Morphine in palliative care

The best way to treat pain is assessing the pain. Knowing the root cause of the pain will help the doctor to prescribe the best type of medication.The medication can rage from a combination of different pain killers and their dosages.

Generally morphine is given to patients, when end is mostly obvious and there is no hope. For most of the patients- who are given morphine, It is generally not the stage of the cancer, but the degree of the pain endured by the patient.  The pain is constant and continuous.

Assessing Pain

To treat the pain, It is extremely important that it is analyzed properly with careful observation. The best way to assess the pain is to get the patient to talk, be involved in the treatment. Apart from this the family of the patient can monitor the patient( at least once a day) taking into consideration the following factors. 

• Physical effects 
• Practical Impact
• Emotional factors. 
• Spiritual needs

Route(s) to administer Morphine

• Oral 
• Rectal
• Sublingual
• Subcutaneous
• Intramuscular
• Intravenous. 
• Transdermal (The most common used nowadays)

Towards the end, pain becomes stubborn and responds poorly to opioids. No drugs or most of the drugs fail to provide relief from pain. However, morphine- one of the oldest drug is still used extensively in palliative care for the patients with fast approaching end.

Intolerance to Morphine

The patient tolerance to morphine can be attributed to the following factors

• Exposure to opioids in the past. 
• Hereditary
• Opioids providing no relief
• Rate of dose titration. 
• Additional treatment being given. 
• Disease related 
• Kidney and liver function.

The best way to improve  morphine intolerance is to start with a low initial dosage and gradually titrate upwards. Despite of best efforts, if things don’t change then consider substituting the opioid. 

If the condition still persist, try changing the route in which the opioid is administered. If still there is no change in the condition, then probably the pain was not assessed properly, look for other causes of pain. Besides, it is important to manage the side effects with additional medication.

I love you, Papa!

Opioids for CANCER pain

In my previous post I have talked about “PAIN” relief in cancer. In this post, I will be talking about about opioids- drugs which are used to provide some relief from the constant "difficult" pain.

With each passing day, cancer becoming more aggressive, pain becomes a 'constant' part of life. The pain is not only acute but is chronic and with time, it tends to become more uncontrollable. At this stage doctors prescribe OPIOIDS.

What are opioids?

Opioids are medicines that are used to provide relief from moderate to  severe pain( usually in cancer) .These medicines work on the principle of "reducing the intensity" of the pain signals being sent to the brain and affect those areas controlling these senses, and thereby considerably minimising the effects of the painful signals.

Opioids act much like endorphins-  natural substances created by the body to restrict or limit pain. Some of them work better than others in terms of providing  relief from terrible pain. 

Opioids were once formulated from the opium poppy( plant), but today many pharmaceutical companies are creating these drugs synthetically in laboratory, though addiction to these drugs still remains a critical issue .

Types of Opioids

Severe Pain

• Morphine 
• Buprenorphine
• Fentanyl and Alfentanil  
• Hydromorphone 
• Diamorphine
• Methadone
• Oxycodone 

Moderate to mild pain 

• Tramadol
• Codeine 

All  of the above mentioned drugs are available at drugs store strictly on prescription. 

Side effects

Most of the people taking these drugs over a period of time develop a kind of tolerance to these drugs. Therefore, the doctor has to prescribe higher dosage to provide relief from pain  or the other reason can be  increase in pain due to the advancement of the disease. 

A little  increases in the dosage or a change in the type of medicine will help in relieving the pain.

Common Side-effects

• Hallucinations
• Confusion
• Vivid dreams 
• Myoclonic jerks.
• Sedation
• Nausea and vomiting 
• Constipation
• Dry mouth 
• Itchy Skin 
• Coughing,wheezing, and shortness of breath
• Difficulty in passing urine
• Blurred vision

All these symptoms are common, and usually the treating doctors provide medicine to help overcome these effects. 

Im my personal view these symptoms never actually go away. Though the doctor’s do prescribe some medications to control these symptoms, but they prove to be of little or no help. Eventually all the symptoms emerge. ( In case of my father, where I tried my level best to read about the symptoms before hand, so that I could "prevent" them from emerging. With absolutely no result, my father went away!)

Towards the end, when pain becomes “difficult", the body has become resistant to opioids and nothing helps- the focus should be on making life easy- good palliative care.

Because you love them, tell them, show them- be with them. They need you, for the last time!

I love you papa!

Cancer- Dealing with pain

As CANCER advances, pain only increases. Treatment is almost over. Nothing much can be done now medically, only efforts to reduce the pain can be done ( Palliative Care).  Around 2/3 of the patients suffering from cancer experience acute pain. The pain is almost unbearable for the patient and is equally painful for you to see your loved one in pain. 

For treating pain, Doctors use all sorts of medicines - from simple drugs like Paracetamol (Analgesics) to Morphine (Opioids). Honestly nothing helps, but if the medicines are given timely  and in proper dosage, then they are of some help. The patient do experience some relief, if the pain has been analyzed properly and timely.

A study conducted by doctors in UK, says that Tolerance to pain can be Increased in the following ways

• Rest 
• Diversion
• Physiotherapy 
• Relaxation therapy
• Empathy 
• Support from family
• Listening to Music
• Expressing emotionally

Tolerance to pain is reduced by

• Anxiety
• Sadness
• Introvert Attitude
• Insomnia
• Socially Cut-off
• Fear
• Fatigue
• Anger
• Mental Separation
• Depression

Pain can be described as physical expression of social, spiritual and psychological isolation. To feel pain, one need not suffer. Dealing with pain, a lot of effort is required that too in a very organized and a sensitive way.

• Proper Medication
• Counseling
• Other Therapies
• Spiritual Support

Apart from all  of the mentioned above, support from family plays a pivotal role in making life easy for your loved ones. Talk to them, make them express, listen to them-After all you love them and this is the least you can do for them.

I love you Papa!

The Last week

By this time last year, papa never woke up..he just lay in the bed lifeless. I would sit next to him in the hope that he would wake up. But now he never opened his eyes. He never smiled. He never looked at me.The morphine patches kept papa drowsy the whole day.

Every now and then, me and my mother would moisten papa’s dry lips. His pain was unbearable.The pain killers were no help. Allopathy din't help. Homeopathy was not helping. Ayurveda was not helping. Nothing was working. The doctor advised morphine patches. Usually patients are advised to take oral morphine, or through injection.But papa was too weak to  swallow…and injection I din’t want. 

I used to buy these morphine patches from the hospital…I was giving my own father morphine. Yes, the addictive drug- Morphine. It is not a pain killer but keeps the patient drowsy all the time and  he becomes  oblivious to his pain. Papa now was unconscious all time.  I prayed every single moment , that his suffering should end….and I  wished that he fades  …I am sorry papa, what a bad bad baby I have been.

Love you PAPA!

Chapter 6- Radiation therapy begins...

As time passed, pain only increased and papa spent most of his time lying on the bed. Even for turning to his sides, he now needed support. He stopped having food. The last time he had anything to eat was on 12th August 2012 and then finally having his last meal ( half a cup of his favorite apple juice),  on the morning of 26th October 2012  - the day he left us! 

I remember,  once i got his favorite sweet. He got very annoyed and threw it. Cancer has reached his mouth and he had stopped feeling taste. In my last frantic attempt, I decided to go ahead with RADIATION THERAPY. Papa’s oncologist has suggested it as the last resort to help my fading father.  

I had reached at a stage in my life, where if anyone  would have told me about something that can help my father in easing his pain. I would have done with my eyes closed. I don’t care. I just wanted papa to be  free of pain. 

An ambulance was arranged. Papa had to be carried on a stretcher. Our house being on  2nd floor, with the help of my brother, my husband and 2 more people,  papa was brought down and  taken to the hospital.

I have often have come across a saying,

"The only permanent thing in life is change"

And, now when I think of it, having seen it  with my own eyes. I can say,  how true it is.

When i was a baby, my father  held my hand and I followed him because i believed him. Papa will only decide the best for me. And now years later. I am holding his hand and he is following me. He believed in me, in my decisions. He knew, I knew-  nothing was happening. But our  belief in each other kept us strong all through  the treatment.  

Papa lay on his bed, when the nurse came and said, it’s time for the therapy. He looked at me and I looked at him. I got up. Papa was helped on the stretcher by the attendants . I carried his reports/files in my hand. On our way to the radiation therapy “room",  I started telling him about the man, i met in the lobby and how radiation therapy has helped him walk again. He was listening very carefully. Like every other time, this time also -I was sure, papa will feel good after the therapy. 

I waited outside the room. After 15 minutes, papa was brought out. His eyes were closed. He looked exhausted. His dark circle looked more prominent now. And his hands- the hands that taught me too walk, write and paint were frozen. I held his hand, and put his shoes under the stretcher and started walking with the stretcher, towards the room. 

In all 9 cycles were planned by the oncologist. Papa did feel better for the initial few days. But as the days progressed, so did CANCER. Side effects of radiation therapy emerged. Skin problems like itching, dryness, lumps formed behind his ears, changes in bowel movement, mouth ulcers, nausea, vomiting and difficulty in swallowing or coughing. 

The emerging symptoms only added to his miseries. Despite of taking preventive measures,  symptoms could not be controlled and papa’s condition deteriorated further.

After 6 cycles, papa gave up. He din’t want to. In respect to his wish, I decided to stop taking further radiation therapy sessions. For many weeks- Papa, lay on the bed motionless for hours, absolutely unaware of what was happening to him or around him.  To avoid bed sores, we would turn him on the sides. But from his side- he would  open his eyes only for few seconds, as if trying to gain energy and then fall back to sleep. His back bone completely ruptured. He would continuously writhe in pain. Bed sores appeared. They were painful. The lump(node) behind papa’s ear burst and pus started flowing. The ulcer in papa’s mouth turned black and he could not even swallow a spoon of water. Days passed since papa had any bowel movements.

He lay motionless for weeks, under the effects of MORPHINE and other pain killers. I would sit all day, by his side (for fear,  i would not move for a  minute, what if...... ).  I prayed, prayed and  prayed. I wanted ....the AGONY to end!

The END came, Papa went far far away...

Dear papa,  no matter where you are ….I LOVE YOU , always!