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To all of you hospice pain gurus: I have a pt that has been taking Lortab 6xday with MS Contin (100mg) bid and Roxanol (20mg:1ml) 1ml q1-3 hrs prn breakthrough pain, and Fiorcet prn for headache (he takes at least 3 per day). Every time I ask him what his pain is - it's always at least a 7 and usually 10+ (Dx: lung CA). Meanwhile, he is conversing with me and his spouse without any apparent distress, joking around and such. Spoke with his MD and his meds got changed to Methadone, Decadron and Roxanol for breakthrough. He lasted 2 days and requested to be switched back to the Lortab regimen. He had a change of mental status (per spouse), and broke out in blotches - although he did not complain of a rash or itch. I'm just astonished that the methadone did not work - I've heard such good things about it. It makes me wonder whether this pt just loves his Lortab??? What do you think???
Some of my response regarding looking at things beyond pain meds (in chronic pain, NOT for people on hospice) is coming out of my work background -- which is the VA. In the VA, anyone who is going to be on long-term opiods is required to sign a opiod contract. The idea is to direct people to resources that may, or may not help them, but have to at least be attempted. If someone with DJD expects to gain a pain free state from the use of meds alone, it ain't gonna happen.
The idea is to look at what is realistic, and reasonable, and then work w/them to achieve that, as well as to see what are the other factors in their pain profile besides their disease. B/c it is the VA, they can say to them: "if you want to be tx here, you have to play by our rules, and that includes trying to achieve pain control through multiple modalities." The other part of this is that it seems that part of hyperanalgesia is that as you up the pain meds, you actually increase the excitability of the pain pathways -- in other words, it can get to the point that just throwing more opiods at it may make the pain WORSE.
I've heard talks/read papers by several of the experts in pain management, and some of them are saying that maybe we went too far in just giving folks what they want -- that maybe we've created some problems and that a different approach is actually going to be more efficacious.
Personally, I think bringing in more CAM (acupuncture, massage, guided imagery) would help a lot of people with CP.
Oh, and if you're not aware of this site, and you're interested in pain management, you should check it out! It includes specifics for palliative care, cancer pain, etc. etc.
ah, ok.
i thought you were referring to our hospice pts.
since that is not the case, i agree w/you 100%.
and yes, the medical community has indeed, created 'monsters'...
meaning, these folks who live w/cp, often refuse any supplemental txs.
that, only narcotics work.
and it's unrealistic to think that all pain will be absolved.
you're right.
it's not going to happen.
and, these pts ultimately proclaim that "only xxx works".
they don't even see that they're addicted because, well, they have actual pain and need these meds.
yes, i too have seen the paradoxical responses.
i'm glad we're on the same page.:)
leslie
leslie :-D
11,191 Posts
i just don't think that biobehavorial approach is realistic if the pt isn't interested in obtaining such insight.
clearly, qol is subjective, meaning many things to many people.
i do believe in these approaches for those w/chronic pain.
such regimens are multi-faceted to living w/cp:
including opioids, antidepressants, psych/behavorial and physical therapies.
yet, it is something i wouldn't expect hospice pts to pursue.
if they chose to, wonderful.
if not, that's perfectly ok too.
whatever makes it easier for them to deal.
leslie