Was just in a debate with someone over this. My understanding is that pain management and palliative care has come a long way in recent decades.
Have we got to the point where it can always be effectively managed though, ie the patient can remain awake and essentially ‘there’, rather than be sedated? I know in the large majority of cases it can, but understood there were still various exceptions, and a bit of googling seems to confirm this. My mother was one of these a while back, Im just wondering if it has recently become a thing of the past given appropriate care, due to some recent development Im unaware of.
The person offered nothing to back up his assertion, he’s just so definite about it that I figured I might as well see what people have to say here.
Let me guess. The debate was whether terminally ill patients should have the option to be euthanised?
I’ve been in similar debates in the past and I’ve heared the same thing: that modern medication can take care of every kind of pain with minimal side effects. I know nothing about medicine, so I couldn’t refute that statement. But I’ve heared about a lot of patients that want to terminate their lifes, so I guess that this medication is either very expensive or isn’t working for all cases.
Pretty much, and I dont quite buy it. Large majority I can believe that no problem, but when I hear ‘without exception’ and I know that wasnt the case previously I start getting pretty dubious.
While my mother was a while ago now given how fast medicine can change, this was after the ‘we dont want them to get addicted/die faster’ period.
I don’t know about being able to do it without sedation, but it’s probably possible in most cases, though of course there are always rare exceptions (I’ve heard of people who don’t get any pain relief at all from any medications, for instance; perhaps they have mutations in the genes that code for opioid receptors or something).
It seems like many doctors are reluctant to prescribe painkillers above a certain point, though, and that is probaby what limits effective pain relief. When my friend’s grandmother was dying of cancer, her doctor wouldn’t give her more than a certain dosage of morphine, even though she was still alert with normal breathing and blood pressure and was still in a lot of pain, because “it seems like too much.” She was in agony for weeks because it seemed like too much to him.
And then there are drugs that might work but that are unavailable due to cost or availability issues (new or experimental prescription drugs, say) or legality issues (medical marijuana, for instance).
So my basic point is that we might be able to control pain in most terminally ill patients, but not necessarily keeping them conscious and alert, but various other problems mean that we don’t currently (and probably won’t for some time) end up controlling pain in nearly as many patients as we theoretically could, and definitely not every single terminally ill patient.
Unfortunately, pain managment is only as good as the doctor prescribing it.
There are some types of pain that can only be dulled, pain from bone tumors are especially bad.
Most oncologists are very knowledgable in pain management, surgeons and general medicine docs, are hit and miss. They often have a dose range set in stone, that isn’t effective.
If the patient is able to have some control over their pain meds they seem to get better relief from less drug. In-hospital patients have an option called a P(patient) C(controlled) A(administration) pump. The pump is set to deliver a specified dose as often as the patient needs it, within certain limits. Usually, they can deliver a dose every 4-6 minutes with a maximum lock out per hour. (ex. they may have 1 mg every 4 minutes to a max of 15 mg per hour.) This works especially well with post surgical pain. If you fall asleep, you won’t get an overdose, because, well, you’re asleep, so won’t give any doses. Then, upon awakening, you get your dose right away, instead of having to wait for a nurse.
One problem is the media telling us how easy it is to become “addicted.” The physical addictiveness to opiates can be managed over a matter of less than a week, and that’s after having a regular dose for weeks.
Often patients are afraid to take the meds they need, because the don’t want to become addicts
When someone is having severe pain, they can often tolerate larger and larger doses without forming a psychological attachment to the drug. When the drugs are no longer needed for pain, they are withdrawn slowly, so the physical withdrawal symptoms aren’t harsh. Once off, they usually don’t become drug seekers. (You just don’t see that many grannys ducking down alleys to meet their dealer)
In the case of terminal cancer, the pain can be overwhelming. Even with excellent management, these patients might not get total relief. PCA pumps aren’t as effective in this arena because the pain isn’t gradually decreasing, in most cases it will continue to increase. The most common way to keep control, in this scenero, is a continous infusion of whatever drug is helping.
The choices are much broader than in the past. Things like Dilaudid & Fentanyl can be heaven sent. Unfortunately, they all have the side effect of respiratory depression and sleepiness. That said, when someone is in severe pain, the side effects aren’t as pronounced. The problem is, once pain is suppressed, so is respiration.
There are a few non- narcotic drugs that work better than you’d expect. They are related to the NSAIDs like Ibuprophen, only much more potent. They’re given IV or IM (not often.) They don’t supress respiration and don’t cause sleepiness, so the patient can “be there.”
Sorry, I just can’t seem to pick a name of any of them right now. (Ultram is one, but I think it got pulled.)
Toward the end though, the bigger guns are needed.
Anyway, that’s a bit about the progress of pain management in the 21st century.
I hope I helped.
Good night.
You’re very welcome.
I kinda shot myself in the foot in another thread (I posted the wrong website) made myself look like a tinfoil hat.
I’m glad I could redeem myself a bit.
Here’s another vote for the PCA machines. My wife was recently on one for about 10 days and it helped a lot. They were giving her extremely small doses of fentanyl and she healed quickly and was never in serious pain. They tapered her off with injections of some less effective opiate. We were lucky in our choice of docs. They sent her home with a bottle of tylenol 3 and she’s been good ever since. As you say, there was no risk of her OD;ing as she would push the button and go to sleep about 5 minutes later.
Heck no! I’m way smarter than a doctor! I’m a nurse!
All seriousness aside, I did start medical school about 30 years ago, but hated it stayed less than a month.
I was a critical care nurse for nearly 40 years, I guess I pick up a thing or two along the way.
I’ve worked in 3 trauma units,
2 cardiac care units,
5 or 6 pediatric ICUs,
2 burn units,
a bone marrow transplant and research unit,
2 dialysis units,
1 hem-onc unit( that would be a cancer ward)
one metabolic research unit.
I did critical home care for a short time (didn’t like that)
AND I was a medical corpsman in the USAF during Viet Nam (didn’t go, though.)
Excellent post, picunurse. Dog80, my guess would be that picunurse is a nurse in a PICU.
PCA machines are a godsend compared to waiting for a doctor to get around to you when you’re in pain – I was on one a few years ago after my appendectomy – but not an end-all. The above-mentioned grandmother of my friend was on a PCA, but the doctor set it to deliver no more than 10mg of morphine every four hours. That was highly insufficient for her pain.
On the topic of addiction, picunurse is right on the money. Several government studies demonstrated that under medical supervision, the risk of a patient becoming addicted (defined as “exhibiting problematic drug-seeking behavior,” as I recall) is virtually nil – the rates were, IIRC, something like 3 in 10,000, or 0.03%.
And as for the NSAIDs that work well – in another thread, people were talking about how great Vioxx worked for them and how mad they are that it was recently pulled from the market. Similar drugs like Celebrex and other COX-2 inhibitors seem to work pretty well for arthritis and some other painful conditions. I think Vioxx is what you were thinking of, right? Not Ultram – Ultram is still on the market as far as I know, and it’s more of a weak opioid than an NSAID, I believe.
Was a nurse in in PICU. I stay home and make stained glass now.
not Vioxx, I’ve known for years that was a bad drug. I wouldn’t take Celebrex either.
The reason I thought Ultram was pulled was it has been found to quite addictive. It controls pain great, but the euphoria it causes seemed to have some heads up a couple years ago. It also had some pretty strange interactions with other drugs. I’m not sure why making one feel good and pain free is a bad thing but…
I’m glad to hear its still around.
More and more hospitals are making pain managment a seperate specialty, so when you or a loved one isn’t getting proper pain relief ask for a referral to the pain team. Its usually an anesthesioloigist.
Oh I didn’t mention earlier one of the other in hospital pain managment modalities. Epidurals. for really intractable pain, the anesthesiologist places a very tiny catheter into the the epidural space to deliver meds. Its more drastic, during the administration the patient isn’t able to move their legs, but someone in that much pain isn’t moving much anyway.