End of Life

Addressing Pain

Dealing With Pain

Struggling with pain can be draining. It can affect mood, making someone seem angry and irritable. Pain can make it hard for someone to talk, to share thoughts and feelings. Untreated or poorly controlled pain can prevent a dying person from spending time with loved ones in a meaningful way.

Dying does not have to be painful. Experts believe that care for someone at the end of life should focus on treating pain without worrying about the person becoming “addicted.”

Easier To Prevent Than Relieve

Pain is easier to prevent than to relieve, and overwhelming pain is hard to manage. It is important to keep pain under control -- do not be afraid to take as much pain medicine as prescribed.

If the pain continues, ask your health care provider to help you contact a palliative care specialist or hospice provider. If these providers are not available, a pain specialist should be able to help. Any of these specialists will understand how to help relieve a dying person’s pain.

How You Can Help

To help a dying person get effective pain relief, follow these tips for describing, tracking, and communicating pain to the specialist or provider.

  • Help the dying person describe the pain in as much detail as possible, including where it is, what it feels like, how long it lasts, when it started, what makes it better, and what makes it worse.
  • Help the dying person keep a record to track the pain. You may want to use a number from 0 to 10 to describe the pain, with 10 being the worst pain the dying person can imagine and 0 being no pain at all.
  • When the dying person cannot communicate her or his pain or other symptoms, watch for and record other cues such as grimacing or agitation, which may signal the person needs symptom relief.

Treatment Decisions: Morphine and Other Opiates

Morphine is an opiate, a strong medicine used to treat serious pain that is not relieved by drugs such as acetaminophen (also known as Tylenol®) or ibuprofen (also known as Advil® or Motrin®). It is also given to ease the feeling of shortness of breath (dyspnea). Other opiates, like hydrocodone and oxycodone, are also used to treat serious pain.

Opioid drugs work by binding to opioid receptors in the brain, spinal cord, and other areas of the body. They reduce the sending of pain messages to the brain and reduce feelings of pain. They are safe and effective for the relief of pain when used as prescribed.

While serous pain may not be relieved by Tylenol® or Advil® alone, these medicines are often given along with morphine or other opiates to treat the underlying causes of a patient’s pain, such as inflammation.

Opioid Dosage Levels

Around-the-clock dosing, which provides regularly scheduled doses of opioids day and night, may be required to treat severe pain. Once pain is under control and the dose of opiate has been the same for several days, it may be possible to lower the dose of opiate gradually without the pain coming back.

This change in dose to meet a patient’s varying pain needs is called titration by health care providers. Titration should be done carefully and only under the supervision of your health care provider.

Experts recommend that anyone who has been taking opiates for more than two weeks should reduce his or her intake gradually over time, rather than stopping suddenly, so the body has time to adjust.

If Pain Is Not Well Controlled

If the pain is not well controlled with around-the-clock dosing, there is no need to wait until the pain is unbearable. Untreated or poorly controlled pain can become hard to manage, causing unnecessary suffering. Do not be afraid to ask the health care provider to increase the around-the-clock dose if pain does not go away or comes back.

Sometimes pain is episodic, meaning it returns before the end of a dose or as a result of an event such as being moved. If this happens, ask your provider for breakthrough or rescue dosing. This is a dose of an opiate given in addition to the patient’s usual dosing schedule.

Some people develop a tolerance for opiates, which means a stronger dose may be required to get and keep pain under control. Tolerance is not the same thing as addiction. A common treatment for tolerance is to switch to a different opiate medication. Such a change may restore a higher level of pain relief.

Side Effects

All opiates can cause nausea, drowsiness, confusion, constipation, and other side effects. However, as the dying person’s body adjusts to the medicine, most side effects (except constipation) will decrease or go away completely. Those side effects that remain are usually easy to manage, such as taking laxatives for constipation.

People near the end of life who have chronic, severe pain are often unable to get a good night’s rest. When first taken, opiates like morphine may result in an initial sedation period that lasts as long as 24 hours as the dying person catches up on lost sleep. With continuing doses, normal mental activity should resume.

Other Concerns About Opiate Use

Some people worry that the prescribed use of morphine and other opiates to treat severe pain in a dying person will lead to addiction or a premature death. It is important to weigh the benefits of using opiates to improve the quality of life for the person against such concerns.

Most experts believe the risk of addiction for people near the end of life who take morphine and other opiates for pain relief is very low. Studies show that a brain in pain reacts to morphine differently than a brain not in pain. People become addicted to or dependent on opiates when they take them for fun or when they do not have pain.

Most experts also think it is unlikely that morphine or other opiates will lead to a quicker death, especially if the dosing is managed carefully by a palliative care, hospice, or pain specialist. Studies have shown that when pain is well controlled with appropriate use of pain medications, including opiates, people live longer than those with the exact same condition whose pain is not well controlled.

For more specific questions or concerns about opiate use, talk to your health care provider.