Intro to Comfort Meds: Morphine

You Don't Have to be Afraid of Morphine

Morphine is the most widely recognized hospice comfort medication, and it’s also the one that people are most afraid of. A lot of the fear and anxiety about morphine is because people believe that the morphine hastens death. The root of this fear is that the oral liquid morphine, which is primarily used in hospice, is frequently not used until patient’s are actively dying and no longer swallowing pills. The mental and emotional association between the liquid morphine being started and the patient dying exists for almost everyone who’s had a family member or close friend die while on hospice. The problem with this association is that it’s created from the human brain’s love of pattern-matching and insufficient education on the part of hospice staff. Morphine doesn’t hasten death, and it might actually delay death in some cases.

It is very important to understand that hospice is not in the business of hastening death. Most hospice agencies are torn on legalized euthanasia laws in the states that have them, and most¹ of the hospice agencies that will participate at all will only do so if the patient is able to physically administer the medication themselves. A medical professional acting in a manner that will hasten a patient’s death is murder.

This part is for other medical professionals: One of the things that I hear medical professionals of all stripes say is, “Even if it does hasten death, isn’t that better than having people suffer?” Stop downplaying the legitimate fears that patients and their families have, and stop giving people the impression that we’re willing to kill them before their time. That isn’t what you mean, but that’s what people hear when you say that. I have had strong, reliable, dangerous men collapse into a puddle of tears and pain because they felt like I was trying to euthanize their wives or mothers. I have had to hold them until they stopped crying long enough for me to provide real education and promise to stay at the bedside for at least an hour in order prove to them that the morphine wouldn’t kill their loved ones. They believed that it would because some doctor or nurse uttered that nugget of idiocy rather than provide real education. Please strike that entire line of thinking from your brain. You are hurting rather than helping. Stop it.

A Note for this Post: The formulation of morphine most often used in hospice is an oral suspension in a 20mg/1mL concentration. The brand name for this concentration is Roxanol. It comes in other concentrations, but that’s the most common one. Morphine also comes in pill form, both short and long-acting. For the purposes of this post, I will be talking about the Roxanol exclusively. I will talk about the pill formulations at a different time, but a lot of the information in this post applies to all formulations of morphine.

What is Morphine?

Morphine is the most classic opioid analgesic, and all other opioid analgesics are measured against it. There is literally a process to convert all opioids that a person is taking into the morphine equivalent dose (MED) in order to condense the number of medications that the patient is taking without reducing the functional dose. This is such a fundamental aspect of medication management that there’s an online calculator for it.

I’m not going to get bogged down in a bunch of technical jargon, so I will beg the indulgence of the people who really want the information about the exact mechanism of action for medications. If you want that kind of information, I heartily invite you to go read this (relatively) basic article from the National Library of Medicine. The important thing here is that morphine acts on both the central and peripheral nervous systems. In terms of the desired results of taking morphine, pain control is a result of the action on the peripheral nervous system, and the effects it has on breathing is a result of the action on the central nervous system.

When is it Needed?

Hospice uses morphine to treat pain and shortness of breath, and these are pretty much the same reasons why morphine is used in a hospital setting. A lot of people think that Roxanol is only used during active death or that people have to keep taking it forever if it’s given once. Neither of those two things are true. Some patients will use Roxanol exclusively for pain management for months due to issues swallowing. This is particularly common for patients with cancers of the mouth and throat, but it’s not exclusive to them. I’ve had several patients who felt better taking a dose of Roxanol when they were having breakthrough pain, because the Roxanol worked faster than a pill, and most of them used it once a week or less. Some patients will use the Roxanol once when they’re having trouble breathing due to an exacerbation of COPD or chest pain for CHF, and they’ll never need it again.

**One thing to make note of here is that, if a patient is on a routine pain regimen, increased use of medication for breakthrough pain (whether its the Roxanol or something else) is an indicator that the routine pain medications may need to be adjusted. Please write down when you use medication for breakthrough pain, no matter what it is. Even if it’s only Tylenol, write it down. People always think that we want to make sure that they’re not abusing the medication. That’s true, but it’s secondary to making sure that the pain regimen is sufficient for the patient’s needs.

How Much Do I Need?

Because Roxanol is an oral medication, the doses are often much higher than morphine given via IV, which is the most common way to get this medication in the hospital or from EMS. The reason for this is that IV medication isn’t impacted by the first pass effect, but oral medication is. More often than not, the starting dose for Roxanol is 5mg or 0.25mL. The normal adult dose for Roxinol is 10mg-30mg every 4 hours as needed. The average starting dose is, therefore, half of the lowest average adult dose. The normal range for IV dosing is 5mg-15mg every 4 hours as needed. The IV dosing is literally half the oral dosing. The reason why I bring this up is that paramedics and people who work primarily in hospitals will often do a double take at the dosing on the Roxanol and feel like it’s very high, because they don’t instinctively do the translation between oral and IV dosing.

Earlier in my career, I attempted to make a family who was nervous about morphine feel more reassured by explaining that the dose that was ordered was so low that it literally was not expected to be effective in a full grown man. I explained it badly, the family got mad at their regular nurse, and they yelled at her until she cried. I still feel very bad about that, because she’s a very good nurse. My perpetual self-imposed penance is to explain why that initial dose is so low, and there are a lot of reasons for it. They all mostly boil down to the fact that we don’t want to risk hurting the patient by assuming they’re going to metabolize the drug like an average healthy adult. Anyone on hospice is already fragile, and we’d rather be safe than sorry.

1. Hypersensitivity to morphine (or any medication) does happen. We would rather find out that the patient is hypersensitive to morphine at a super low dose than at a high one.

2. No one knows about drug allergies until the patient takes the drug for the first time. It’s easier to deal with a newly discovered drug allergy at a super low dose than at a high one.

3. Kidney and/or liver failure either due to direct disease or because of active death is as common as mud in hospice patients. Either or some combination of both will impair the body’s ability to get rid of the medication.² This can cause the medication to build up in the body and cause an overdose, even when the dose shouldn’t have been high enough for an overdose to happen.

4. It’s not uncommon for hospice patients to have lost so much weight that adult doses are too high, and they legitimately need to have medication orders done by weight (which is how doses are calculated for children) and we still need to take the first three issues into account. The morphine is usually ordered before it’s actually needed because we would like to avoid the patient not having it when they do need it, so it’s not possible to actually calculate the dose by weight when taking the initial order. There is also a really high probability that we won’t even have a realistic way to weigh the patient by the time they do need it. 5mg is a really good compromise for a starting point when balancing all of those factors.

Ultimately, hospice nurses and doctors are cautious critters. We would rather have people mad that the medication didn’t work the first time than hurt someone who has exactly zero capacity to recover from our mistake. We are pretty much all inclined to start low and increase medication to the lowest effective dose. If we suspect that the medication isn’t going to be cleared from the body effectively, we will sometimes even wait for the patient to get multiple doses of morphine before asking for new orders. We don’t want people to suffer, but we also have to balance some potential suffering against potential harm.

That said, how much patients actually need is really variable. Some patients will never need the morphine at all, and some (very rare) people will get 40mg an hour for 2 months or more. If the patient was taking either multiple opioid medications or a high dose of one opioid before they stopped swallowing and had to start the morphine concentrate, we frequently have to convert the previous opioid dose to the morphine equivalent and then give enough morphine to replace whatever the patient was taking plus a PRN³ order for when the patient is having an exacerbation of pain or shortness of breath.

People are very frequently afraid of causing an overdose, but the truth is that you have to work pretty hard to cause an overdose on Roxanol. The hospice physician will literally never give orders to give it in a way that might possibly cause a patient to have an overdose.

Allergy vs Pseudoallergy (or Side Effect)

If I had a dollar for every time I’ve seen a person listed as having a morphine allergy because they had really bad itching or vomited when they took morphine once, I’d have a healthy retirement account by now. If you want the high level discussion about allergy vs. pseudoallergy, please check out this article. The simple version is that a true allergy is caused by a very specific immune response. You can have similar types of reactions that are caused by a different immune response, and those reactions are classified as a pseudoallergy. If you believe that you or your loved on has an allergic reaction to morphine, codeine, or other opioids; please discuss the reaction with the hospice nurse or with a physician.

Common side effects and indications of pseudoallergy include:

• Itching, flushing (face or other skin becomes red and warm to the touch, but this goes away), sweating, mildly low blood pressure, and sneezing.⁴ All of these things are indications of pseudoallergy, and they’re generally well-controlled with something like Benadryl. Sometimes they’ll go away on their own, sometimes they won’t.

• Nausea and/or vomiting is very common in the first couple of days that someone takes an opioid. It is usually well-controlled with Compazine or other anti-nausea medications and will go away after several days.

• Heavy sedation is extremely common in the first several days that someone takes an opioid. This will usually go away in a few days, maybe up to a week.

• Constipation is pretty much expected, and anyone taking an opioid should also be taking medication to prevent constipation unless there’s some clinical reason not to. (Active death is one situation in which medication for constipation isn’t usually prescribed at the same time the opioid is, and that’s only if bowel function is already either severely diminished or has already stopped.)

Signs of a true allergy include:

• Any kind of rash that doesn’t go away on its own. There’s dozens of types of rashes, and most people can’t tell the difference between them. For safety’s sake, just go with all rashes.

• Any kind of issue breathing.

• Any kind of swelling, especially in the mouth, eyes, or tongue.

• Severely low blood pressure.

If the response that your loved one has was psychological (agitation, confusion, hallucinations, etc), it’s pretty likely that the issue was opioid toxicity, otherwise known as overdose, rather than a true allergy.

If you have any questions that I didn’t answer here, or any other input, please feel free to hop into the comments or the chat!

1. I only say most because I am only passingly familiar with the laws regarding legalized euthanasia, or medically assisted death. Hospice agencies may not be allowed to administer the medication at all. I don’t live in a state that allows it, so I’m not sure.

2. Drug clearance is the more technical term for the body getting rid of medication during metabolism.

3. Every time you see a weird abbreviation like this in the medical field, it’s Latin or Greek, and usually Latin. PRN is short for pro re nata, which is Latin for, "in the circumstances," or, "as the circumstance arises." It basically means, “as needed,” when used in medication orders. Example of a written medication order using this: Morphine Concentrate (20mg/mL) Give 5mg (0.25mL) by mouth every 3 hours PRN for pain or shortness of breath.

4. Hives and asthma exacerbation should also be on this list, but hives can also be an indication of a true allergy, and asthma exacerbation is almost impossible to distinguish from bronchospasms without invasive testing. Out of an abundance of caution, I always treat both of these as indications of true allergy.