Using morphine to relieve pain in a seriously ill person

Using morphine to relieve pain in a seriously ill person

Pain is one of the most severe and common symptoms experienced by palliative care patients. We often write about this on our portal. In the Pain Management section you can find a lot of materials on this topic - both for doctors and for relatives of seriously ill people. In this article, we have collected key points from the report “Using morphine to relieve pain in a seriously ill person” by British palliative medicine physician Bruce Cleminson, which he presented at the palliative care conference in Yaroslavl in 2021. We would like to thank Olga Vasilyevna Osetrova, chief physician of the Samara Hospice ANO, for her assistance in preparing the publication.

Treatment of mild, moderate and severe pain in palliative patients Tatyana Vladimirovna Kravchenko, chief freelance palliative care specialist in Moscow, talks about the features of drug therapy in palliative patients with different types of chronic pain
Tatyana Kravchenko

Anesthesia

Morphine. Figures and facts

• Up to 70-80% of cancer patients receive opioid analgesics during their illness.
• Non-cancer patients with serious, life-threatening illnesses often also require morphine.
• Cancer patients may experience pain not only in the terminal stage of the disease: 59% receive morphine during curative therapy (intermittent pain relief) and 33% after the end of curative therapy.
• In the terminal stage of the disease, morphine is required in 60-80% of patients.
• Not all pain is susceptible to morphine. For example, neuropathic pain is not treatable with opioids.

general information

According to the so-called “pain ladder” of the World Health Organization, morphine belongs to the third, highest step. Unlike second-stage opioids, it does not have a “ceiling effect” - a condition where increasing the dose as pain increases does not produce the desired effect, but only leads to side effects.

Currently in Russia there are non-invasive forms of short-acting morphine (tablets in a dosage of 5-10 mg) and extended-release morphine (10, 30, 60 and 100 mg).

Titration is best done with short-acting morphine. Its action begins within an hour and continues for 4 hours. If the effect does not occur within an hour, the dose should be repeated. When titrating extended-release morphine, it takes 4 hours to see the full effect of this drug.

Extended-release drugs are recommended to be prescribed when the amount of morphine has been titrated. If only extended-release morphine is available for titration, titration will take longer.

For breakthrough pain, short-acting morphine should be prescribed in an amount of 1/6 to 1/10 of the daily dose.

“Breakthrough pain” is a new term, not a new problem. Doctor Guzel Abuzarova on the evolution of the term, characteristics of pain, diagnosis and treatment options Guzel Abuzarova

Anesthesia

Methods of taking morphine

Orally. The most preferred method because it allows the patient to maintain as much independence as possible.

Parenterally. Morphine is best administered subcutaneously. It is safer than intravenous administration. This method makes sense when the patient cannot swallow. In addition, this method allows you to double the effect (and, accordingly, halve the amount of the drug).

When administering morphine using a dosage syringe (syringe driver), the maximum effect should be achieved after 4 hours. If this does not happen, you should add a dose for breakthrough pain.

If there is no pump, you can install a butterfly needle subcutaneously and train the caregiver to administer the drug every 4 hours (6 times a day) .

The daily dose is administered using a dosing syringe continuously throughout the day. This allows you to maintain a constant level of morphine in the blood and, thus, control pain and avoid pain spikes. If there is no syringe, then injections must be done every 4 hours (6 times a day).

To extend the effect of the drug to 6 hours, you should increase the dose. Caution: This may cause side effects. For example, intoxication!

Important If morphine is given only as needed, the patient will experience frequent pain because morphine only lasts 4 hours.

For safety reasons, parenteral morphine should be started at 2.5 mg every 4 hours. However, in Russia the minimum volume of available ampoules is 10 mg. By law, the ampoule can only be used as a whole. A way out: using a siring driver.

“From that day I began to live.” about the choice between morphine and pain. Irina Novikova, a patient of the Samara hospice, talks about the fact that pain cannot be tolerated, about personal experience in dealing with pain syndrome, and myths about opioid analgesics. Irina
NovikovaOlga Osetrova

Anesthesia

Situation 1: the doctor has both short-acting morphine and long-acting (extended) morphine available.

• Conduct a pain assessment.
• If pain is grade 2, the recommended drug is tramadol.
• After a day, reassess the pain. If there is no improvement, prescribe the maximum dose of tramadol.
• If after another day there is still no improvement, prescribe morphine in a minimal dose (5 mg orally after 4 hours).
  Important Switching from tramadol to morphine requires caution. Tramadol is absorbed in the intestines and converted into an active metabolite in the liver. This transformation occurs differently in different patients: in some very quickly, in others very slowly. In order not to overdose on morphine when moving from the second stage, no more than 30 mg/day should be prescribed initially.

• If pain relief does not occur after dosing, add morphine (5 mg) every hour until full effect is achieved.
• Reassess pain every day, changing the single/single dosage depending on the daily dosage (see How to calculate the required morphine dosage).
• When pain is controlled, give half the daily dosage as extended-release morphine twice daily after 12 hours.
• Maintain the option of short-acting morphine for breakthrough pain.

Situation 2 : the doctor only has short-acting morphine available.

Proceed as in the first situation, selecting the minimum effective dosage of morphine.

• Reassess pain every day until pain relief is achieved.
• When the pain is relieved, you need to calculate the daily dosage of morphine, a single/one-time dosage (see How to calculate the required dosage of morphine).
• Maintain the option of supplementing with short-acting morphine for breakthrough pain.

Typically, the pain relief effect is achieved within two days.

Situation 3 : The doctor only has extended-release morphine available.

Webinar: Extended infusion in palliative medicine (master class) Indications for the use of infusion, demonstration of methods for conducting extended infusions in conditions of various medical equipment Arif Ibragimov

Anesthesia

Titrate the required daily amount (this takes about a week):

• 10 mg twice a day → reassessment of pain after 24 hours.
• If there is no effect: 20 mg twice a day → reassessment of pain after 24 hours.
• And so on - until the effect of anesthesia is achieved.

Situation 4 : the doctor only has parenteral morphine available (or the patient does not swallow) .

• The initial single dosage is 2.5 mg subcutaneously every 4 hours, which is quite difficult to organize. For this reason, the best solution is administration using a dosage syringe (syringe driver).
• Reassess pain every day until pain relief is achieved.
• When the pain is relieved, you need to calculate the daily dosage of morphine, a single/one-time dosage (see How to calculate the required dosage of morphine).

How to calculate the required dose of morphine

• All doses of morphine that the patient received within 24 hours must be summed up.
• Divide the resulting amount by 6.
• Give/administer the resulting dose every 4 hours.

Example: a patient receives 5 mg of morphine orally every 4 hours on the first day of pain relief. Over the course of 24 hours, he had to be given 12 doses. In total, he received 60 mg per day. This means that the one-time dose on the second day will be 10 mg.

Important If the amount of morphine you have given has reached 50 mg parenterally per day (or 100-120 mg orally) and it does not help, you may be treating pain that is not responsive to opioids. For example, neuropathic pain. You can read about this in the article “Factors of difficult-to-control pain.”

According to St. Christopher's Hospice, about 50% of patients require 60 mg or less of oral morphine per day.

Side effects of morphine use

Side effects of morphine and how to cope with them

Factors in difficult-to-control painPalliative medicine professor Robert Twycross explains pain assessment and relief using examples from clinical practice

Robert Twycross

Anesthesia

Morphine intoxication

A low degree of morphine intoxication manifests itself in the form of colorful dreams and mild clonic convulsions.

What to do?

• Monitor symptoms of intoxication - ask the patient about dreams, find out if he often drops things.
• Consider the risk of dehydration and encourage the patient to take plenty of fluids.
• Check renal function, especially if the patient is receiving nonsteroidal anti-inflammatory drugs.
  Important By reducing the dose of morphine due to toxicity, we cause increased pain. Discuss with the patient whether he or she will choose to endure some pain or accept the symptoms of intoxication.

To avoid toxicity, it is necessary to find the minimum effective dosage and, if necessary, reduce the dose of morphine to the minimum that relieves pain.

Shared decision-making Chief physician of the Samara Hospice ANO Olga Osetrova on how to help a seriously ill patient make a difficult choice Olga Osetrova

About palliative care

Is morphine addictive?

As a rule, addiction to morphine does not occur.

Example: A patient received morphine for 60 weeks. After radiation therapy, the dose of morphine was reduced. This was possible because the titration of morphine was done very carefully and the dosage was appropriate to the pain.

Tolerance to morphine practically does not develop. This is clearly visible in the therapy chart of one of the patients.

Timeline for morphine therapy and development of tolerance to the drug

The average dose of morphine consumption after 12 weeks and after 24 weeks is practically the same. A slight increase in the curve only indicates tumor growth, but not tolerance to the drug.

Important And remember: there is no evidence that morphine, when used correctly, reduces life expectancy.

Several articles on the topic that will be of interest to you:

Control of pain “breakthroughs” and rotation of opioids About the causes of pain breakthroughs and means to stop them. We present a fragment of the brochure for doctors “Pain management in palliative care. A practical guide for a doctor", prepared by the Vera charity foundation.

Tactics for treating the side effects of strong opioidsWhat are the side effects of strong analgesics and how to deal with them

Features of the approach to symptoms in palliative care Doctor Olga Vasilyevna Osetrova talks about what needs to be taken into account to help a patient with shortness of breath or itching, pain or constipation.
In addition to standard schemes, there are subtleties that are suggested by experience and attentiveness. The material was prepared using a grant from the President of the Russian Federation for the development of civil society provided by the Presidential Grants Foundation.

ANTICOAGULANT THERAPY SCHEME FOR COVID-19

1. Anticoagulants are prescribed to ALL hospitalized patients (in the absence of contraindications)

NB! In special cases - the patient's weight is less than 45 kg or more than 145 kg - the dose of the anticoagulant should be calculated individually.

2. If there are clinical or instrumental signs of thrombosis, as well as when initiating pulse therapy, use therapeutic doses of LMWH:

Enoxaparin – 1 mg/kg * 2 times a day or Nadroparin – 0.4 ml (weight < 50 kg), 0.6 ml (weight 50-70 kg) or 0.8 ml (weight > 80 kg) * 2 times a day

3. If there is a pronounced decrease in renal function (eGFR <30 ml/min/1.73 m2), use an individual dosage regimen or UFH (under the control of AST/APTT)

4. Initial therapy with therapeutic doses is used in cases where, before hospitalization, patients received anticoagulants due to atrial fibrillation, after an acute episode of VTEC, after implantation of mechanical prosthetic heart valves

• when taking warfarin: discontinuation, daily INR monitoring, if INR < 2.0, start a therapeutic dose of LMWH, stop INR monitoring
• when taking direct oral anticoagulants (rivaroxaban, dabigatran, apixaban): at the time of the expected intake of the next dose of the drug, administer the first dose of LMWH

Side effects that occur in morphine addicts

The gastrointestinal tract is most affected by the drug. But this does not mean that any of the organs or systems have natural protection from the drug - it is toxic to everything. After its administration, the following may occur:

• nausea, vomiting, abdominal pain;
• symptoms of bile stagnation, discomfort in the right hypochondrium;
• spasms of the stomach, epigastrium;
• the skin acquires a painful icteric tint;
• paralytic ileus;
• enlarged colon;
• dizziness;
• headache;
• fainting;
• tremor of the limbs;
• muscle spasms;
• depression;
• impaired coordination of movements;
• disturbance of consciousness;
• surges in intracranial pressure;
• stroke;
• seizures;
• dilated pupils;
• decreased vision;
• involuntary eye movements.

From the cardiovascular system, tachycardia and decreased blood pressure are possible. Morphine often causes severe bronchospasm and even lung atelectasis. They inhibit diuresis, spasm the ureters and urethra. As a result, an imperative and painful urge to urinate occurs. Addicts often experience impotence and erectile dysfunction.

The occurrence of allergies cannot be ruled out. Then the skin becomes covered with a rash, urticaria occurs, and Quincke's edema or bronchospasm develops.