Use of Opiates to Manage Pain in the Seriously and Terminally Ill Patient

By Cheryl Arenella M.D., M.P.H.

Albert Schweitzer once said, “Pain is a more terrible lord of mankind than even death itself.”

Pain is a significant problem for persons who are seriously ill.  If existing expert clinical guidelines for the management of pain were consistently followed, serious pain would be controlled acceptably 80-90% of the time. Yet pain remains under-treated.  Studies have shown that among those suffering with cancer, significant pain occurs in 30-40% throughout the spectrum of the disease, and in 65-85% of persons with advanced cancer.  Half of seriously ill children suffer pain, and 20% of them have moderate to severe pain.  Among elders living in the community, up to half suffer important pain problems, and this increases to up to 80% of elders living in institutions, such as nursing homes.  One-third of persons with HIV disease living in the community, and nearly two-thirds of those in inpatient facilities, suffer from moderate to severe pain.  Members of minority groups who are seriously ill fare even worse: Recent studies show that 50-80% of the time, pain in these populations is not well managed.

Why is this happening?

The class of medications called opiate analgesics (commonly known as narcotics) is generally the class of drugs that is indicated for the treatment of moderate to severe pain.  Unfortunately, there are many myths and misconceptions about the use of opiates for pain management, among health care professionals as well as among the public, that interfere with the appropriate prescription and use of opiates for control of severe pain.  We shall examine some of these misconceptions later in this article.

Recently, opiates have been receiving a great deal of “bad press,” which is feeding these misconceptions.  For instance, in southwestern Virginia, people with substance abuse and addiction problems have discovered fentanyl patches (a potent opiate), have learned how to abuse them, and have caused a serious misuse problem in this part of the state.

But we need to clearly differentiate the use of opiates by seriously ill people in pain from the inappropriate and illegal use of opiates by addicts trying to get a “high.”

Why does this matter?

People in serious pain cannot function well, cannot relate fully to others, become isolated, and suffer from depression, anxiety, and insomnia as a direct result of their pain.  Because of the physical stress people in constant pain suffer, their immune system is weakened: they are less able to fight infections and those with cancer are less able to fight the growth of the cancer.  This leads not only to significant suffering, but also to possible premature death and even suicide.

What are opiate medicines?

Opiates are a class of medications used for management of moderate to severe pain.  They act on what are called “opiate receptors” in the nervous system and the brain, and diminish the experience of pain by the person.  Medications in this class that are commonly used by experts in pain management are:

Single drugs (used for control of moderate to severe pain) such as:
•    Morphine (e.g., Roxanol, MS Contin, Kadian)
•    Oxycodone (e.g., Oxycontin)
•    Fentanyl (e.g., Duragesic patches, Actiq)
•    Hydromorphone (e.g., Dilaudid)
•    Methadone (e.g., Dolophine)
Many of these drugs come in both short-acting (lasting for 3 to 6 hours) and long-acting (lasting from 8 hours to 3 days, depending on the type of opiate) forms.

Combination drugs (used for control of moderate pain) such as:
•    Codeine/Acetaminophen combinations (e.g., Tylenol #2, 3, or 4)
•    Hydrocodone/Acetaminophen combinations (e.g., Vicodin)
•    Hydrocodone/Ibuprofen combinations (e.g., Vicoprofen)
•    Oxycodone/Acetaminophen combinations (e.g., Percocet)
•    Oxycodone/Aspirin combinations (e.g., Percodan)
These all last about 4 to 6 hours.

Let’s now examine some of the common misconceptions about the use of opiates for the management of moderate to severe pain in the seriously ill.

My mother was prescribed morphine for her pain due to her cancer, but I don’t like to give it to her because I’m afraid she’ll become an addict.

People who are prescribed opiates for the management of pain in accordance with generally accepted guidelines do NOT become addicted.  Addiction is a psychological disorder marked by craving for a substance (alcohol, drugs) in order to experience a “high” (state of euphoria), lack of control over the use of the substance, and continued use of the substance in spite of harm to the person.  It can be accompanied by behaviors that are harmful to the individual or to society (e.g., stealing to get money for the drugs).  In a study of over 11,000 patients who received opiates for pain following surgery, only 3 or 4 patients developed subsequent problems with substance abuse.  This is much lower than the actual rate of substance abuse in the general population (about 8%).

I’ve heard that using opiates is very dangerous!

Actually, when opiate medications are prescribed as recommended by pain management experts, they are extremely safe.  This class of medications is a lot safer than other classes of medicines that are used routinely by doctors.  For instance, opiates have a better safety record than aspirin (which can cause ulcers and significant bleeding, hearing damage, or kidney damage), arthritis medicines like ibuprofen (Motrin, Advil) or naproxen (Naprosyn) (which can cause ulcers, bleeding problems, kidney damage, or heart damage), or even acetaminophen (Tylenol) (which can cause liver damage when used in higher than recommended doses).

But I heard of a case where a boy was given a fentanyl patch by his dentist, and he stopped breathing and died!

Opiate medicines can suppress breathing in people who haven’t used them before when these medicines are first started, but this is a very rare occurrence when recommended starting doses of short-acting opiates are used.  Patients in need of opiate pain medicines who are opiate naïve (haven’t used opiate medicines previously) should not be started on long-acting formulations, and never in larger than recommended initial dosages.  The fentanyl patch is a long-acting form of opiate that stays in the person’s system for up to 3 days.

Most people who are taking opiate medicine for more than a few days no longer experience depression in their breathing from taking opiates, so it is only a concern in someone who is using opiates for the first time, or in a person who is taking other non-opiate medicines that can depress the breathing reflex (such as tranquilizers and sleeping medicines).  A person who is opiate naïve should be given a short-acting agent and monitored carefully for the first few days.  A person will become sleepy long before breathing is affected, and stopping the medicine temporarily is the appropriate solution, followed by a switch to a smaller dose afterward.  Even when breathing is suppressed (becomes very slow or shallow), doctors have very effective antidotes which can quickly and effectively reverse the breathing problem.

Unfortunately, even some doctors and nurses have an exaggerated fear of the depressant effect on breathing of opiate medicines, so they withhold appropriate treatment for pain at times.

My doctor’s nurse told me that hospice gives patients too many narcotics and causes them to die sooner.

Studies have actually 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.

Hospices frequently do not receive referrals to their programs until a person is imminently dying.  Thus, the observation that patients die quickly when they enter a hospice program can become a self-fulfilling prophesy.  There are no data to show that people in hospice die sooner than people with the same condition who are not being cared for in hospice programs.  In fact, there is some evidence supporting just the opposite finding, that people live longer with hospice care than people with similar conditions without hospice support.  Hospices do their best work in caring for patients and families if they are involved earlier in the course of the illness, well before death is imminent.

My brother was on Oxycontin for pain, and then he had a procedure that took away the pain, so he stopped taking the Oxycontin.  He got very sick, and the doctor said he was withdrawing from the narcotic.  Doesn’t that mean he got addicted?

When a person is on an opiate medicine regularly for more than a week or so, his system becomes “physically dependent” on the medicine.  That is, the body becomes accustomed to having a certain level of the medicine in the bloodstream, the nervous system and brain.  If the medicine is then stopped abruptly, that person may suffer symptoms of “withdrawal” (they may have sweats, rapid heartbeat, abdominal cramps, and runny nose).  This is NOT the same as being addicted (remember the definition of addiction above as a psychological disorder marked by craving for a substance in order to experience a “high,” lack of control over the use of the substance, and continued use of the substance in spite of harm to the person).  The withdrawal is a physical response to the sudden absence of something the body has become used to having around.  It is easily avoided by gradually lowering the dose of the opiate taken by the person over the course of several days. This person will NOT suddenly develop a craving for the opiate medicine, and the medication can easily be stopped.  Several other classes of medicines cause similar adverse physical effects when stopped suddenly, including some blood pressure medicines, some heart medicines, steroids, and medicines for diabetes.

My sister has bad pain from bone cancer, but I’m afraid if she starts using strong pain medicines now, they won’t work for her when she gets sicker and the pain gets worse.

What you are referring to is the phenomenon of “tolerance,” where there is reduced effectiveness of a given dose of a medicine over time.  Tolerance is not a serious concern in this situation.  Many people who use opiates, if they have the same level of pain, stay on the same dose of opiates for months, even years, with good control.  When people require increasing doses of an opiate, it is often because their disease is worsening and causing more pain – the patient is NOT really becoming tolerant.  Even in the case where a person is becoming tolerant, this is not a concern.  The administered dose of most of the single agent opiates can be increased indefinitely to a level that controls the pain, as long as side effects are managed.  There is no need to “save” strong opiates for when the person becomes worse.

I’ve heard that opiates cause lots of side effects, like nausea and vomiting, being too groggy, or getting confused.

All medicines have the potential to cause side effects, and the opiate medicines are no exception.  They can cause symptoms like nausea, grogginess, constipation, itching, and confusion. The good news is that most of the side effects can be managed quite easily with other medicines, and they usually go away on their own after a few days.  The one side effect that does not go away with time is constipation, and everyone who is taking an opiate should also be taking bowel medicines stronger than a simple stool softener to keep the bowels moving (e.g., Senekot). If a person continues to have difficulty with one particular opiate medicine, the person can usually be switched to another alternative opiate that may not cause problems.

I told my husband, who is now on Percocet, 2 tablets every 4 hours, that if his pain gets worse, he should just take more of his Percocet, instead of taking the “big guns.”  Is that right?

This could actually be a mistake since the current dosage of 2 tablets every 4 hours is the maximum recommended dose.  When pain is not controlled on the maximum recommended dose of a combination medicine like Percocet (which contains oxycodone and Tylenol), it is safer to progress to using a single agent opiate, such as morphine or oxycodone alone.  Percocet medicine contains Tylenol, which, when taken in larger than recommended doses, can seriously damage a person’s liver. Combination medicines that contain aspirin or ibuprofen can cause serious bleeding, ulcers, kidney damage, or heart problems, even when taken at recommended doses.  The same holds true for using larger than recommended doses of plain Tylenol, aspirin, or some arthritis medications.  Someone who is taking the maximum recommended dose of a combination medicine should NOT also take “as needed” doses of any of the medicines that are in the combination. For instance, your husband is on Percocet, which contains Tylenol.  He is already taking the maximum recommended daily dose of Tylenol, and he should NOT take plain Tylenol to supplement the Percocet medicine.

Why doesn’t my doctor seem to know about all this?

Many physicians and other health care professionals did not receive adequate training in how to expertly manage pain and other symptoms when they were going through school.  Health care providers are also subject to societal misconceptions and biases, and physicians also have a somewhat exaggerated fear that government drug enforcement agencies may penalize them if they prescribe “too much” opiate medication.

Many professional health organizations have published guidelines and recommendations for the management of moderate to severe pain in the seriously or terminally ill patient.  Among them are the World Health Organization, the Agency for Healthcare Research and Quality, the National Comprehensive Cancer Network, the American Medical Association, the American Society of Clinical Oncology, the American Pain Society, the American Academy of Pain Medicine, the American Geriatric Society, and others.  More and more continuing education programs are being offered to practicing health care professionals to correct the deficiency in their early training.

The bottom line is that a person in pain has a right to expect expert management of pain.  Tell your doctor if you or your loved one is having pain, including where it is, how bad it is, how often you have it, whether it is constant or intermittent, how long it lasts, what it feels like, what makes it better, what makes it worse, and how it affects your life.  Insist that it be addressed as a serious issue.  If your doctor is unable to reduce the pain to a manageable level, ask for a referral to a palliative care expert or an expert in pain management.

You and your loved one don’t have to live with pain.  You have the right to be free from pain!