cancer patients and strong analgesics

August 20, 2007

Something I have learned and experienced working at Hospice in San Diego is that

it takes qi to die. If qi is being used to deal with pain, then it is not

available to use for the death process. Sometimes when the pain is dealt with

(and there is no unfinished business), the qi can then move to the death

process. Death can, and sometimes does, follow palliation of pain. This is not

referring to patients who are being given or taking higher doses than necessary

for palliation, nor those whose pain is not able to be palliated.

JMHO.

Sincerely,

Margi Duran, LAc

wrote:

Dear friends, colleagues and teachers,

I want to compare notes with those of you who have treated cancer patients. Last

week, I treated a lung cancer patient (a non-smoker, BTW) , who had been given

up on and sent home to die by her Western physician--except that he insisted

that she receive a high dose of IV morphine to " help her cope with pain. " She

and her family will very cooperative, and excitedly called me each evening to

report on how much better they felt she was doing. The level of her pain was

down significantly Friday, after my second treatment with her (I also brought

her a decoction of herbs which her family faithfully gave to her), but

nonetheless, her Western physician said that since her signs and Xrays were so

discouraging, he felt it would be beneficial to increase the IV morphine. After

that it was all downhill, and she passed away this morning. I strongly suspect

that the Morphine may have just too strong for someone in her fragile state, and

did her in. My question is, have any of

you had similar experiences with strong pain killers such as Methadone, Morphine

or Vicodin? This is my 3rd " coincidence " when a patient who was showing

significant improvement, passed away after receiving the analgesic Western

intervention.

Sincerely,

Yehuda

Take the Internet to Go: Go puts the Internet in your pocket: mail, news,

photos & more.

August 20, 2007

Yehuda

if you do give advise on the use of methadone or other analgesics make sure you

really know the clinical reality of these drugs. One cannot look at a PDR and

think that is a reflection of the real world. Narcotics are remarkably safe,

except for addiction which is not a problem with end of life care (overdose is a

different problem and usually not from medical intervention). The problem i see

every day is patients have not been managed with regard to the cause of their

pain so they end up addicted to narcotics. There are however many cases were the

only solution is to include narcotics if the patient is to become functional.

-

yehuda frischman

Monday, August 20, 2007 11:12 AM

Re: Re: cancer patients and strong analgesics

Geoff,

IMVHO, I don't believe that the understanding you have of my post is

completely clear. The statement that narcotics killed the patient, is just not

accurate. Nor is the statement that cancer killed the patient, completely

accurate. Cancer is not some monster that invades the body like an aggressive

exterior pathogen. It is a long unrelenting, insidious excruciatingly

complicated process, that sometimes takes 20 or 30 years before its ugly face

reveals itself openly. The question is not blame, either. It is rather

incredibly important to begin to understand the pathogenic factors in order to

stop and hopefully reverse them as early as possible. So, in viewing a cancer

patient I feel it is inappropriate to judge like in a court of law. There was a

bootleg Bob Dylan song that I used to listen to called, " Who Killed Davy Moore? "

In it all the different killers of a prize fighter give excuses that " it wasn't

me, I was just doing my job! " , including the fighter who

knocked him out, the manager, the doctor, the promoter, the fan asking for

more blood, etc. The same here. I feel that blame doesn't change anything.

Rather we need to ask ourselves, what elements have contributed to and

accelerated a given patient's functionality, quality of life and ultimately

death. I say that heroic pain killers in the context of a hospice patient must

be used with greater thoughtfulness and humility, and should not be administered

automatically! Of course, relief of pain is incredibly important, but everything

is not a straight forward black and white!

As far as relating to family members, again, you have to set your own

priorities, and risks for that matter. I am not afraid of giving a patient's

family, information either orally or in writing, for them to make an informed

decision on the use of Methadone, morphine or other heroic analgesics and the

risks involved. I am not afraid of engaging a hospice nurse or attending

physician in an informative civil conversation empowering them with information

that they may not have had heretofore.

The decision is yours.

Respectfully,

Yehuda

G Hudson <crudo20 wrote:

Yehuda,

Early treatment is great - and the best chance you have to attack the

cancer. I get the feeling you are blaming the narcotics for the

patients death. Cancer killed the patient, and at some point nothing

is going to change that. Alon noted the 'off-label' use for the

respiratory suppression. God only knows where the cut-off point is.

As for the patient wanting to fight, that's great, and hope helps!

Paraphrasing an earlier post by Alon on another topic he said you have

to objectively evaluate the results of your treatment independently

from the patient's desire (and ours!) that it's working. Treating

terminally ill patients, it's hard to not to let your personal

feelings prevent you from seeing the true nature of the disease.

Personally, after working with several terminally ill patients and

having some friends in town who are in hospice nursing, I know it

takes a very special kind of person to endure that labor - and I'm

just not one who could do it day in and out like they do.

As for sharing your experience with the docs who are experts in their

field about their medicine and informing the family contradictory to

what the oncologists are informing the family about, that will be

another war you will decide to wage. It can have some serious

personal, professional, and malpractice ramifications. The " maybe you

should ask your doctor about the side-effects of this medication " can

easily become " my acupuncturist told me to stop taking this

medication " - regardless of how well you document in your chart!

Best regards,

Geoff

Pinpoint customers who are looking for what you sell.

August 20, 2007

Oral methadone has demonstrated an excellent record of effectiveness and safety

during the more than 60 years since its development. During more than 40 years

clinical use as methadone maintenance treatment (MMT) for opioid addiction,

hundreds of studies have examined the pharmacology and efficacy of oral

methadone. With a greater understanding of methadone and its proper prescribing,

it has proven to be a well-tolerated medication, without serious adverse

reactions or associated organ damage, even in patients taking the drug for more

than 20 years (Leavitt 2003, 2006). As a result, methadone also has re-emerged

as an important opioid analgesic.

-

yehuda frischman

Monday, August 20, 2007 1:31 PM

Re: Re: cancer patients and strong analgesics

Alon,

I am constantly learning and re-evaluating. I would point out, though, two

considerations which have been articulated in our groups which are the basis of

my conviction:

1. There is clearly an agenda in hospice medicine

" to assist the pt & family for a peaceful passing " Pts are given heavy doses of

narc, usually morphine, to induce coma, then death.It takes 24-48hrs to work "

quoting nurse Amy, an insider in hospice care.

2. The literature clearly indicates that Methadone and Morphine do damage

internal organs and hasten death.

Yehuda

Alon Marcus <alonmarcus wrote:

Yehuda

I would therefore be careful not to come to any conclusion as of yet. And by

the way cancer pain is not considered to be sympathetically mediated, related to

facilitated segments or dural related. It is by definition none of the above

being a true nociceptive lesion

-

yehuda frischman

Monday, August 20, 2007 11:17 AM

Re: Re: cancer patients and strong analgesics

Alon,

As I have said on multiple occasions, I am a relatively new practitioner. This

was my 5th hospice patient.

Alon Marcus <alonmarcus wrote:

Yehuda

How many hospice patients have you treated cancer pain

August 20, 2007

Alon,

I posted a link previously unscoring the concern that the FDA had with

life-threatening respiratory depression and cardiac arrhythmias resulting from

inappropriate methadone dosaging. As it hasn't been posted yet here it is

again.

http://www.medscape.com/viewarticle/548340?src=mp

I believe that compare apples and oranges: The use of methadone as a

treatment of opiate addiction where often the patient is quite hardy, is very

different than its use in debilitated cancer patients.

Yehuda

Alon Marcus <alonmarcus wrote:

Oral methadone has demonstrated an excellent record of effectiveness

and safety during the more than 60 years since its development. During more than

40 years clinical use as methadone maintenance treatment (MMT) for opioid

addiction, hundreds of studies have examined the pharmacology and efficacy of

oral methadone. With a greater understanding of methadone and its proper

prescribing, it has proven to be a well-tolerated medication, without serious

adverse reactions or associated organ damage, even in patients taking the drug

for more than 20 years (Leavitt 2003, 2006). As a result, methadone also has

re-emerged as an important opioid analgesic.

-

yehuda frischman

Monday, August 20, 2007 1:31 PM

Re: Re: cancer patients and strong analgesics

Alon,

I am constantly learning and re-evaluating. I would point out, though, two

considerations which have been articulated in our groups which are the basis of

my conviction:

1. There is clearly an agenda in hospice medicine

" to assist the pt & family for a peaceful passing " Pts are given heavy doses of

narc, usually morphine, to induce coma, then death.It takes 24-48hrs to work "

quoting nurse Amy, an insider in hospice care.

2. The literature clearly indicates that Methadone and Morphine do damage

internal organs and hasten death.

Yehuda

Alon Marcus <alonmarcus wrote:

Yehuda

I would therefore be careful not to come to any conclusion as of yet. And by the

way cancer pain is not considered to be sympathetically mediated, related to

facilitated segments or dural related. It is by definition none of the above

being a true nociceptive lesion

-

yehuda frischman

Monday, August 20, 2007 11:17 AM

Re: Re: cancer patients and strong analgesics

Alon,

As I have said on multiple occasions, I am a relatively new practitioner. This

was my 5th hospice patient.

Alon Marcus <alonmarcus wrote:

Yehuda

How many hospice patients have you treated cancer pain

August 20, 2007

, yehuda frischman

< wrote:

>It is a long unrelenting, insidious excruciatingly complicated

process, that sometimes takes 20 or 30 years before its ugly face

I thought that way but I'll never forget a school mate a year younger

than me who had one leg amputated and died of lung cancer 6 months

later - in kindergarten. I think we sometimes overthink things being

a long drawn out complex process.

>empowering them with information that they may not have had

heretofore.

That's quite interesting.

Geoff

August 21, 2007

Dear Yehuda, and everyone,

I've taken care of 3 patients who have died of cancer; 2 since I became an

acupuncturist. Two accepted pain meds, one didn't.

It's important to remember that a terminal patient (or any patient) can refuse

treatment or medication; your patient wasn't forced to hook up the morphine

drip. If our patients have forgotten that ultimately they can and should make

these important (and informed) decisions, despite their doctor's (or our)

suggestions and instructions, we can gently remind them.

I think it's also important to keep in mind that it hasn't been very long since

the western medical establishment finally came to grips with the idea that if

pain can be relieved, it should be relieved, especially in terminal patients,

and no more forcing people to buck up and bear it. As far as I know, we (in

Chinese medicine) don't have legal access to herbs that are anywhere nearly as

effective for this type of massive pain relief, nor have I seen acupuncture to

be reliably useful for controlling this immense type of pain - if I'm wrong,

someone please direct me to sources where I can learn better! But of the 3

patients I've been with, one was terrified of experiencing the kind of pain

terminal cancer patients can experience, and as a nurse, she knew exactly what

was possible as far as pain goes. Not providing her with sufficient morphine, in

spite of its side-effects, would have been the same as forcing her to undergo

extended torture, a practice regularly engaged in by western med until it was

seen to be an ethical dilemma. The second patient was so exhausted from months

and months and months of treatments that she literally begged to be allowed to

die, and experienced horrible anxiety attacks (in part induced by her extreme

lung qi xu) that were agony to watch and agony for her to bear; her pain levels

were not so high, so her narcotic intake was low, but without it she would have

been even more exhausted from fighting a greater level of pain and fear. The

third, who refused pain meds, didn't experience great pain, although it grew as

she grew closer to death; but she also experienced terrible anxiety attacks as

she grew closer to death - again, not uncommon in terminal cancer patients as

the lung and heart qi become so frail.

The two patients I was treating as an acupuncturist received great physical and

emotional/mental comfort (and some hours of apparently remarkable energy and

seeming recovery) from treatments until just about a day and a half prior to

death; at that point, needles became too much for them to bear; nor were they

able to tolerate herbs at that point. This is also when the anxiety attacks

began, and it wouldn't be surprising if the groaning and pain your patient

endured were also from this anxiety. The qi in the chest becomes too frail to

root the spirit, the patient feels as if she's unable to breath, the heart

becomes uncertain, anxiety and great discomfort is overwhelming. Both of these

patients - with and without narcotics - seemed to rally and improve hours before

going into their final decline, which was consequently seemingly sudden and

surprising.

All patients have different abilities to tolerate pain and exhaustion and

strange sensations in the body; and what we think we will willingly endure, we

often discover we cannot bear once we're deeply into the actuality of the

experience. I'm glad that western med is making sure that adequate pain relief

is available to such patients, whether they think they want it or not, so they

can make quick use of it if they discover they do want it. Enduring pain can

also hasten death in the frail.

As healers, it's our ability, as well as our grace, to be able to fortify those

who wish to endure, as well as to bring ease to those who are undergoing the

unbearable. But at some point, each spirit will release itself from the body,

and the physical breakdown that accompanies that is inevitable and mysterious

and universal. I think that at that point, we healers must become witnesses and

comforters; we must comfort our patients and their companions that what is

happening is what is supposed to happen; and we must comfort ourselves that

we've done whatever could be done, and that it was important, and good, and a

blessing. I think, from your description, that if your patient was not beyond

the point of healing, the morphine she had wouldn't have made a difference in

her lifespan and she would still be living; and if she was so close to death

that the morphine did shorten her life, it was shortened only by a matter of

hours, and that her body and spirit had already untied most of the knots that

keep them bound together. The morphine didn't kill her, the cancer and the

cancer treatments and her own immune system failure did; the morphine may have

shortened her experience of dying. You gave her some good hours in the short

time she had left, that she might not have had without your care; try to take

some comfort in that. I think you need comforting, dear heart.

The time for us to intervene, if we can, is earlier in the treatment of cancer,

so we can help our patients survive the cure, and increase the chances that

there will be a cure. That will be a big struggle, because western cancer

treatment is still uncertain, and the MDs are terrified of adding any variable

into their already uncertain attempts.

---Deb Marshall

August 21, 2007

Thank you, Deb.

Very sobering, indeed. I would like to humbly add two thoughts in response to

your elequent comments: first, though patient's are not forced to accept strong

pain killers, often, they are either in an extremely weakened state or

semi-conscious, and there is tremendous pressure placed upon family members to

" ease the suffering. " The implication is that to not accept heroic doses of the

narcotics shows heartlessless. Yet even that is not an unreasonable argument on

face value. Which brings me to point two: Rarely, as many of you have said, is

acupuncture analgesia adequate. The key is integrating other powerful

modalities as well such as CranioSacral therapy and SomatoEmotional release. I

have found often that very sick patients hold onto deep physical, emotional,

mental and spiritual traumas, which they carry around with them like heavy

weights and promote a continued pattern of guardedness and sympathetic

hypertonicity (chronic fight or flight). This causes yet

more inflammation and the release of cortisol and adrenaline. It may even be

the root and pathogenetic cause of the cancer. By releasing the trauma, the

patient experiences deep relaxation and relief of pain. This evening, I treated

a young 25 year old woman who had been having digestive disorders her whole

life. She had all the five accumulations indicated in Yue Ju San, (Qi

stagnation, blood stasis, food stagnation, heat, and phlegm/dampness). Yet

while treating the area of her liver and diaphragm, I felt a hard rubberiness

and I engaged her in therapeutic dialogue. To make a long story short, her

father was physically and verbally abusive, and the trauma of seeing her mother

abused as a six year old, left a profound imprint on her which she consciously

didn't remember at all. The session took two hours, but afterwards she said

that she felt 20 lbs lighter and her countenance was completely different. I

didn't initiate anything but merely " listened " to her

body and facilitated what she needed to do. I feel that this needs to be an

essential element in the treatment of cancer patients as well.

All the best,

Yehuda

Deb Marshall <taichideb wrote: