Caregiver.com

For About and By Caregivers
 
Effective Pain Management

By  Cheryl Ellis, Staff Writer 

 

In both acute and chronic health conditions, pain is top on the list of concerns for patients, caregivers and physicians.  Effective pain control improves the individual’s state of mind and ability to move through the healing process.  There are a variety of options for pain control, and doctors work toward addressing side effects that can occur with pain medications.

Coming to terms with being in pain, acute or chronic, is a hurdle for many folks who grew up learning to “put aside” pain.  Individuals who have been vocal about pain levels and received negative responses may feel angry, refusing treatment as an expression of emotional pain.

Fortunately, pain control centers, physicians and other healthcare personnel have become more aware over the years.  Asking about pain levels during office visits is as common as checking vital signs. 

TYPES OF PAIN

Acute pain can occur at the same time chronic pain is experienced.  The euphemism “breakthrough pain” is one type of acute pain an individual can undergo.  This pain can occur because of movement or activity, but it can also happen when the body has involuntary movements, such as expelling gas or muscle twitches.  Medication can be prescribed for the “break” in pain that around the clock medicating provides.

Breakthrough pain may occur in the same area as the chronic pain, but not always.  Noting the events leading up to the episode of breakthrough pain can help caregivers adjust activity levels if needed.  In some cases, the area in pain and/or the event that contributes to it cannot be pinned down.  Recording episodes, including seemingly random incidents, will still help when pain management is reviewed.

When pain resurfaces before the next scheduled dose of medication and isn’t associated with a voluntary or involuntary action, the physician can be notified to examine the timing and amount of around the clock medication.  Noticing the time of pain onset and keeping a record can help the doctor make a decision about keeping pain relief consistent.  Caregivers will find their loved one complains at or about the same interval of time prior to their next dosage.

Chronic pain is consistent and “stable.”  While there may be some fluctuating of intensity, it is “reliable” in its characteristics.  Medication for this type of pain is generally around the clock to provide continuity of relief.  Over time, medications are adjusted to account for changes in the pain cycle, including a patient’s tolerance to a given dosage.

AGE DOESN’T MATTER

Children and adolescents with cancer or AIDS experience pain just as deeply as an adult.  They may be better equipped to admit to pain and track where they are hurting, as opposed to adults who may have dementia as a hindrance to assessment.

Physicians have a specific protocol, or pathway, to follow when managing pain for adults and children.  When dealing with “pain psychology,” caregivers will learn to watch facial expressions, body positions and other gestures to determine if their loved one is understating their pain level.  Kids may not want to worry their parents, or be afraid of a visit to the doctor or hospital.  As the healthcare experience continues, parents become more attuned to what their child is feeling, and may find that personnel involved in their child’s care are able to help them understand what is typical at different stages of treatment.

While the same is true for caregivers of adults, the adult-to-adult psychology can have a wider range of variation.  Children helping their parents through a health crisis may take time to relate to them on an adult-to-adult level, and parents may attempt to mask their fear and pain by amplifying “Parent Mode.”  When possible, ask the doctor to allow for some time alone with the parent, to allow them to express their needs without feeling “weak.”

Relationships of every kind are challenged when there is a health problem, and relationship dynamics should be evaluated at the time of diagnosis by loved one and caregiver.  Understanding that there will be changes in any relationship is a first step toward coping with those changes, and making them positive ones.

PAIN MANAGEMENT IS A SCIENCE

Over the decades, the perspective on managing pain has widened.  Healthcare practitioners and patients have a closer relationship in deciding pain management routes, incorporating “natural” and prescribed medications and “alternative” methods of pain relief. 

Pain management was once considered “doping up” the patient in some circles.  Today’s viewpoint incorporates consistent pain relief with keeping the patient alert and functioning. 

The variety of conditions that require pain management has created a demand for an accurate “science” to provide help based on condition and individual need.  The World Health Organization has a “ladder” for managing cancer pain.  Level One uses non-steroidal anti-inflammatory medications (such as aspirin) and “adjuvant,” or supplementary medications that have a secondary effect of controlling pain by eliminating a side effect.  As pain increases with cancer progression and/or treatment, professional caregivers step to the next level of pain management.  By Level Three, opiates are incorporated and the adjuvant medications are there to assist with opiate side effects.

OPIATES AND PAIN CONTROL

In the classic film “The Wizard of Oz,” the Wicked Witch deters Dorothy and her friends by creating a field of poppies they must walk through before reaching the Emerald Castle.  Dorothy and the Lion fall asleep until the Good Witch intervenes with snowflakes to wake them up, and the crew moves toward their destination. 
The poppy plant is used to create opiates such as morphine and codeine, which relieve pain, but also make the individual sleepy or lethargic.  The effects of “Opiates from Oz” are shorter lasting than those administered for those in chronic pain.  Since alertness is a factor in complying with pain medications, patients may be unwilling to try them, looking to “natural” remedies instead.

The brain has receptors that recognize both opiates and endorphins.  Endorphins are “feel good” chemicals produced naturally in the brain, and have an analgesic effect.  While they are preferable to medications, both acute and chronic pain sufferers may not produce sufficient quantities of endorphins to dull or eradicate pain.  Even simple pain relievers like acetaminophen or aspirin may not do the trick, and pain control must include opiates.

Morphine and its opiate cousins can be given by mouth or intravenously.  In some cases, morphine can be delivered by a nebulizer, dispersing the drug into an aerosol that can be inhaled.  The lungs also contain receptors for opioids, absorbing and processing the medication.

Caregivers should be aware that any medication delivered by nebulizer can disperse through the room.  Taking precautions when it comes to room ventilation and proximity to the patient will help the caregiver with unwanted exposure to medication.  The concern for precautions has less to do with a “secondary high” for the caregiver than with residuals of the medicine showing up in their urine if drug tested.

The type of morphine nebulized is the intravenous type without preservatives.  When given by aerosol, morphine can activate histamines and constrict breathing passages.  The goal of morphine by aerosol is to alleviate difficult, painful breathing rather than bring it on, so doctors may order an aerosol treatment with medication to keep the airways open prior to nebulized morphine. There is a specialized, single dose nebulizer that delivers morphine to the lungs.  The medication “strips” look very similar to the ones used to test blood sugar, but contain the correct medication dosage.  Aerosol particles do not “fly” around because of the design.

TOLERANCE IS NOT ADDICTION

Caregivers and loved ones may worry that tolerance means addiction, but they are not the same. Over extended periods of time, the dosage of the medication may need to be increased because the individual has developed a tolerance to the medication, or there has been a rise in pain levels.  Doctors work to use the lowest effective dosage to keep the patient alert and pain free.

Medication dependence occurs when there is a physical reliance on the medication and withdrawal symptoms (that are specific to the drug class) occur.  There may be tolerance present, but the withdrawal symptoms are noted if the medication is suddenly removed and/or levels of the medicine in the bloodstream decrease. 
When addiction is present, caregivers and medical personnel notice that the patient may “lose” prescriptions, and/or take their medications at inappropriate times.  A number of other behaviors may be present, including behavioral changes that include isolation from family members.

Rather than diagnose your family member, bring concerns to the family physician to evaluate the situation.  What seems like dependence or addiction may be the response to changes in pain level, tolerance or other factors that the doctor must evaluate.  Behavioral responses such as anger or depression may be due to poorly controlled pain, especially if the pain control journey is just beginning.

AIDS AND THE PAIN EXPERIENCE

With better medications and awareness on the part of doctors and patients, individuals diagnosed with AIDS are receiving improved care.  The pain experience varies from one person to another, even in the AIDS journey.

Neuropathy (“nerve damage”) affects an estimated 20 million Americans according to The Neuropathy Association.  Damage to the nerves can create burning and sometimes “stabbing” pains in the feet.

In some cases, anti-cancer and retroviral treatments may create their own painful side effects, some of which can be balanced by other medications, including antidepressant therapy. 

This immune deficiency virus makes patients of all ages susceptible to yeast infections, throat and mouth sores and other viruses that can attack the body.  Bacterial infections are experienced, too, and require antibiotics as the doctor decides. 

The AIDS patient may have skin eruptions, and these sores or rashes contribute to pain and require treatment.  For example, Kaposi sarcoma is a skin lesion seen in the AIDS patient that initially doesn’t cause pain, but as it becomes worse, pain can be extreme.  While Kaposi is not considered “curable,” it can be treated by an oncologist or dermatologist with experience in this area. 

Mouth sores or other conditions affecting the mouth can hamper eating, whether the foods are acidic or not.  Physicians are familiar with this aspect of the challenges of living with AIDS, and may recommend supplements in addition to other treatment for thrush or mouth sores.  Accommodate your loved one’s choices in whether or not to eat at given times, and oversee that medications are taken when ordered, even if alternate routes must be prescribed.

In some cases, individuals with AIDS may have a concurrent infection with the Hepatitis C virus, which also challenges pain management and treatment.  When doctors assess for pain in the AIDS patient, they look for other causes of pain, even if the pain felt is typical for an AIDS patient.  Hepatitis C is one possibility for a “co-infection,” but other conditions such as cancers of organs or blood may be present. 

Treating the root cause of pain (such as mouth or ear pain from infections) is the doctor’s priority, which is the reason why patients may be at the doctor or hospitalized frequently.  The choice is to act quickly to stop infections from causing more problems.

CONTROLLING PAIN IN CANCER

The National Cancer Institute (www.cancer.gov) offers an online booklet to assist cancer patients and their caregivers with pain management. 
“Cancer pains” may arise from chemotherapy or radiation, creating nerve damage or phantom pain from body parts that have been removed.  Radiation can cause painful “sunburn” during treatment.

Whenever there is surgery performed, temporary pain may be experienced because skin and organs are cut and maneuvered around.  Post-surgical pain fades with time and appropriate management, which may include physical therapy and resuming daily activities. 

The growth of cancer within the body contributes to pain, also.  As cancer is being treated, therapeutic levels of controlling the growth are sought; but patients may still experience pain while waiting for the abnormal cells to be eradicated.  This is where pain control offers a great deal to assist in stress reduction and continuing patient compliance with therapy.  It’s difficult to ask a loved one to continue with treatment when pain makes them feel they aren’t getting better, and the goal is to quickly assess the level of pain to begin pain control.  It makes the treatment much easier to cope with, for caregiver and loved one.

Differential pain assessment in cancer is important also, to help the treatment team to discern if new pain is from cancer that has moved to a new area, or if there is an acute condition that must be addressed (such as appendicitis or gall bladder stones).  It may seem unlikely that cancer patients may experience an acute episode of pain unrelated to their cancerous process, but it is possible.  It may help to keep a written record of pain to offer feedback to the physician during visits, or if a call must be placed after hours. 

Swelling, itching and rashes cause pain, and while minor when compared to pain from cancer, they can actually make it harder to tolerate pain levels if the minor pain is left unaddressed. 

COMPLEMENTARY PAIN TREATMENTS

Biofeedback has been around for some time, and there are competent technicians able to instruct patients in controlling their breathing and heart rate.  The technique has worked well for persons who have an ability to focus on these measurable parameters, which can help reduce pain and the anxiety that comes from being in pain.

Massage therapy can work in almost any case to reduce pain and improve the relaxation effect.  It is not necessary to “work” the area where pain is felt to provide comfort and a sense of healing. 

Patients with swelling from radiation or surgery (such as removal of lymph nodes) can look for a lymphedema therapist, who is trained in proper technique for massaging swollen areas as well as the rest of the body. 

Reflexology can be performed on the hands or feet to help release tense areas which may be related to painful spots.  The body in pain will tense itself in a variety of ways in response to pain, and by relaxing one part of the body by massage, the rest of it can follow. 

Massage can be combined with biofeedback, imagery or other alternative therapies (such as aromatherapy) to diminish stress response. 

WORKING WITH OPIATE SIDE EFFECTS

Constipation arising from opiate medications is a frustrating consequence for caregiver and loved one.  A common misconception is that fiber and exercise will address all types of constipation.  When opiates are given, the bowels are slowed down; the result is constipation, which occurs in many people who take opioid/opiates.

The buildup of waste in the intestines creates discomfort in all people.  In general, suggestions to alleviate and control constipation include increasing water intake to soften food passing through the digestive tract, and exercise, which helps muscles “massage” the internal organs.  The intestines made “sleepy” by opiods can be helped by these two suggestions, but more help may be needed; especially when pain hinders the ability to move.

Fiber is an excellent “homespun” cure to deal with constipation, and as long as the individual has a somewhat hearty appetite, salads and vegetables can be given as snacks and meals.  When appetites are poor or finicky, fiber bought at the health food store can be sprinkled on easy-to-consume foods (like pudding or baby food).  Fiber is helped by fluid intake, and those who are having trouble keeping up with their liquids may prefer “fun fluids,” such as snow cones and popsicles. 
Caregivers and loved ones may be reluctant to continue pain medication when constipation is the result.  The key to working with this side effect is to allow for the body’s changing ability to pass waste as usual.  Constipation may also be a result of compressed nerves or other factors that are at work in a health challenge.  Continuing medications is important, but advise the doctor about constipation and the success of any home remedies.  Combining simple fixes like diet and exercise with physician-prescribed solutions may be what is needed.
Laxatives and slow-release magnesium are over the counter remedies that are helpful, but should not be used without speaking to the doctor.  Overuse of laxatives can create or increase constipation in the long run.

There are prescribed medications which work to counteract the effects of various drugs.  “Antagonist” medications are given at the doctor’s discretion.  Discussion of possible medications to counteract medication effects can be done when there are problems noted, but as always, caregivers must give as much information possible to the doctor so he can be guided.

PAIN CAN HAVE POSITIVE EFFECTS

If an area is completely numb from treatment, pain may be an indicator that the area is “coming back to life,” however uncomfortably.  When pain is addressed within a reasonable time, corrective measures can be taken to alleviate it.  This assists the body in healing, and helps loved one and caregiver enjoy their time together as they move toward the next step in recovery.

 

 Subscribe to our weekly e-newsletter