Discussing a Painful Subject: Fear of the Process of Dying

BY MARK SCHOLZ, MD

Many men tell me that they fear the process of dying—suffering and experiencing pain—more than they fear death itself.  While I am no fan of pain, as a medical oncologist I have been responsible for the treatment of hundreds of patients with terminal cancer. I have learned that with good communication and proper medical management, pain can almost always be effectively controlled.

However, when reviewing the results of a recent patient survey at a meeting sponsored by Bayer Pharmaceuticals with a number of patient advocates, healthcare experts, and other physicians, it became sadly apparent that many patients are not being managed expertly. The survey indicated that many men with advanced cancer are suffering needlessly, mostly due to a lack of good communication with their doctors.

This survey of 410 men with advanced prostate cancer reported that two-thirds of men are trying to handle their pain by ignoring it!  One-third of all the men surveyed felt that acknowledging pain made them more fearful, raising anxiety about the possibility that their cancer is progressing.  A quarter of the men said, “It was difficult to talk about their pain,” relating that such discussions made them feel weak.

In other words, these men are using a common psychological defense mechanism called “denial.” One thing I have learned from years of experience treating patients is that denial can be a wonderful approach, but only if the situation is totally hopeless. I have observed men who appear to be in denial who are quite happy even when everyone knows that they are dying.

On the other hand, denial is a serious problem if what is being denied, in this case pain, can be fixed or remedied.  If men who are in denial fail to discuss pain with their doctors, their access to a solution is blocked.

Using denial can effectively control pain for short periods of time, however, using it on an ongoing basis is psychologically exhausting. Also, while denial might work for the patient, it can’t fool their surrounding loved ones. They see the effects of pain in the patient manifesting as fatigue, depression, inactivity, impatience, insomnia and hopelessness. Ultimately, the caregivers who are not shielded by denial end up suffering even more than the patient.

Cancer patients experience pain from multiple causes, not just their cancer.  Invariably, life itself is painful.  However, most types of cancer pain can be resolved.  The first step is to acknowledge its existence. The second step is to diagnose whether the pain is cancer-related. In the prostate cancer world, cancer-related pain is usually the result of bone metastases. Of course, not all bone pain is from cancer and not all bone metastases cause pain. If a man has pain in one of his bones and a bone scan shows a metastatic lesion in the exact same area as where the pain is occurring, then the probability is high that the pain is cancer-related.

The third step, once it has been confirmed that the pain is cancer-related, is to undertake the appropriate treatment. How to treat cancer-related pain is a topic big enough for another blog all its own. In my next blog I will also elaborate further on the correct medical approach used to distinguish cancer pain from non-cancer pain.

Someone has said, “Not knowing what to do is the worst kind of suffering.”  Helping men find a workable solution for pain not only relieves their pain, but it also releases them and their caregivers from the uncertainty and anxiety that comes from not knowing what to do.   

Cannabis and Pain

BY RALPH BLUM

In the course of attending various workshops and meeting and corresponding with men in various stages of prostate cancer, those whose condition hurts my heart, are the men with chronic pain from advanced forms of the disease. For some of them, hope is already spent, and what remains is the pain. A number of them have turned to tetrahydrocannabinol, medicinal cannabis, as a palliative and effective way to cope with their suffering.

 

Proper name, delta-9-Tetrahydrocannabinol, THC is a psychoactive compound extracted from the resin of Cannabis sativa (marihuana, hashish). The isomer THC is considered the most active element, producing characteristic mood and perceptual changes associated with this compound. In recent years, the use of medical cannabis for the relief of pain has become an accepted practice, especially in those states where the possession of cannabis has been decriminalized.

 

In patients seeking pain relief, the compound is not employed for entertainment of adventure. If you can demonstrate a need, and with your doctor’s prescription, you can obtain THC for medicinal use, almost always specified as relief of chronic pain.

 

The stories I have heard from men who have benefitted from ingestion of THC are very encouraging. “I am pain free for the first time in two years,” one man told me. Another reported, “The constant nausea has subsided, I am able to get to sleep again.”

 

A number of these men are aware that they are dying. And prior to getting medical marijuana nothing else had helped. One must ask: Should these dying men be deprived of an effective palliative because it is known to be “habit forming” or might lead to the use of “stronger drugs?” Not one of those I have spoken with has sought relief or pleasure from “stronger drugs.” They do not have the time or the will to form habits.

 

Public support for medical marijuana has increased. As of this writing, more than 20 U.S. states plus the District of Columbia have legalized cannabis in some form, and recreational use of marijuana is legal in Colorado and Washington state. Medical conditions such as cancer, Parkinson’s disease and HIV are commonly treated with medicinal marijuana. And yet many physicians are still reluctant to recommend it, because federally cannabis remains illegal.

 

The situation is very different in the nation of Israel, where medical marijuana has been legal since the early 1990s. In the past decade, Israeli scientists have developed a strain of marijuana without THC. Apparently the Israeli government funds the research on medical marijuana, which today benefits some 18,000 or more Israeli patients and is grown on eight farms for a state-run medical cannabis distribution center.

 

The irony of the U.S. position on cannabis as a palliative was summed up in an e-mail I received from a man whose prostate cancer had advanced to his bones. “I’m dying and in constant pain,” he wrote “and they’re protecting me from addiction?” Perhaps in the future the controversial aspects of medical marijuana can be resolved by producing a “pleasure free” medical marijuana specifically for pain alleviation. In the meantime, the medical community needs be bolder in recommending such an effective agent that is now readily available to most.