Controlling Judy Abernathy’s pain became one of the greatest challenges at the end of her life, as it may be for many who are dying. Uncontrolled pain exacerbates other problems, such as sleeplessness and limitations in daily functioning. Judy’s self-management of her pain medication and refusal to explore options presented to her made it more difficult for her physician to find alternatives.
Cancer pain is most often treated with opioid medication. Lauren Shaiova, MD, director of the department of pain medicine and palliative care for Metropolitan Hospital Center in New York City, says every person has individual variability in how pain pathways are affected by medications. For example, there are variations in opioid receptors, which allow the pain medication to bind to them with the resulting pain relief. However, she says, one opioid may work well for one patient but not at all for another. “It’s constant readjustment and titration,” she says.
“There are at least 10 different opiates that can treat pain effectively,” Shaiova says. “But it might work successfully in Patient A, but Patient B might not get benefit—only side effects.” The selection of the medication has to fit the patient, she says.
Shaiova practices opioid rotation with the use of different opiates to find the best fit to alleviate pain with the fewest side effects. She says any physician skilled in analgesic pharmacology will be able to identify opiates to provide the patient good pain relief.
Shaiova says there is variety not only in which pain drug is used but also in the delivery system, which includes oral, transdermal (skin absorption), or a permanent intravenous line that allows the patient to push a button for medication delivery.
Pain medication may have side effects, such as constipation, fatigue, and nausea, and Shaiova recommends patients look for a palliative care physician who has had specific training in pain management and symptom control. “It is a new specialty, so I would get information and interview those trained in palliative medicine.”
Read more about pain management in “Under New Management.”