At the end of life, we want to make sure that we are comfortable. People across the globe fear dying in pain. It’s a real fear because the World Health Organization estimates that 1/10 people alive today risks dying a painful death. This is true for developing countries, as well as developed countries like the United States, Canada, and Australia. Patients with cancer suffer from pain. In fact, chronic cancer pain occurs in about 33% of patients in active therapy and 67% of patients with active disease. Opioids are the mainstay of treatment for cancer pain, but are they effective and worth the treatment? Are there a lot of side effects? We are going to explore how opioids can impact those suffering from pain at the end of life.
Physical pain is common and most feared by those nearing the end of their life. Cancer pain is a large component, but stiffness from being immobile is also common. For most patients, pain medications are taken around the clock. But, patients also have breakthrough pain which require short acting opioids. The last thing patients and doctors want is suffering – especially toward the end.
Opioid abuse continues to be a major concern for patients and their families in the United States. Many studies show that there is a low rate of addiction for the severely ill. Therefore, opioids should be offered and provided for those at the end of life. They should not be withheld due to a fear of abuse or addiction. Surprisingly, access to pain-relieving medicines such as morphine for dying patients is impeded by the government or certain regulations in some countries.
There can be side effects from opioids, but most of the time they can be managed. Withdrawal is possible if the opioid is reduced too quickly or stopped abruptly. Opioids are individualized for each patient, because each person responds differently based on numerous factors such as genetics, other diseases or illnesses and kidney or liver problems. Opioids can be administered in different ways too – orally, transdermally, rectally, intranasally, and intravenously, for instance. Some routes are more helpful at the end of life when oral administration may be difficult from conditions like a decreased level of consciousness, difficulty swallowing or nausea.
The cost of the opioids is another consideration. Some newer opioids can cost more than those that have been on the market for many years. For instance, newer fentanyl products that are administrated as a spray in the nose or the mouth can cost more than opioids like oxycodone (Percocet), hydromorphone (Dilaudid), or morphine. Insurers may not cover these newer drugs unless the patient has failed more standard opioid medication therapy first. On the other hand, opioids should be customized to each patient based off their specific needs related to route of administration, side effects and especially efficacy. The ultimate goal is to maximize pain relief and minimize side effects so that the patient is free to choose how to live the remainder of life.
If a patient is just starting an opioid regimen at the end of life, there may be a greater risk of side effects due to changes in the body’s ability to metabolize drugs and excrete them. Sometimes more than one opioid needs to be trialed (opioid rotation) before the most effective drug with the fewest side effects is found. Patients not taking opioids (opioid naïve) will not have an immediate tolerance to a new opioid that is provided. Proper timing of opioid therapy and careful assessment of side effects should occur for those at the end of life.
For patients having a hard time breathing or functioning because of the pain, opioids can make a big difference. Don’t be misled into thinking that starting or escalating an opioid to a dying patient will unethically cause death. Research suggests that aggressive pain control at the end of life does not necessarily shorten life. Rather, it can be life-prolonging by reducing the body’s exposure to uncontrolled pain. In general, there is no correlation between opioid dose, timing of administration, and time of death.
Talk with your doctor or pain specialist about the appropriateness of opioid therapy if faced with a terminal illness.
For more information on managing pain towards the end of life you can listen to an interview I had with Patrick Swayze’s wife, Lisa, in Caregiving When Life Ends with Lisa Swayze Part I.
You can also listen to my show Will We Die in Pain? in which I interview Mike Hill, Director, Writer and Producer of “Life Before Death,” a documentary highlighting the battle by physicians and nurses to stop the epidemic of pain that threatens to condemn one in every ten of us to die a painful death.
Remember, no one is immune to pain, but together we can overcome it.
Source Information: American Family Physician