We are often afraid of the unknown, and although approaching an unfamiliar situation with hesitation is a normal reaction, this feeling can prevent us from choosing the best options.
One of the best tools that hospices possess in their arsenal is Morphine. Unfortunately, there are a lot of myths about morphine—which may limit its administration to patients in the moments they need it the most.
It is not uncommon for family members or even healthcare workers to hold the incorrect belief that Morphine accelerates death when simply it is not the case. A painful death is not a dignified end to a loved one’s life, a painful death can strain the heart which can cause a cardiac event. Morphine simply relieves the symptoms caused by a failing body.
What do the experts say?
In a conversation with Dr. Robert J Wielenga, we further explored the effects of Morphine and the myths surrounding this useful medication. It is important to note that our goal is to palliate the symptoms, we do not wish to sedate unnecessarily nor cause harm to our patients.
There are many possible routes of administration of the drug: as a tablet form both short and long-acting (MS IR vs MS Contin), rectally, subcutaneously, intramuscularly, intravenously, transdermally, sublingually (many are familiar with this easy-to-use, hard-to-overdose method of administration called Roxanol)
“Our job is to control the pain– we always aim to start low and go slow” Dr. Wielenga stated in our interview. Morphine continues to be the standard for pain management due to this medication’s rapid onset of action, its safety, scalability, and reliability. The Centers for Disease Control recommends the calculation of all opioids in a 24hr period to be done in Morphine Milligram Equivalents (MME)
When dosed appropriately there are very little side effects
To give a point reference Morphine has a one to one equivalency with Hydrocodone (this is the opioid used in Norco and Vicodin which more people are familiar with). Two of the most common doses of Norco are 5/325 (5mg of hydrocodone with 325mg of Tylenol [acetaminophen]), and 10/325 (10mg of hydrocodone with 325mg of Tylenol [acetaminophen]).
Why do I mention this? because essentially the starting dose of Roxanol (Liquid Morphine) for hospice is the same as one tablet of Norco 5/325, and the highest possible dose contained in the dropper or sublingual syringe is two tablets of Norco 10/325. These are not dangerous doses
As Dr. Wielenga mentioned, “as long as the patient has the pain that requires morphine there are very little side effects to it”. One of the advantages of the use of this narcotic is that “it’s extremely effective” and “you can titrate it to where the pain is controlled but they’re not having too many symptoms.”
Effective pain management
The University of Pennsylvania Oncolink explains that Roxanol [Liquid Morphine] “will begin working to relieve pain in 15 to 30 minutes and reaches its peak effect in 1 hour. It will continue to work for 2 to 4 hours”.
This is mainly why most hospices use the starting dose of 5mg of Roxanol every 4 hours as needed. Hospices attempt to use the least effective dose first but if the suffering is not relieved then, a sound approach to pain management is to increase the dose before increasing the frequency. Again, this explains most hospices’ approach to move to 10mg every four hours as needed, then 20mg every four hours as needed if the pain is uncontrolled.
It is interesting to point out that in a conversation with Sameh Mounir -— Pharmacist in charge/ President at Trinity Care Rx— it is recommended that the patient does not eat or drink for 15 minutes after the administration of sublingual Roxanol as to allow enough time for the drug to absorb into the oral mucosa.
Our loved ones deserve a pain-free life and a dignified death
The National Center for Biotechnology Information published the article named “Killing the Symptom Without Killing the Patient” written by Romayne Gallagher MD CCFP, where he showed reported studies that point to the fact that appropriate use of opioids (like morphine) do not cause respiratory depression- In 27,000 patients the instances of respiratory depression were less than 0.5%. No significant relationship has been found between opioid dose, change of dose, use of sedatives, and time of death.
I, however, per my time on the field as a nurse, have witnessed that when families withhold the use of Morphine on a suffering patient fearing that giving the drug will hasten the death-Or they wish to stop giving morphine in an attempt to “wake up” the patient in hopes for a lucid goodbye. The suffering, moaning, grimacing, agitation, shortness of breath, and air hunger are unbearable.
When Morphine is used appropriately the patient’s quality of life improves. Pain affects many aspects of a person’s life physically, emotionally, and psychologically. Appropriate pain management can lead to increased appetite, increased strength, and movement (many patients isolate themselves and are afraid to move as much due to fear of pain) improved social interactions as patients’ moods are overall better when pain is controlled. Adequate pain management decreases blood pressure, decreases shortness of breath, improves oxygen -CO2 exchange, improves sleeping patterns.
Sometimes we mean well, and our love blinds us, our hopes, our fears can overwhelm us, it is ok to be scared. This is hard, but we have to advocate for our loved ones and respect their wishes of a pain-free life and, dignified death.