About Morphine

FEAR OF REGULATION BY MEDICAL AUTHORITIES IS THE NUMBER ONE REASON THAT PHYSICIANS ARE RELUCTANT TO PRESCRIBE OPIOIDS TODAY.

Morphine history

Opioid-type drugs, which are derivatives of the juice of the opium poppy, have been used for centuries. For hundreds of years they were one of the few worthwhile medications available to doctors. In the 1600's, Thomas Sydenham, a famous physician, wrote: "Among the remedies which it has pleased almighty God to give to man to relieve his sufferings, none is so universal or efficacious as opium."
Morphine was first isolated from the juice of the poppy in 1803 and became widely available as the over-the-counter drug, Laudanum, in the late 1800's. This easy access lead to morphine being abused in the same way as alcohol by people who were susceptible to addiction. These factors, in addition to the realization of the economic benefits of controlling opioid use, led to legislation in the United States in 1914. The Harrison Act changed the abuse of opioids from a medical illness to a criminal offence. This legislation influenced opioid distribution and use worldwide. Fear of regulation by medical authorities is the number one reason that physicians are reluctant to prescribe opioids today. These fears and others are shared by the people who take morphine for medical reasons. Attitudes towards the use of opioids for pain management are changing, however, particularly for terminal cancer patients. But a great deal of education, change in attitude and further research needs to be done before our society uses opioids in a medical rather than moral manner.

Romayne Gallagher, BSc, MD, CCFP, in association with medbroadcast.com

Pain control with opioid drugs

1. Regular pain requires regular, preventive medication

IF YOU HAVE PAIN MOST OF THE DAY, THEN YOU NEED TO TAKE REGULAR MEDICATION.

If you have pain most of the day, then you need to take regular medication. Here, the goal is to prevent pain rather than wait until the pain gets bad enough that you need medication. If you wait until the pain medication "wears off" and the pain gets bad again, you will have periods of unnecessary pain, and it will take longer to get the pain under control than if you take the medication regularly (see Figure 1).
The timing of the regular dose is adjusted according to how long the medication works. For example, short-acting morphine and hydromorphone will work for 4 hours, so they should be taken every 4 hours.  Long-acting morphines and hydromorphone can be taken every 12 hours. The fentanyl patch continuously releases medication for a period of 3 days.Controlling your pain.

2. Always have a "breakthrough" dose of medication available

Your pain will vary through the day, depending on your
activity level, fatigue, or other factors. Because of this variation, at times the pain will "break through" the pain control. If this occurs, have extra medication on hand to deal with it. Again, don´t wait until the extra pain gets severe. Earlier treatment results in easier control. A usual breakthrough dose is up to 1/3 of the regular, scheduled dose. If the pain breaks through more than 2 or 3 times a day it means you need an increase in the scheduled dose of medication.

3. The side effects of opioids can be prevented by treating them from the start

The common side effects of opioids are constipation, drowsiness, nausea and dry mouth. Almost everyone experiences some constipation. This is because opioid receptors in the large and small bowel respond to the opioid by slowing down the action of the bowel muscle. The result is hard, dry stool that is infrequent and hard to pass. Some people dread constipation as much as they do the pain, however, constipation can be prevented by increasing fluid intake, dietary fiber, exercise and using laxatives appropriately.
Another common side effect of opioids is drowsiness. It can be very frustrating to doze off in the middle of a conversation, however, this generally lasts only for the first day or two that you are on the medication, and for the first day or two after a change in the dose. Within a short time, the body adapts to the medication and the drowsiness is gone. Be sure to avoid activities like driving or operating machinery if you experience significant drowsiness. If the drowsiness persists, then you need to discuss this with your doctor. Sometimes a change in the opioid is necessary.
The side effect of nausea occurs because of an effect of the opioids on the brain's vomiting center. Also, opioids slow down the movement of food and fluids through the stomach, causing nausea and vomiting. Mild nausea will usually disappear in a day or two. If it persists, there are various ways to cope with it and helpful medications that can control it. If the nausea is severe or persistent despite treatment, a change in the type of opioid is necessary.

4. Opioids that often work best when combined with other medications

Different kinds of pain require different combinations of medication. For example, if the pain is in the bones, pain control is best when opioids are combined with acetaminophen or anti-inflammatory medications. Pain due to nerve damage will respond best with the addition of steroids to reduce swelling around the nerve, or with an antidepressant to lower the sensitivity of the nerves to pain. Taking an antidepressant in this way does not mean you are depressed. Adding an anticonvulsant drug can also be helpful in nerve pain. There are numerous other helper ("adjuvant") medications that can be used.

5. Keep a diary of the medication you are taking and how it is working

It is very helpful for both you and your health care team if you keep a diary in which you record your pain and your response to the medication.

6. Visit your doctor or health care team regularly

Gaining control of pain usually requires several regular visits with your doctor or health care team. At the end of a visit, make sure you have a follow-up appointment arranged. Many people feel embarrassed or frustrated to return to their doctor "complaining" of pain, however, by viewing yourself, your doctor and others as part of a team working to control your pain, you will not feel that you are alone. Your part of the work is to take your medication and keep track of what happens to your pain.
Romayne Gallagher, BSc, MD, CCFP, in association with medbroadcast.com