Abstract
Managing symptoms at end of life can be one of the more challenging and rewarding aspects of medical care. Pain management in particular can be made difficult from an unlikely source. Surrounded by myth, misconception, and cultural bias, opiates remain the mainstay of treatment. Frequently, patients themselves may be the most formidable barrier to their effective use. Presentation of a reality-based case serves as the basis for exploring some of these attitudes and beliefs that may be a stumbling block to opiate use in effective pain management.
The inhibiting fear associated with prescribing drugs classified as “narcotic” is illustrated through 10 common misconceptions regarding their use and is characterized by the term Opiophobia. Not all the misconceptions originate from patients, but also from family members, cultural and regulatory agency norms, and even physicians themselves. A brief discussion follows each of such flawed concepts as “morphine use indicates death is imminent,” “enduring pain enhances character,” hospitalization is required for effective pain management,” and “opiate use always leads to addiction.” Regarding the hot button issue of addiction, a glossary is provided to help in distinguishing nonaddiction etiologies that explain the frequent need for dosing increases.
The formal recognition of hospice and palliative medicine as a certified sub-specialty confirms the notion that it is the duty of physicians to provide optimal care through the dying process. Undoubtedly, evidence-based guidelines will lead to new standards of practice improving end-of-life care. This article adds perspective to past practices and opens the door to adding perspective to new ones.
The representative couple referred to in this vignette as Fred and Audrey could not be more in love. Fred, a former US Navy pilot, and his blonde beauty could not wait to be in each other's arms, and it is no surprise that it fueled their passion for dancing all these years. In fact, through most of the nearly 20 years that I cared for them, every Saturday night was “Swing Night.” I can only imagine how effortlessly they glided and twirled across the floor as I had seen so many of that “Greatest Generation” do as I grew up. In fact, it was not until Audrey's Alzheimer disease was quite advanced that Fred stopped taking her to the dance hall. He was quite the stalwart in his commitment to Audrey. He was totally devoted to her care. They never had children, and their closest relative was a niece who lived 2000 miles away. Fred was there for Audrey 24/7. As her condition deteriorated, he learned to do it all—cook for her, feed her, clothe her, walk her, and diaper her. He knew he was her only world, and she was his. I often wondered if he would be totally devastated after her death, or if there would be a sense of relief and some motivation for him to move on. Only he was more surprised than I to realize it would be Audrey living on without him.
Fred had been ignoring his symptoms of abdominal pain, weakness, and weight loss, chalking them up to the stress of dealing with Audrey's progressive decline. How could he possibly get sick when Audrey needed him so badly? He was finally coaxed into updating some blood tests as it had been some time since he had scheduled a visit for himself. His pallor and weight loss suggested that more than stress was at work.
Fred was found to have metastatic liver disease and an unidentified primary tumor. His decline was very rapid, and it seemed sudden that I found myself seeing him in my role as a hospice clinician. The hospice nurse had reported that Fred had increasing severe pain and had been steadfastly refusing to take any of the “dope” that had been prescribed in spite of his obvious suffering. “I can't be doped up. Who is going to take care of Audrey? I gotta keep my wits about me.”
Few modalities used in standard medical practice can rival the legacy that opium and its derivatives has built since its first mention as an analgesic by Theophrastus in the third century BC.
1 The history that has accompanied the cultivation, trade, uses, and the legal, political, and profitability status of the unripe seed pod of the poppy plant,
Papaver somniferum, is a significant part of world history. It has been romanticized and vilified, from Broadway plays to outright wars, from billions in illegal trade to bloody murders—all of it tied to its distribution and control. It is no surprise that with such a notorious history, many myths and preconceived notions have developed around opium, not only in the United States, but also in most all other cultures.
Morphine is a daughter of opium, and in the eyes of many, she cannot escape the sins of her mother. It is a purified derivative of opium and commonly indicated for analgesia in a variety of circumstances, not the least of which is suffering frequently associated with symptoms accompanying end-stage disease. Despite its checkered past, morphine sulfate has the efficacy, safety, side effect, and cost profile that is at least comparable to those of other high-quality pharmaceuticals used routinely in medical practice. All available drugs classified as opiates generally share these characteristics. Reference resources reviewed for this article are consistent in their recommendation for morphine as a standard in pain and symptom management.
Although several barriers (eg, fear of governmental regulatory policies, physician education and experience) to appropriate opiate use in chronic and progressive pain syndromes of end-stage disease may complicate efforts to provide quality end-of-life care, it is the reluctance of patients and caregivers that is most likely to be encountered with regularity. Success in improving patient and caregiver compliance has been shown to improve quality of living for those with a life-limiting prognosis.
2 An effective way to improve compliance is for physicians to upgrade their own education and understanding and to use their communication skills to identify and dispel patient and caregiver fears based on the mythical history of these drugs.
The last misconception permeates the culture of both physicians and society in general, and as such, it can be the toughest misconception to overcome. It is not unusual for some physicians to underprescribe or for family and care-takers to take it upon themselves to hold doses or discard prescribed opiates for the sake of fears surrounding addiction and the legality of their activity. Understanding and explaining the nature of opioids and the frequent need for titration and at end of life may provide the confidence and trust necessary to ensure compliance and offer quality for the remainder of a patient's life.
The following definitions
5,6 may be useful to clarify patients' status and allow for better understanding of their needs and the rationale for changes that may be necessary.
Tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.
Pseudotolerance: The need to increase dosage that is not due to tolerance, but due to other factors such as disease progression, new disease, increased physical activity, lack of compliance, change in medication formulation, drug interaction, addiction, and deviant behavior. When a once-fixed opioid dose is no longer effective, the foregoing listed conditions should be reviewed to exclude pseudotolerance.
Physical dependence: A state of biolgical adaptation that is manifested by a specific withdrawal syndrome that occurs after abrupt cessation of pharmacotherapy, rapid dose reduction (which decreases blood levels of the drug), and/or administration of an antagonist.
Addiction: a primary chronic neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addiction is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, craving, and a high rate of recidivism.
Pseudoaddiction: a term that has been used to describe patient behaviors that may occur when a patient is under-treated for pain. Patients with unrelieved pain may become focused on obtaining medications, may “clock watch,” and otherwise seem inappropriately drug seeking.” Even behaviors such as illicit drug use and deception can occur in the patient's efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.
5,6
Fred's motivation to remain in severe pain was indeed admirable but totally unnecessary and even counterproductive to his goal: to remain in control of his helpless wife's well-being. When he realized how much the pain distracted from his ability to concentrate, how much physical and emotional energy had to be invested to fight it, and that it might even make him less effective for Audrey's well-being, he accepted recommendations to control his pain.
We kept a journal to document our discussions and his wishes so memory would be less of a concern. He rested and slept better noting more energy. When his niece visited him, he was able to interact and convey his wishes and affections unencumbered by physical suffering. The arrangements Fred made for Audrey with the help of his niece were satisfactory, and his niece was more than willing to lovingly take over wherever he left off, taking Audrey close to her home.
Fred remained the dutiful husband that he needed to be until the day he died, and his life ended in peace. It was the best possible ending to a tragic situation. Dr Sydenham and I were pleased.