In both acute and chronic health
conditions, pain is top on the list of
concerns for patients, caregivers and
physicians. Effective pain control
improves the individual’s state of mind and
ability to move through the healing process.
There are a variety of options for pain
control, and doctors work toward addressing
side effects that can occur with pain
Coming to terms with being in pain, acute or
chronic, is a hurdle for many folks who grew
up learning to “put aside” pain.
Individuals who have been vocal about pain
levels and received negative responses may
feel angry, refusing treatment as an
expression of emotional pain.
Fortunately, pain control centers,
physicians and other healthcare personnel
have become more aware over the years.
Asking about pain levels during office
visits is as common as checking vital signs.
TYPES OF PAIN
Acute pain can occur at the same time
chronic pain is experienced. The
euphemism “breakthrough pain” is one type of
acute pain an individual can undergo.
This pain can occur because of movement or
activity, but it can also happen when the
body has involuntary movements, such as
expelling gas or muscle twitches.
Medication can be prescribed for the “break”
in pain that around the clock medicating
Breakthrough pain may occur in the same area
as the chronic pain, but not always.
Noting the events leading up to the episode
of breakthrough pain can help caregivers
adjust activity levels if needed. In
some cases, the area in pain and/or the
event that contributes to it cannot be
pinned down. Recording episodes,
including seemingly random incidents, will
still help when pain management is reviewed.
When pain resurfaces before the next
scheduled dose of medication and isn’t
associated with a voluntary or involuntary
action, the physician can be notified to
examine the timing and amount of around the
clock medication. Noticing the time of
pain onset and keeping a record can help the
doctor make a decision about keeping pain
relief consistent. Caregivers will
find their loved one complains at or about
the same interval of time prior to their
Chronic pain is consistent and “stable.”
While there may be some fluctuating of
intensity, it is “reliable” in its
characteristics. Medication for this
type of pain is generally around the clock
to provide continuity of relief. Over
time, medications are adjusted to account
for changes in the pain cycle, including a
patient’s tolerance to a given dosage.
AGE DOESN’T MATTER
Children and adolescents with cancer or AIDS
experience pain just as deeply as an adult.
They may be better equipped to admit to pain
and track where they are hurting, as opposed
to adults who may have dementia as a
hindrance to assessment.
Physicians have a specific protocol, or
pathway, to follow when managing pain for
adults and children. When dealing with
“pain psychology,” caregivers will learn to
watch facial expressions, body positions and
other gestures to determine if their loved
one is understating their pain level.
Kids may not want to worry their parents, or
be afraid of a visit to the doctor or
hospital. As the healthcare experience
continues, parents become more attuned to
what their child is feeling, and may find
that personnel involved in their child’s
care are able to help them understand what
is typical at different stages of treatment.
While the same is true for caregivers of
adults, the adult-to-adult psychology can
have a wider range of variation.
Children helping their parents through a
health crisis may take time to relate to
them on an adult-to-adult level, and parents
may attempt to mask their fear and pain by
amplifying “Parent Mode.” When
possible, ask the doctor to allow for some
time alone with the parent, to allow them to
express their needs without feeling “weak.”
Relationships of every kind are challenged
when there is a health problem, and
relationship dynamics should be evaluated at
the time of diagnosis by loved one and
caregiver. Understanding that there
will be changes in any relationship is a
first step toward coping with those changes,
and making them positive ones.
PAIN MANAGEMENT IS A SCIENCE
Over the decades, the perspective on
managing pain has widened. Healthcare
practitioners and patients have a closer
relationship in deciding pain management
routes, incorporating “natural” and
prescribed medications and “alternative”
methods of pain relief.
Pain management was once considered “doping
up” the patient in some circles.
Today’s viewpoint incorporates consistent
pain relief with keeping the patient alert
The variety of conditions that require pain
management has created a demand for an
accurate “science” to provide help based on
condition and individual need. The
World Health Organization has a “ladder” for
managing cancer pain. Level One uses
non-steroidal anti-inflammatory medications
(such as aspirin) and “adjuvant,” or
supplementary medications that have a
secondary effect of controlling pain by
eliminating a side effect. As pain
increases with cancer progression and/or
treatment, professional caregivers step to
the next level of pain management. By
Level Three, opiates are incorporated and
the adjuvant medications are there to assist
with opiate side effects.
OPIATES AND PAIN CONTROL
In the classic film “The Wizard of Oz,” the
Wicked Witch deters Dorothy and her friends
by creating a field of poppies they must
walk through before reaching the Emerald
Castle. Dorothy and the Lion fall
asleep until the Good Witch intervenes with
snowflakes to wake them up, and the crew
moves toward their destination.
The poppy plant is used to create opiates
such as morphine and codeine, which relieve
pain, but also make the individual sleepy or
lethargic. The effects of “Opiates
from Oz” are shorter lasting than those
administered for those in chronic pain.
Since alertness is a factor in complying
with pain medications, patients may be
unwilling to try them, looking to “natural”
The brain has receptors that recognize both
opiates and endorphins. Endorphins are
“feel good” chemicals produced naturally in
the brain, and have an analgesic effect.
While they are preferable to medications,
both acute and chronic pain sufferers may
not produce sufficient quantities of
endorphins to dull or eradicate pain.
Even simple pain relievers like
acetaminophen or aspirin may not do the
trick, and pain control must include
Morphine and its opiate cousins can be given
by mouth or intravenously. In some
cases, morphine can be delivered by a
nebulizer, dispersing the drug into an
aerosol that can be inhaled. The lungs
also contain receptors for opioids, absorbing
and processing the medication.
Caregivers should be aware that any
medication delivered by nebulizer can
disperse through the room. Taking
precautions when it comes to room
ventilation and proximity to the patient
will help the caregiver with unwanted
exposure to medication.
The concern for precautions has less to do
with a “secondary high” for the caregiver
than with residuals of the medicine showing
up in their urine if drug tested.
The type of morphine nebulized is the
intravenous type without preservatives.
When given by aerosol, morphine can activate
histamines and constrict breathing passages.
The goal of morphine by aerosol is to
alleviate difficult, painful breathing
rather than bring it on, so doctors may
order an aerosol treatment with medication
to keep the airways open prior to nebulized
There is a specialized, single dose
nebulizer that delivers morphine to the
lungs. The medication “strips” look
very similar to the ones used to test blood
sugar, but contain the correct medication
dosage. Aerosol particles do not “fly”
around because of the design.
TOLERANCE IS NOT ADDICTION
Caregivers and loved ones may worry that
tolerance means addiction, but they are not
Over extended periods of time, the dosage of
the medication may need to be increased
because the individual has developed a
tolerance to the medication, or there has
been a rise in pain levels. Doctors
work to use the lowest effective dosage to
keep the patient alert and pain free.
Medication dependence occurs when there is a
physical reliance on the medication and
withdrawal symptoms (that are specific to
the drug class) occur. There may be
tolerance present, but the withdrawal
symptoms are noted if the medication is
suddenly removed and/or levels of the
medicine in the bloodstream decrease.
When addiction is present, caregivers and
medical personnel notice that the patient
may “lose” prescriptions, and/or take their
medications at inappropriate times. A
number of other behaviors may be present,
including behavioral changes that include
isolation from family members.
Rather than diagnose your family member,
bring concerns to the family physician to
evaluate the situation. What seems
like dependence or addiction may be the
response to changes in pain level, tolerance
or other factors that the doctor must
evaluate. Behavioral responses such as
anger or depression may be due to poorly
controlled pain, especially if the pain
control journey is just beginning.
AIDS AND THE PAIN EXPERIENCE
With better medications and awareness on the
part of doctors and patients, individuals
diagnosed with AIDS are receiving improved
care. The pain experience varies from one
person to another, even in the AIDS journey.
Neuropathy (“nerve damage”) affects an
estimated 20 million Americans according to
The Neuropathy Association. Damage to
the nerves can create burning and sometimes
“stabbing” pains in the feet.
In some cases, anti-cancer and retroviral
treatments may create their own painful side
effects, some of which can be balanced by
other medications, including antidepressant
This immune deficiency virus makes patients
of all ages susceptible to yeast infections,
throat and mouth sores and other viruses
that can attack the body. Bacterial
infections are experienced, too, and require
antibiotics as the doctor decides.
The AIDS patient may have skin eruptions,
and these sores or rashes contribute to pain
and require treatment. For example,
Kaposi sarcoma is a skin lesion seen in the
AIDS patient that initially doesn’t cause
pain, but as it becomes worse, pain can be
extreme. While Kaposi is not
considered “curable,” it can be treated by
an oncologist or dermatologist with
experience in this area.
Mouth sores or other conditions affecting
the mouth can hamper eating, whether the
foods are acidic or not. Physicians
are familiar with this aspect of the
challenges of living with AIDS, and may
recommend supplements in addition to other
treatment for thrush or mouth sores.
Accommodate your loved one’s choices in
whether or not to eat at given times, and
oversee that medications are taken when
ordered, even if alternate routes must be
In some cases, individuals with AIDS may
have a concurrent infection with the
Hepatitis C virus, which also challenges
pain management and treatment. When
doctors assess for pain in the AIDS patient,
they look for other causes of pain, even if
the pain felt is typical for an AIDS
patient. Hepatitis C is one
possibility for a “co-infection,” but other
conditions such as cancers of organs or
blood may be present.
Treating the root cause of pain (such as
mouth or ear pain from infections) is the
doctor’s priority, which is the reason why
patients may be at the doctor or
hospitalized frequently. The choice is
to act quickly to stop infections from
causing more problems.
CONTROLLING PAIN IN CANCER
The National Cancer Institute
(www.cancer.gov) offers an online booklet to
assist cancer patients and their caregivers
with pain management.
“Cancer pains” may arise from chemotherapy
or radiation, creating nerve damage or
phantom pain from body parts that have been
removed. Radiation can cause painful
“sunburn” during treatment.
Whenever there is surgery performed,
temporary pain may be experienced because
skin and organs are cut and maneuvered
around. Post-surgical pain fades with
time and appropriate management, which may
include physical therapy and resuming daily
The growth of cancer within the body
contributes to pain, also. As cancer
is being treated, therapeutic levels of
controlling the growth are sought; but
patients may still experience pain while
waiting for the abnormal cells to be
eradicated. This is where pain control
offers a great deal to assist in stress
reduction and continuing patient compliance
with therapy. It’s difficult to ask a
loved one to continue with treatment when
pain makes them feel they aren’t getting
better, and the goal is to quickly assess
the level of pain to begin pain control.
It makes the treatment much easier to cope
with, for caregiver and loved one.
Differential pain assessment in cancer is
important also, to help the treatment team
to discern if new pain is from cancer that
has moved to a new area, or if there is an
acute condition that must be addressed (such
as appendicitis or gall bladder stones).
It may seem unlikely that cancer patients
may experience an acute episode of pain
unrelated to their cancerous process, but it
is possible. It may help to keep a
written record of pain to offer feedback to
the physician during visits, or if a call
must be placed after hours.
Swelling, itching and rashes cause pain, and
while minor when compared to pain from
cancer, they can actually make it harder to
tolerate pain levels if the minor pain is
COMPLEMENTARY PAIN TREATMENTS
Biofeedback has been around for some time,
and there are competent technicians able to
instruct patients in controlling their
breathing and heart rate. The
technique has worked well for persons who
have an ability to focus on these measurable
parameters, which can help reduce pain and
the anxiety that comes from being in pain.
Massage therapy can work in almost any case
to reduce pain and improve the relaxation
effect. It is not necessary to “work”
the area where pain is felt to provide
comfort and a sense of healing.
Patients with swelling from radiation or
surgery (such as removal of lymph nodes) can
look for a lymphedema therapist, who is
trained in proper technique for massaging
swollen areas as well as the rest of the
Reflexology can be performed on the hands or
feet to help release tense areas which may
be related to painful spots. The body
in pain will tense itself in a variety of
ways in response to pain, and by relaxing
one part of the body by massage, the rest of
it can follow.
Massage can be combined with biofeedback,
imagery or other alternative therapies (such
as aromatherapy) to diminish stress
WORKING WITH OPIATE SIDE EFFECTS
Constipation arising from opiate medications
is a frustrating consequence for caregiver
and loved one. A common misconception
is that fiber and exercise will address all
types of constipation. When opiates
are given, the bowels are slowed down; the
result is constipation, which occurs in many
people who take opioid/opiates.
The buildup of waste in the intestines
creates discomfort in all people. In
general, suggestions to alleviate and
control constipation include increasing
water intake to soften food passing through
the digestive tract, and exercise, which
helps muscles “massage” the internal organs.
The intestines made “sleepy” by opiods can
be helped by these two suggestions, but more
help may be needed; especially when pain
hinders the ability to move.
Fiber is an excellent “homespun” cure to
deal with constipation, and as long as the
individual has a somewhat hearty appetite,
salads and vegetables can be given as snacks
and meals. When appetites are poor or
finicky, fiber bought at the health food
store can be sprinkled on easy-to-consume
foods (like pudding or baby food).
Fiber is helped by fluid intake, and those
who are having trouble keeping up with their
liquids may prefer “fun fluids,” such as
snow cones and popsicles.
Caregivers and loved ones may be reluctant
to continue pain medication when
constipation is the result. The key to
working with this side effect is to allow
for the body’s changing ability to pass
waste as usual. Constipation may also
be a result of compressed nerves or other
factors that are at work in a health
challenge. Continuing medications is
important, but advise the doctor about
constipation and the success of any home
remedies. Combining simple fixes like
diet and exercise with physician-prescribed
solutions may be what is needed.
Laxatives and slow-release magnesium are
over the counter remedies that are helpful,
but should not be used without speaking to
the doctor. Overuse of laxatives can
create or increase constipation in the long
There are prescribed medications which work
to counteract the effects of various drugs.
“Antagonist” medications are given at the
doctor’s discretion. Discussion of
possible medications to counteract
medication effects can be done when there
are problems noted, but as always,
caregivers must give as much information
possible to the doctor so he can be guided.
PAIN CAN HAVE POSITIVE EFFECTS
If an area is completely numb from
treatment, pain may be an indicator that the
area is “coming back to life,” however
uncomfortably. When pain is addressed
within a reasonable time, corrective
measures can be taken to alleviate it.
This assists the body in healing, and helps
loved one and caregiver enjoy their time
together as they move toward the next step
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