“More!” The demand takes on a different character depending on the context on the conversation. The word can often be heard with urgent giggles at a park with children on the swing, demanding another push. “More” is the mantra of children at dessert time or movie theaters requesting treats. It’s the refrain of hope for an extra bedtime story. In the context of positive, healthy relationships, “more” is a request that loved ones want to fulfill for one another. “More!” however, is not nearly so endearing of a request in light of the so-called “war on drugs” in the 1980’s. Addicts were portrayed as craven collectors of “more” – another hit, another dose, another round – without any ability to stop themselves from wantonly demanding more.
Drug Use and Media Attention
Where the 1980’s war on drugs targeted illegal substances such as marijuana, cocaine, and other banned substances, commonplace addictions in the current decade has broadened to more accessible options: prescription medications (painkillers, psychotropic medications, and the like). Today, the war on drugs does not focus much on fears regarding the ways in which drugs can cause erratic outbursts, people believing they can fly from the tops of buildings, and other dramatically difficult or unusual behaviors.
Instead, more current media has focused on the prevention of the creation of so-called “zombies” – people who are over-medicated to the point that they cannot feel pain or, behave both unpredictably and dangerously. These fears are perhaps most closely linked with opiate drug use.
What are Opiates?
Opiates are drugs that bind to receptors in the brain that receive pain signals. Once a person has taken an opioid medication, their brains don’t receive these pain messages with the same strength as they might have experienced without them – which speaks to how and why they are such effective drugs. Commonly recognized and/or prescribed opioids include Oxycontin, morphine, codeine, and fentanyl.
The war on drugs has put medical science in an interesting predicament. While, on the one hand, pain management and relief is a positive thing, overutilization of certain narcotics can be problematic. Opioid pain management comes with important considerations such as weighing the potential for comorbidity and an array of potential side effects.
Among the major concerns of health care providers when prescribing drugs and other treatments are comorbidities. Comorbidity is one or more diseases or conditions occurring at the same time, or where the presence of one physical symptom amplifies or presents another condition. When patients use opioids to manage pain at the end of life, there is often a primary concern that the drugs themselves can lead to coma and death. Medical science is unable to clearly define the line between helping people ease into the dying experience nd actually helping a patient progress more quickly to the end.
Medical ethics does not allow for opioids to be used as a method of or partner in euthanasia. Therefore, medical teams treating patients for pain toward the end of life will be cautious to treat symptoms with a proportional dose of drugs, so as to manage their symptoms and not encourage death to arrive sooner than necessary.
Opioids, like most drugs, come with their own menu of side effects. Those may include issues like sweating, shaking, headaches, drug craving, nausea and vomiting, abdominal cramping, diarrhea, inability to sleep, confusion, agitation, depression, anxiety, and other unusual or unexpected behavioral fluctuations. However, prescribing opioids to treat pain at the end-of-life involves a different set of values than treating long-term chronic pain. The side effects a prescribing physician will focus on at the end-of-life will look towards increasing the overall quality of a patient’s remaining days. A patient will certainly not want to struggle with additional unpleasant symptoms (such as nausea), but physicians may be able to counteract some of those difficulties with a combination of other medications to accompany opioid pain management.
Furthermore, a patient’s primary goal is likely to enjoy opportunities to see family and friends who wish to visit. Too much opioid use can reduce alertness. Too little opioid and the patient may suffer too much pain to engage with others in a meaningful way. Physicians in concert with a patient’s care team should listen carefully to the patient’s goals and prescribe medications accordingly.
The Social Stigma of Managing Pain
The primary issues that patients may face in managing pain at the end-of-life are the social stigmas and fears that may come with opioid use. The reality is that opioids are effective in curbing severe pain that people often face because of disease and other problems towards end-of-life. However, most of the social stigma surrounding opioid use is about people’s experience of demands for “more.” However, dying patients are unlikely to ask for “more,” as in “so much that it becomes a habit.”
Patients who are suffering during end-of-life simply need help in controlling pain so they can achieve their end-of-life goals involving comfort care and maintaining relationships. “More” is not what patient wants. “Enough,” is what patients both want and need.
Assessing and Managing Pain
Among the best resources patients have in identifying personal goals at end-of-life and therefore discerning what kind of pain management is needed is hospice care. One of hospice’s founders, Dr. Cicely Saunders described pain associated with the end-of-life as “total pain,” which includes physical pain, emotional pain, interpersonal conflict, and disbelief that the end has come. Physicians, nurses, and other caregivers will help manage the multiple challenges of pain through constant assessment asking questions about pain location and level.
Care teams can provide over-the-counter drugs, but chances are, they will offer much stronger medications to manage more complex pain symptoms, such as opioids for pain. A hospice team working alongside physicians will responsibly offer patients appropriate dosages, modify doses as needed, and help to manage side effects.
Contact Harbor Light Hospice for End-of-life Assistance
Pain relief is a priority and challenge for healthcare teams and loved ones alike who help patients during end-of-life. There are excellent resources to explore pain management options available. For more information about the challenges of opioid pain management during end-of-life or to learn about the benefits of hospice care, please contact Harbor Light Hospice for a private consultation.