotolerance.
Physical dependence: A state of biolgical adaptation that
is manifested by a specific withdrawal syndrome that occurs after abrupt
cessation of pharmacotherapy, rapid dose reduction (which decreases blood
levels of the drug), and/or administration of an antagonist.
Addiction: a primary chronic neurobiologic disease, with
genetic, psychosocial, and environmental factors influencing its development
and manifestations. Addiction is characterized by behaviors that include one
or more of the following: impaired control over drug use, compulsive use,
continued use despite harm, craving, and a high rate of recidivism.
Pseudoaddiction: a term that has been used to describe
patient behaviors that may occur when a patient is under-treated for pain.
Patients with unrelieved pain may become focused on obtaining medications, may
"clock watch," and otherwise seem inappropriately drug
seeking." Even behaviors such as illicit drug use and deception can
occur in the patient's efforts to obtain relief. Pseudoaddiction can be
distinguished from true addiction in that the behaviors resolve when pain is
effectively
treated.5,6
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Comment
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Fred's motivation to remain in severe pain was indeed admirable but totally
unnecessary and even counterproductive to his goal: to remain in control of
his helpless wife's well-being. When he realized how much the pain distracted
from his ability to concentrate, how much physical and emotional energy had to
be invested to fight it, and that it might even make him less effective for
Audrey's well-being, he accepted recommendations to control his pain.
We kept a journal to document our discussions and his wishes so memory
would be less of a concern. He rested and slept better noting more energy.
When his niece visited him, he was able to interact and convey his wishes and
affections unencumbered by physical suffering. The arrangements Fred made for
Audrey with the help of his niece were satisfactory, and his niece was more
than willing to lovingly take over wherever he left off, taking Audrey close
to her home.
Fred remained the dutiful husband that he needed to be until the day he
died, and his life ended in peace. It was the best possible ending to a tragic
situation. Dr Sydenham and I were pleased.
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Footnotes
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"Among the remedies which it has pleased
Almighty God to give man to relieve his sufferings; none is so
universal and so efficacious as opium."
Thomas Sydenham, English physician (1624–1689)
Dr Parise has no financial conflicts of interest.
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References
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1. Fulop-Miller R. Triumph Over Pain. London,
England: Hamish-Hamilton Ltd; 1938.2. Syrjala KL, Roth-Romer S. Non-pharmacologic management of pain. In:
Principles and Practice of Palliative Care and Supportive
Oncology. 2nd ed. Philadelphia, Pa: Lippincott, Williams and
Wilkins; 2002.
3. Lamers WM Jr. A brief history of pain. In: Doka KA, ed.
Pain Management at the End of Life: Bridging the Gap Between
Knowledge and Practice. Washington, DC: Hospice Foundation of
America; 2006: 17-38.
4. Rich BA. The ethical dimensions of pain and suffering. In: Doka KA,
ed. Pain Management at the End of Life: Bridging the Gap Between
Knowledge and Practice. Washington, DC: Hospice Foundation of
America; 2006: 245-260.
5. American Academy of Pain Medicine, American Pain Society, American
Society of Addiction Medicine. Definitions related to the use of opioids for
the treatment of pain. 2001. Available at:
http://www.ampainsoc.org/advocacy/opioids2.htm.
Accessed June 26, 2007.
6. Pappagallo M. The concept of pseudotolerance to opioids.
Journal of Pharmaceutical Care in Pain & Symptom
Control. 1998:6:95
-98.
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Opiophobia
Ten Common Misconceptions About...
