Relieving pain in palliative care Whakaoraora i te mamae ki te manaakitanga whakamaene
Many people receiving palliative care worry about pain. While not everyone has pain, there are a lot of things that can be done to manage it if you do.
Managing pain
If you are experiencing pain or you or your whānau are worried about pain, talk to your healthcare provider. They can explain what can be done to help.
Your healthcare provider may need to change your medication over time to work out the right dose. As your illness progresses, they may also need to increase the dose. This usually happens because the pain is getting worse. It does not mean that the medication is losing its effect.
Pain relief medicines
There are lots of types of pain relief medicines that can be used. These include simple pain relief medicines like paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin.
Pain relief medicines for adultsexternal link
If you have strong pain, your healthcare provider may prescribe stronger pain relievers called opioids.
Opioids only help some types of pain. You may need to take other pain relief medicines at the same time. Your healthcare provider will talk with you about this. The most commonly used opioid is morphine. Opioids used in palliative care include:
Opioid medicines
Fentanyl is an opioid medicine that can relieve severe pain. It is similar to morphine and is used by people who cannot take morphine. This might be due to:
- allergies
- side effects
- throwing up (vomiting)
- difficulty swallowing.
In palliative care, the time to start using fentanyl is when you have strong pain. It does not mean you are dying.
Fentanyl only helps with some types of pain, and you may need to take other pain relief medicines as well. Your healthcare provider will discuss this with you.
You may need to steadily increase the dose of fentanyl to work out the right dose. Your healthcare provider will do this slowly and steadily over a few days. It can take up to 2 weeks to get the right dose.
As your illness progresses, you may need to increase the dose. But this usually happens because the pain is getting worse. It does not mean that the fentanyl is losing its effect.
When used correctly at the right dose, there is no evidence that fentanyl either shortens or prolongs life.
Taking fentanyl
You most often take fentanyl through a patch that you put on your skin. You absorb the fentanyl into your blood.
Fentanyl (patch) — New Zealand Formulary Patient Informationexternal link
Possible side effects
Fentanyl can cause a few side effects, including:
- drowsiness
- dizziness
- dry mouth
- constipation
- feeling sick (nausea)
- itching
- skin rash.
If you have problems with any of these side effects, it is important to tell your healthcare provider.
Fentanyl addiction
Addiction can happen when you:
- take opioid medicine for a long time
- abuse opioid medicines.
It may be possible to reduce your fentanyl dose if another treatment can relieve your pain. If you need to reduce or stop your fentanyl, make sure you talk to your healthcare provider about it. They will reduce your dose gradually to reduce the risk of withdrawal symptoms.
If you need to take higher and higher doses, it may be because:
- your body is getting used to the methadone
- your disease is getting worse.
It does not mean you are becoming addicted.
Driving
Taking fentanyl does not automatically mean you cannot drive. You need to talk to your healthcare provider about this.
You should not drive if you:
- have difficulty staying alert or concentrating
- are physically weak or ill.
If your healthcare provider says driving is okay, follow these general guidelines:
- do not drive in the dark or in bad conditions
- do not drink any alcohol before driving
- do not exhaust yourself by driving long distances
- talk to family and friends about any concerns you have
- do not drive if you are in severe pain.
If you are involved in an accident, you will be questioned closely if you seem to be under the influence of drugs.
Alcohol
The combination of fentanyl and alcohol will probably make you feel sleepy or drunk much sooner than usual.
You should drink less than you are used to until you know what effect it has on you.
Recording your fentanyl use
Keep a diary of:
- the doses and times of any medications you take for any breakthrough pain
- any changes to your medication
- how often you do a poo.
Have this available for your healthcare provider each time you see them.
Methadone is a medicine like morphine that works as a strong pain reliever. Healthcare providers prescribe it when someone has strong pain.
In palliative care, the time to start using methadone is when you have strong pain. It does not mean you are dying.
Methadone only helps with some types of pain, and you may need to take other pain relief medicines as well. Your healthcare provider will discuss this with you.
You may need to steadily increase the dose of methadone to work out the right dose. Your healthcare provider will do this slowly and steadily over a few days. It can take up to 2 weeks to get the right dose.
As your illness progresses, you may need to increase the dose. But this usually happens because the pain is getting worse. It does not mean that the methadone is losing its effect.
When used correctly at the right dose, there is no evidence that methadone either shortens or prolongs life.
Taking methadone
You can take methadone as a tablet or as a solution.
For tablets, follow the instructions and take them with a glass of water.
For the solution, measure it and take it according to the instructions.
You must only take:
- the amount of methadone you have been prescribed
- the dose at the times on your instructions.
If this does not control your pain, talk to your healthcare provider.
If you miss a dose, take it as soon as possible. But if it is almost time for your next dose, skip the missed dose and continue as usual from your next dose. Do not take 2 doses at once.
Keep track of when you take each dose of methadone. This can help to avoid missing doses or taking extra ones.
If you are forgetful, have someone else give you each dose of methadone and keep a record of it.
Possible side effects
Constipation
Methadone is a good pain reliever. But almost everybody who takes it gets constipated.
You should make sure your healthcare provider routinely prescribes a laxative. You need to take this regularly.
You can also help to ease constipation by:
- drinking at least 8 cups of fluid daily
- having regular meals and snacks, if possible
- eating more fibre-rich foods such as vegetables, fruit, wholegrain breads and cereals
- being as physically active as you can.
Feeling sick (nausea) and throwing up (vomiting)
About a third of people starting methadone can feel sick or even throw up in the first 1 to 10 days of treatment. This usually goes away.
If this is a problem for you, your healthcare provider can prescribe an anti-nausea tablet. But other things might be causing you to feel sick or throw up — it may not be the methadone. Talk to your healthcare provider if you are having problems.
Feeling sick and throwing up in palliative care
Drowsiness
Sometimes people feel more sleepy or drowsy than usual for a few days after:
- starting methadone
- increasing the dose.
This usually wears off quickly. If methadone affects you in this way, you must not drive or operate dangerous machinery.
Less common side effects when taking methadone include:
- unsteadiness
- confusion
- hallucinations
- sweating
- blurred vision
- shaking
- difficulty weeing
- a dry mouth.
If you have any of these side effects, tell your healthcare provider.
Methadone addiction
Addiction can happen when you:
- take opioid medicine for a long time
- abuse opioid medicines.
It may be possible to reduce your methadone dose if another treatment can relieve your pain. If you need to reduce or stop your methadone, make sure you talk to your healthcare provider about it. They will reduce your dose gradually to reduce the risk of withdrawal symptoms.
If you need to take higher and higher doses, it may be because:
- your body is getting used to the methadone
- your disease is getting worse.
It does not mean you are becoming addicted.
Driving
Taking methadone does not automatically mean you cannot drive. You need to talk to your healthcare provider about this.
You should not drive if you:
- have difficulty staying alert or concentrating
- are physically weak or ill.
If your healthcare provider says driving is okay, follow these general guidelines:
- do not drive in the dark or in bad conditions
- do not drink any alcohol before driving
- do not exhaust yourself by driving long distances
- talk to family and friends about any concerns you have
- do not drive within 4 hours of taking a dose of methadone
- do not drive if you are in severe pain.
If you are involved in an accident, you will be questioned closely if you seem to be under the influence of drugs.
Alcohol
The combination of methadone and alcohol will probably make you feel sleepy or drunk much sooner than usual.
You should drink less than you are used to until you know what effect it has on you.
Recording your methadone use
Keep a diary of:
- the doses and times of any medications you take for any breakthrough pain
- any changes to your medication
- how often you do a poo.
Have this available for your healthcare provider each time you see them.
Other medicines
You might also have other types of medicines to go with your pain relief. These may include:
- steroids such as prednisone
- antidepressants such as nortriptyline or amitriptyline — at low dose, these medications block the signals that overactive nerves send out, which can make them effective in treating nerve (neuropathic) pain
- anticonvulsant medicines such as gabapentin or pregabalin.
These medicines can help control pain.
Other techniques for managing pain
Other (complementary) techniques can also help with pain or anxiety. They may be used alongside your regular medications so long as it is safe to do so. Techniques include:
- massage or acupressure
- hot or cold compress
- distraction techniques such as listening to music or a podcast or reminiscing with friends and loved ones
- traditional techniques such as Rongoā Māori
- pacing the tasks you do and learning new ways of doing your everyday tasks.
You can also use relaxation techniques such as:
- breath work (focus on taking long, slow, deep breaths)
- box breathing (inhale for 4 counts, hold for 4 counts, exhale for 4 counts, hold for 4 counts)
- progressive muscle relaxation (tense and relax each muscle group from your toes to your head)
- listening to guided imagery or a mindfulness meditation.