Pain control: basic information and resources

pain control basic info

By Eileen T Geller, RN, BSN

"Pain," as Albert Schweitzer once said, "is a more terrible lord of mankind than even death itself. We all must die, but if I can save a person from days of torture, that is what I feel is my great and ever new privilege."

Obviously no one wants to die in severe, uncontrolled pain.

Yet even over a hundred years ago, Albert Schweitzer was able to adequately control pain in dying individuals. Even then, during what could now be termed the 'dark ages of pain control', this physician was able to ensure that his patients lived-and died-comfortably and with real dignity. He didn't need lethal drug overdoses then, and we certainly don't need them now.

Before the advent of the hospice movement in the early 1980s, a patient with severe pain would have had only a few choices for good pain control-and most of which involved hospitalization. Now, many more good options exist for care and pain control during life-limiting illnesses, most of which can be accomplished at a patient's residence or in a hospice center, rather than in a clinical setting like a hospital.

According to Dr Ronald Melzack, in an article some years ago entitled, "The Tragedy of Needless Pain," we have 'broken the sound barriers,' of pain control. Yet the myth of uncontrollable pain continues. This myth, advanced in part by individuals and groups whose agenda is legalized assisted suicide, frightens vulnerable ill people and their families, causing them to consider lethal drug overdoses rather than the good medical and hospice care they deserve.

In fact, by 1997, trained hospice and palliative care professionals and pain specialists could already alleviate between 90-99% of all physical pain-without causing addiction or leaving the patient in a stupor. The remaining 1% could, even then, be controlled within tolerable levels, albeit with some increased sleepiness.

Radical suicide proponent and author or the Final Exit, Derek Humphrey, admits in his book, Let Me Die Before I Wake, that "only a small amount of physical pain cannot be controlled today." But that didn't stop suicide advocacy organizations from selling assisted suicide to the voters of Washington and Oregon based on reports of uncontrolled pain and needless suffering.

Since the mid-1990's, health care's ability to control pain in people with life-limiting illnesses has only improved. Now, most patients, even those who develop severe pain, (which is actually a minority of patients with widespread cancer) can be cared for comfortably at home, with effectively controlled pain, and hospice assistance.

Much of the time, simple and nonintrusive methods can adequately treat pain through a combination of long and short acting medications, some of which work very quickly, by being placed under the tongue. In other circumstances, pain patches, pain medication via a patient-controlled pump, or other means can be used to eradicate or radically reduce pain to an acceptable level.

Home-based pain control options for people with terminal illnesses now include, but are not limited to:

  1. long-acting sustained release morphine pills that last up to twelve hours,
  2. small sublingual morphine tablets which melt under the tongue and give immediate pain relief,
  3. a small patch like a band-aid-like pain patch which slowly infuses pain medication for up to 72 hours,
  4. subcutaneous or IV morphine infused by constant infusion via a small computer attached to the patient by a tiny needle, through which the patient can control when he or she needs an added, or bolus, dose.
  5. For severe uncontrolled pain, epidural infusions, inhaled narcotics, or other more high-tech options may be used, usually with the assistance of a pain specialist.

In sum, excellent options exist for good pain control-many more than existed even five or even ten years ago, much less twenty five or a hundred years ago. So, why do reports of inadequately controlled pain persist?

Sadly, for two reasons. Such stories are:

With regard to the latter, multiple studies have documented the need to improve pain-related education of patients, families, and health care professionals in order to improve the practice of pain control worldwide. The curriculum in most medical and nursing schools continues to be woefully inadequate in pain control-although, in the last ten years or so, that has slowly been improving.

Still, far too many health care professionals and family members don't even know, much less adhere to, the actual definition of pain. They have no idea that the definition of pain is as follows: "Pain is what the patient says it is."

In other words, if a patient says he or she is in pain, then he or she IS in pain. And that pain needs to be treated quickly and competently. In fact, Medicare guidelines for hospitals now require pain assessment as 'the fifth vital sign,' after heart rate, blood pressure, respiratory rate, and temperature. Pain control is that important-hospitals can even be penalized for inadequately assessing and treating pain.

Obviously we have a lot of work to do: too many physicians, nurses, and family members fail to implement tried and true pain control techniques simply because they are under-tooled and inadequately educated. The inexplicable-and inexcusable-reluctance of some health care providers to 'find out what they don't know' creates the fuel which fires the 'pain can't be controlled' myth.

Unsurprisingly, studies correlate the link between pain and the desire of for physician assisted suicide. These studies show what is intuitive to most of us: most people who are in pain wish to die. And when the pain is controlled, they wish to live longer-even if they have a terminal illness.

So, we can control pain, but we don't always do so well. And our failure to adequately control pain leads to an environment in which patients may feel coerced into requesting lethal drugs. Thus, assisted suicide spreads like a weed in the noxious environment of fear-fear of pain, and fear of loss of dignity.

What can be done to remedy the situation? How can we create an environment where true compassion, rather than false choices, grows and flourishes?

First: Patients with life-limiting illnesses, family members, and caregivers need to know that pain is controllable. If they, or someone they love or care for, is experiencing uncontrolled pain, then something needs to be done quickly to address and solve the problem. First, a hospice professional or physician should be notified immediately, then an individualized pain control action plan implemented ASAP. (Severe uncontrolled pain is now officially defined as a medical crises.)

Secondly: Be persistent. If at first you don't succeed, try again. And again. Good pain control plans are not static-they evolve and change with the patients ongoing and changing needs. But the rubrics are constant. The infrastructure of good pain control is composed routinely scheduled medications, with additional medications in the home and available for use with 'breakthrough pain.' If the pain is routine, then routine medications need to be given routinely to prevent the pain. Pain prevention is key, giving truth to the old adage: 'an ounce of prevention equals a pound of cure.'

It's far easier to keep pain in control than to play catch up once it's out of control. Give those routinely scheduled long-acting pain medications in ordered doses and amounts-they're essential to preventing pain crises. And don't be shy about giving breakthrough medications as ordered when need be: they, too, are essential to treating episodic pain increases.

Thirdly: Family members or friends serving as patient advocates must not be afraid of being very assertive in pursuit of patient comfort, pain control, and dignity management. The truth is that some parts of our health care system are broken-either by virtue of the skewed way in which reimbursement is handled or the chaos arising from the nursing shortage and resultant increased patient acuity or case management volume.

In health care now-a-days, it is unfortunately often the case that the squeaky wheel really does get the grease. That means it is your job to be politely and persistently 'squeaky' in pursuit of the excellent end of life care your loved one deserves. Remember, good pain control and symptom management is possible, available, and attainable but it might take a good deal of consistent persistence and advocacy to actualize.

Don't assume that the nurse or doctor 'will take care of the pain eventually.' Call right away. If pain or discomfort persists, keep calling. If a hospice home visit is needed, request one, clearly and politely. Don't worry about being labeled. Lovingly and persistently seeking after quality end of life care is exactly the right thing to do. And it's what good health care providers want you to do.

Lastly, truly compassionate advocacy, blended with excellent end of life hospice and palliative care, can ensure comfort and maximize dignity-and eliminate the perceived need for assisted suicide without eliminating the life of the person who needs our help and support.

For additional general resource information about pain control, please refer to Consoling Communities: Communicating About Pain;

National Hospice and Palliative Care Organization: How to Manage Your Pain; or

or your local area hospice.

For specific questions and concrete information, please contact your physician or health care provider.

This web site offers general information rather than medical, social service, or mental health advice. For specific information about medications or to obtain pain control assistance or symptom management for you or someone you care about, please consult with your physician, hospice professional , or other qualified health care provider.

For more information on our important disclaimer.