Relieving Concerns About Pain Medications

Many people have concerns and fears about taking morphine and other opioids. This is often because of misconceptions or a lack of information.

Virtually every authoritative body - from the World Health Organization to the United States Department of Health and Human Services Agency for Health Care Policy and Research - agrees that medications like morphine are best for treating moderate to severe pain.

In individuals with serious illness, opioids are the most commonly used medications in the management of moderate to severe pain because of their effectiveness, ease of dosing and very minimal risk of severe side effects compared to how beneficial they are.

Morphine and other medications like morphine are very safe when used correctly. Arbor Hospice patients are able to utilize these medications safely for many reasons.

• All Arbor Hospice staff receive extensive training in how these medications work in the body to relieve pain, how to give safe doses of the medication and which patients would benefit from taking these medications.
• The hospice pharmacy has licensed pharmacists who double-check all medications ordered. Working with the Arbor Hospice Medical Directors, hospice care team and the patient's attending physician, the pharmacists collaborate to ensure that each patient receives safe, effective medication therapy based on their individual need.
• After patients have been on medications like morphine for awhile, their bodies adjust and higher doses may be needed to provide relief. This can be done safely without causing long-term side effects. Just as people often need changes in blood pressure medicine over time, people often need changes in their pain medication.
• Unlike other pain relievers such as Acetaminophen (Tylenol) and Ibuprofen (Motrin, Advil), there is no limit to an opioid dose and therefore dosages can safely continue to increase throughout the disease progression.
• Since the body can become tolerant to the effects of opioids, the right dose of morphine is that which controls pain. This dose can easily be given without causing unmanageable or dangerous side effects.
• Side effects with any medication are possible. Fortunately, those associated with pain medications go away quickly and can be prevented or treated.
• Addition very rarely, if ever, occurs in patients who take medications for pain. Research has shown that less than one percent of all patients who take medications like morphine for pain develop any signs of addiction.
• Arbor Hospice staff follow dosing standards suggested by the World Health Organization, the Agency for Health Care Policy and Research and the American and International Pain Societies. These dosing standards have been proven safe in numerous studies.

What is Reflexology?

Reflexology is the practice of applying pressure to the feet and hands utilizing specific thumb, finger and hand techniques without the use of oil, cream or lotion. It is based on a system of zones and reflect areas that reflect an image of the body on the feet and hands with a premise that such work effects a physical change in the body. This is one of many techniques massage therapists use on clients, including individuals nearing the end of life.

The concept of reflexology began to emerge in the 19th century with European and Russian research into the nervous system. Reflex therapies were created as medical practices but soon eclipsed by the use of surgery and drugs. The ideas of reflex use for health improvement were carried on sporadically and brought to America in 1909 by Dr. William Fitzgerald, an eye-ear and nose specialist from Connecticut. Physiotherapist, Eunice Ingham is credited with developing a system of reflect areas sometime in 1938.

Research has shown the specific techniques of reflexology to be effective and beneficial in many ways. A survey of 170 reflexology studies from 21 countries showed that reflexology is effective, impacting a variety of physical and psychological concerns.

There are many benefits to a reflexology session:

• Creates relaxation: From the moment the reflexologist's hands start their work, the relaxation begins as shown in research using EEG brain activity. All together, 24 studies demonstrate reflexology's relaxation effects.
• Reduces pain: Pain reduction following reflexology work is documented in 27 studies, including research showing impact on individuals of all ages and health states.
• Enhances medical care: Reflexology helps when nothing else can for many phantom limb pain sufferers, neuropathy patients and hemodialysis patients, to name a few.
• Benefits mental health: Research demonstrates that reflexology can reduce depression and anxiety.
• Complements cancer care: Pain, nausea, vomiting and/or anxiety eased for chemotherapy patients following reflexology work as shown by 16 studies from seven countries.

In general terms, the benefits of reflexology have to do with the reduction of stress. Because the feet and hands set the tension level for the rest of the body, they are an easy way to interrupt the stress signal and reset homeostasis, the body's equilibrium.

Reflexology sessions last from 30 minutes to an hour. The client sits in a reclining chair placing the feet conveniently for the reflexologist to work. The reflexologist uses pressure and stretch movement to work through the foot methodically. Technique is applied to the whole foot or hand.

This blog post was written by Michelle Chaves-Torres, Arbor Hospice Massage Therapist. You may contact Michelle by commenting below or emailing her at mchaves-torres@arborhospice.org.

Music Therapy for Depressive Symptoms

Music therapy can be an effective method for addressing depressive symptoms among hospice patients. Music can be prescriptively applied for patients in various ways to address physical, emotional and biological markers of stress, anxiety and depression.

In music therapy studies, researchers have noted that the use of music can result in cerebral blood flow changes in brain structures that are associated with reward and motivation. These researchers also noticed in opioid-mediated reward and pain relief. These studies illustrate that music, especially music with highly positive associations, can activate areas of the brain that help a person feel reward and motivation.

Additionally, music can be used to address pain and anxiety, which may impact a patient's perception

of their overall situation and can, in fact, address depressive symptoms. Music is strongly associated with emotion and memory, thus providing many opportunities for patients to engage in emotional expression and reminiscence to improve their overall quality of life. Music can promote relaxation and a sense of well-being.

Many of hospice patients may be participating in fewer pleasurable activities. This could be due to physical limitations preventing them from participating in activities, or it could be more related to a mood disturbance. In either case, music therapy interventions can be applied to help promote feelings of pleasure, autonomy and success through instrument playing, singing, reminiscence or songwriting. Additionally, helping patients find new hobbies and activities to take part in as their functioning declines can be useful to stave off depressive symptoms. Listening to, and learning about music can be a fun new hobby for patients who may be bedridden but still in need of cognitive stimulation.

Patients experiencing feelings of worthlessness or guilt may be engaging in self-criticism or an exaggerated sense of responsibility for a negative event in their life. They may be grieving about their loss of independence or guilt for putting a burden on their family. These feelings are common, and can be addressed through positive feedback, and successful music therapy experiences. If a patient is able, they may benefit from music and movement techniques, but they would also have opportunities for self-expression, and gaining a sense of well-being through instrument playing, songwriting and music-facilitated relaxation techniques.

Finally, if patients are withdrawing from interpersonal interactions with family and friends, they may benefit greatly from music therapy interventions that stimulate social participation. Music is a naturally social medium. Bringing a group of people together to sing and make music can increase cohesion and encourage socialization. Additionally, music can be a great starting point for storytelling and reminiscence. Whether there is family members or other residents of a facility nearby, isolated patients may benefit from being engage in music-making with others.

Dementia and Massage Therapy

Many elderly individuals become sensory deprived as their faculties fade but the basic need for touch remains constant. As individuals lose sensory and cognitive skills, they become unable to interact socially, which may lead to feelings of isolation, depression, anxiety and agitation. Touch often remains the last form of communication when all other avenues have surrendered to the disease. When massage therapy is administered to patients in the end stages of dementia, it fosters feelings of intimacy and emotional connectedness.

Dementia is a slow progression of symptoms, sometimes lasting decades. At the onset, patients experience memory loss, confusion, language problems, changes in mood and difficulty performing daily tasks. This leads to an increase in anxiety and agitation, sometimes causing the patient to act out in ways considered socially unacceptable or improper. Sleep patterns become disrupted during the progression of dementia, and massage has been useful in treating insomnia. Additionally, many individuals suffer from a loss of appetite as Alzheimer's progresses, causing significant weight loss, resulting in physical frailty. A gentle hand massage given during light conversation has shown to improve appetite within an hour of the patient receiving it.

Massage can also stimulate the nervous system of Alzheimer's patients, helping to maintain nerve passageways that are in a state of decline due to the disease. A gentle massage provides relief and also aids drug therapies, possibly as a result of increased circulation. A neck and shoulder massage helps maintain upper body strength and muscle tone.

This blog post was written by Michelle Chaves-Torres, Arbor Hospice Massage Therapist and Complementary Therapy Coordinator. You may contact Michelle by commenting below or emailing her at mchaves-torres@arborhospice.org.

End of Life Cancer and Massage

Michelle Chaves-Torres, Arbor Hospice Complementary
 Therapy Coordinator/Massage Therapist, gives an
Arbor Hospice patient a foot massage.

Massage therapy is very beneficial for cancer patients at the end of life. Many patients experience pain throughout their body when cancer has metastasized, and in addition to traditional medicine, massage provides pain relief by relaxing the body. When someone is in pain, it can be difficult to find a comfortable position. Massage offers relief and facilitates the capacity to relax into a more comfortable state.

Massage improves circulation. More often than not, patients at the end of life are not as mobile as they once were. Sometimes they are confined to a bed or chair. Massage helps to stimulate and encourage circulation, providing nutrients and oxygen throughout the body. It helps to prevent pressure wounds in those that are bedbound by keeping the systems and fluids of the body moving.

Massage also decreases swelling often present in the arms and legs due to an impaired circulatory system from radiation or chemotherapy. A certain type of massage, called Manual Lymphatic Drainage Massage, stimulates the circulatory system to move excess fluids out of the body.

On an emotional level, end of life cancer patients may be suffering from depression. Routine massage often alleviates some of the signs and symptoms of depression. Massage stimulates the release of a hormone called an endorphin, a "feel good hormone." Researchers believe that because a massage can promote relaxation and release endorphins, massage can enhance someone's mood.

Sleep deprivation is another common aliment for end of life cancer patients. Massage provides the environment for more restful sleep and/or assists patients into a relaxing deep sleep. I have had many patients tell me "I feel like a new person after receiving a massage," or "I wake up feeling so refreshed."

Patients at Arbor Hospice benefit from massage intervention to alleviate pain, improve circulation and elevate mood. On average, 12-18 patients receive massage treatments per week throughout Arbor Hospice's seven county service area. In a future blog post, I will provide simple steps on how to give a hand or foot massage. That way, you'll be able to give massage therapy to someone you love.

This blog entry was written by Michelle Chaves-Torres, Arbor Hospice Complementary Therapy Coordinator/Massage Therapist. You can contact her by commenting below or emailing her at mchaves-torres@arborhospice.org.