Narcotics as Terminal Pain Treatment

Pain expert Dr. Scott Fishman answers questions about end of life pain:

Q: Are narcotics used differently when treating terminal pain compared with other types of pain?

A: When someone is dying, time is a luxury and wait-and-see is not an option. As a person's remaining days and weeks grow shorter, time becomes more precious. What matters most in the final days is that patients are free of crippling pain and unbearable suffering so that they can finish their lives in ways that bring comfort, peace, and completion.

Concerns about lasting side effects or diminished physical capacity from months of using a drug become secondary to making a patient comfortable. When I weigh the relative risks and benefits, the urgency of end of life always moves me to intervene aggressively to maximize benefits. I use opioids more liberally for end-of-life pain.

Rather than considering a person's ability to function over long periods of time as my gauge for choosing a specific drug and dose, I aim to immediately maintain or improve the quality of daily life.

The delivery route of opioids into the body - orally, by injection, through a skin patch, through mucus membranes, or via an implanted catheter or pump - can have a significant impact on pain relief and side effects. Pills or liquids by mouth can take a circuitous path to the pain site.

They must first filter through the gastrointestinal tract and liver, which detoxifies and metabolizes the opioid. As a result, taking opioid medication orally delivers only a fraction of its punch. Furthermore, as the opioid passes through the stomach, intestines, and bloodstream, it can cause constipation, nausea and vomiting.

However, taking medications by mouth is still the most common route and usually the most convenient method of treatment. Other routes are usually used only if oral medication is not possible.

Opioids like morphine are the centerpiece of pain management for a terminal illness because they remain our most potent and reliable painkillers. And they can be administered in a variety of ways. With the right dose and most appropriate delivery method, opioids can contain virtually any pain.

Nevertheless, surveys of hospitals and doctors reveal that medical practitioners continue to under medicate terminal pain. Hesitant because of social and legal concerns, as well as medical misconceptions, many doctors avoid applying the full might of these wonder drugs.

Both doctors and patients worry about addiction, overdoses and decreased breathing with the use of opioids. But for patients with weeks or months to live, addiction is rarely a significant concern. When a medication is gradually increased with an eye on the patient's breathing rate, the body adjusts and repressed breathing is rarely a problem.

Despite what many people believe, there is no ceiling or single maximum dose of opioids that is automatically fatal. An effective dose for stifling pain can always be found.