Myths About Pain

Many people die without experiencing pain. If pain does occur, it can be relieved safely and rapidly.

There are some types of pain that require combined approaches to pain relief. Recent advances in analgesia assure that all pain can be relieved by using commonly available medications and/or a combination of approaches that may include chemotherapy, radiation therapy, nerve block, physical therapies and whatever else is appropriate.

Most people with severe, chronic pain have been unable to sleep because of their pain. The opioid analgesics (like morphine, codeine, etc.) produce initial sedation (usually about 24 hours) that allows patients to catch up on their lost sleep. With continuing doses of medication they are able to carry on normal mental activities. Sedation often occurs because of other drugs, such as anti-anxiety agents and tranquilizers that have been prescribed for other reasons.

If pain is not relieved by the lesser strength analgesics (aspirin, NSAIDs, codeine, hydrocodone, etc.) then it is best to change to a stronger analgesic to bring the pain under consistent, 24-hour control. Pain that is only partially or occasionally controlled tends to increase in severity. This leads to two mistaken assumptions: the patient mistakenly fears that the pain is so severe that it can never be controlled; and the doctor mistakenly believes that the patient is becoming addicted or is developing tolerance to the analgesic medication. In most cases, an adequate dose of a stronger analgesic (e.g., morphine) prescribed on a regular basis usually brings the pain under control.

When morphine and other opioid analgesics are prescribed for the management of pain, the dose is sometimes raised to be sure that pain is well-controlled 24 hours a day, seven days a week. Opioids given to relieve pain generally do not lead to the development of tolerance. As a disease, like cancer, progresses, more opioids may be needed to control the pain on a continuing basis.

In fact, the converse is true. Once pain is under control and the dose of opioid held at a steady level for several days, the dose of opioid analgesic can be lowered without the pain recurring. Levels of opioid can be raised safely as needed to control increasing pain. Also, the dose can be lowered gradually if pain has been controlled on the same dose for several days. This change in dose to meet patient needs is known as “titration.” The fact that the dose of opioid can be lowered once pain is controlled is one of the paradoxes of treating severe, chronic pain.

Until the mid-1970s it was believed that morphine was not an effective analgesic when administered by mouth, so it was universally administered by injection. We now know that morphine is effective when given by mouth or even by suppository. Patients generally do not like injections, as they are painful in themselves. There are several excellent long-acting opioid analgesic preparations. Morphine and related opioids are available that control pain for 12 hours when used on a regular basis twice daily.

When prescribed on a regular basis in a dose sufficient to relieve pain, there is no empirically based evidence that opioids lead to addiction.

When prescribed for managing severe, chronic pain there is no problem discontinuing the dose once pain is controlled. Withdrawal from the opioid analgesics is not a life-threatening condition as is withdrawal from a number of other commonly prescribed medications, such as barbiturates. The symptoms of withdrawal from opioids are generally mild and fairly easy to manage with commonly available medications. Many patients who receive opioids for severe pain have had their dose adjusted down without experiencing any withdrawal symptoms.

This myth developed in the years before we learned to provide excellent pain management, but is not appropriate today. Suffering does not necessarily enhance character though it is a testament to human resilience that some individuals grow in spirituality, empathy and understanding even while others may become more isolated, spiritually alienated, and personally difficult because of intense pain. The point is that needless pain and suffering can and ought be avoided as  it merely brings about a miserable ending to life, a horrible death and needless anguish in all who see helpless dying people suffer.

Morphine does not initiate the final phase of life or lead directly to death. Morphine provides not only relief of severe, chronic pain; it also provides a sense of comfort. It makes breathing easier. It lets the patient relax and sleep. It does not cloud consciousness or lead to death.

Severe chronic pain never occurs alone, but is usually accompanied by a number of other symptoms including (but not limited to) anxiety, depression, fearfulness, insomnia, anorexia (loss of appetite), withdrawal and thoughts of suicide. All of these symptoms are compounded with memories of pain already experienced, currently perceived pain, and anticipation of more pain yet to come. Unmanaged (or inadequately managed) severe, chronic pain is a complex problem that needlessly aggravates the symptoms of the underlying disease.

It is easier to provide safe, effective relief of severe chronic pain at home than it is in the average hospital. There are fewer medication errors when there is only one patient to receive medications and no other patient emergencies to interrupt the care. Accurate messages regarding pain management can be shared on a regular basis by means of a ‘Comfort Control Chart’ on which the patient indicates the level of pain relief by using numbers (0 to 10) to let the doctor know the adequacy of pain management

The preceding has been excerpted from Hospice Foundation of America’s Clergy Education Project Curriculum.