Dispelling the Myths on Narcotics for Pain
From Hospice and Palliative Care Associates



Hospice strongly advocates good pain control for terminally ill patients, even to the point of using narcotic drugs (we call them opioids) such as morphine as they are needed. With all the concern about drug abuse, patients and their families and friends sometimes question this use of narcotics.  Let's explore some of the myths about the use of narcotics for pain control.



MYTH #1: Morphine is offered to patients only when death is imminent

It is not the stage of a terminal illness, but the degree of pain that dictates which medicine to use. We start with morphine when it's appropriate. Some people never need morphine, while others will require it for quite a while. You can live for a long time on morphine.

MYTH #2: People who take morphine will become addicted

Hospice patients usually don't have drug-seeking behavior. When their pain is in good control, they don't desire more narcotics. Sometimes we can even decrease the dosage. If patients take morphine for a while, their body does become used to it and it should not be suddenly stopped, because side effects could occur. However, Hospice patients on morphine are not considered to be addicts.

MYTH #3: People on morphine are too sleepy to function

When patients start to take drugs like morphine, they often feel drowsy for a few days. But their bodies usually quickly build up a resistance to the sedating effects. Most patients whose pain is well controlled on morphine are not bothered by unusual sleepiness. Some people, however, notice a difference in their alertness and might choose somewhat less than perfect pain control as a trade-off.

MYTH #4: People on morphine die sooner because their breathing is weakened

Fortunately, patients quickly adjust to any effect that morphine may have on their breathing. We prescribe a small initial dose, gradually increasing it if needed. So rarely do breathing problems occur, they are usually not even listed as side effects. In fact morphine is a drug of choice for breathing distress in people with end-stage heart or lung disease: it makes their breathing more comfortable.

MYTH #5: Prior strange feelings after morphine were allergic reactions

Of course you can be allergic to morphine just like any other medicine. But feeling strange is usually not a sign of morphine allergy. Some people may have unpleasant mental sensations when they start to take morphine. But that is not an allergy; and it might never recur. There are other opioids available for those people who are truly allergic to morphine.

MYTH #6: Morphine must be given by injection

We used to think that morphine was not effective unless administered by injection. But Hospice has been a leader in demonstrating the effectiveness of morphine and other opioids taken orally. Even people who required injections of morphine in the hospital (the most common way of giving morphine there) will probably be able to be well controlled on oral morphine at home. There are also long-acting preparations of morphine which can be given every twelve hours, or opioid skin patches which can be applied every 72 hours, to simplify the routine of pain control.
(Note: the Davis patients would take nothing by mouth, and the opioid skin patches are very expensive).

MYTH #7: People should not take morphine before their pain is severe, lest it lose its effect

There is no upper dose limit to the use of morphine or other opioids. If pain increases we can increase the dose; this is true of very few other medications. Using it when it's needed early in the course of a terminal illness does not mean that it won't continue to work later in the disease.



From Hospice and Palliative Care Associates







Bazelon Center for Mental Health Law
Painlaw.org
Using Opioids to Control Pain
Dispelling the Myths



  • Pain patients very rarely become addicted.

  • Distinguishing between "addiction" and "tolerance."

  • There is no such thing as "too much" pain medication for a patient in pain.

  • Careful pain management does not kill.

  • Prescribing pain medication properly is not illegal.  

  • Doctors and Patients Are Unnecessarily Cautious about Using Opioids to Treat Pain



Most people facing a very serious illness fear dying in pain as much as they fear death itself. But 95 percent of pain, including the worst cancer pain, can be controlled. When lesser painkillers fail, morphine and its synthetic cousins (opioids) should be considered.

Patients and American doctors (who should know better) are unreasonably afraid of opioids. This "opiophobia" is not based on fact, but is a product of outmoded knowledge and the 'War on Drugs'.

Medical research demonstrates the utility and safety of opioid use for otherwise untreatable pain. Major medical organizations have created policies and standards to advise doctors on the findings and resultant practice guidelines.

A recent joint statement by the American Pain Society and the American Academy of Pain Medicine outlines current goals and standards for the use of opioids in pain management.

Despite this activity at the top of the profession, pain management in hospitals, nursing homes and doctors' offices in the United States falls far short of the standard for medical care. Doctors only recently had good pain management training available to them. They are often very reluctant to use opioids effectively, even when a patient is dying. Many never even consider opioids for long-term therapy for non-cancer pain.

Very sick patients are entitled to the best modes of pain control. They, not their doctors, are the best judges of how much pain they feel and whether a particular mode of pain management is working.

For chronic pain patients the key is whether the medications make them better able to function in their daily lives than do more frequently dispensed pain medications.

Opioids are not the answer to every pain problem or even every severe pain problem.  However, every patient should receive consideration of pain that is not clouded by ignorance or unreasonable fear of particular medications.



ADDICTION and TOLERANCE

Pain patients very rarely become addicted.

An addict is a person who compulsively takes drugs for nonmedicinal purposes. Addicts will continue to seek out the drugs despite bad effects on their ability to function in the community, to hold a job, to care for their families and to maintain social relationships.

In contrast, pain patients often take very large amounts of opioids and other medications to improve their function, but do not seek out the drug for its own sake or "crave" the medication. Their ability to work, care for families and live productive lives is improved by their medications.

  A recent study demonstrates that fewer than one percent of pain patients receiving opioids become narcotics abusers. No patient in pain should hear that relief is barred because "you will become an addict." No patient in pain should reject opioids out of fear of becoming addicted. Even former and current substance abusers can be treated for severe pain by doctors with experience in the field.

There is a critical difference between "addiction" and "tolerance."

Tolerance is a physical event that will always happen when a patient takes opioids. Tolerance begins with even one dose. This physical fact is not linked to harmful effects. It means only that, over time, pain patients can be expected to need higher doses of the medication to obtain the same relief.

A patient who has been receiving opioids for pain over time can tolerate levels that would kill a person who is "opioid naive" (someone who has not built up any tolerance). For this reason it is often said that there is no theoretical upper limit to the amount of opioids than can appropriately be prescribed to control pain. Careful physicians will monitor dosage closely and increase it when necessary as tolerance builds to maintain a good effect on pain control. Moreover, some medications mix opioids and other pain relievers such as aspirin, acetaminophen and other non- steroidal compounds. A patient taking these medications will reach a ceiling dose at some point because the other drugs in the compound are toxic. Some pain relievers, such as Demerol, should not be used for any extended period because of toxicity.

Confusion between "addiction" and "tolerance" is common even among physicians

Identification of patients with substance abuse problems is even more difficult. The best distinction between the two is the patient's ability to function. Pain patients can expect to improve function with optimal dosages of opioids.

Dependence is another physical fact. It refers usually to the need to maintain opioid levels in a tolerant individual or experience withdrawal. Both addicts and legitimate pain patients will experience withdrawal if the drug is withdrawn abruptly.

Until a patient achieves pain relief there is no such thing as "too much" morphine or other opioids.

Pain experts agree that there is no "theoretical upper limit" for opioid dosages for pain relief. The upper limit is "what works." It is important not to assume that high dosages or a large number of prescribed pills means that the patient is "an addict." Of course, the doctor must monitor to make sure that the dose is appropriate for that patient.

Morphine and its derivatives do have side effects. The most frequent is constipation. Most side effects can be managed. A doctor may have to try a number of pain medications or combinations of medications to reach the maximum relief with minimum side effects. Patient and doctor need to work together to reach an appropriate dose for the patient.


Careful pain management does not kill.




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