Is Morphine Being Overprescribed?

The US is in the throes of a morphine crisis. It is too readily prescribed by physicians and too easily misused by certain patients.

Ray Murphy, who has been a hospital pharmacist for more than 15 years, says “morphine and other prescription drug abuse is more of a problem than heroin or any street drug.” Why is the problem growing? “The prescribers are part of the problem. Some doctors don’t investigate their own patients enough before refilling a prescription,” Murphy says, adding that if patents are requesting that a morphine prescription be refilled, it’s possible the patient now needs morphine to support a habit. (Note: We have an Ask the Pharmacist video with Ray Murphy.)

“Morphine can be a wonderful drug for pain relief. If you break a bone, have a heart attack or have pain after surgery, it can be a gift from God,” says Norman Wetterau, MD, president of the New York Society of Addiction Medicine. “But people get into trouble when it is used for chronic pain.”

Reasons for Morphine Misuse Vary

Symptoms of Morphine Overdose

Source: MedlinePlus

Morphine misuse can stem from patient self-medication or failure on a doctor’s part to point out the potential problems with overreliance on the drug for pain management. After major surgery, a patient given morphine for pain relief may become dependent and take more than the prescribed dosage. Some patients go “doctor shopping,” and others use multiple hospital emergency departments as a prescription filling station. Still others simply ask their physician for another prescription or a higher dose. But with increased use of a powerful painkiller comes a host of other problems.

Escalating numbers of hospital ER visits related to morphine abuse and misuse were reported by the Drug Abuse Warning Network in its 2011 report, the site’s most recent statistics, and illustrate a disturbing trend. In 2011, there were 38,416 morphine problems or complications that resulted in emergency room visits, a 144% rise from 7 years earlier.

The side effects of morphine use, misuse and the symptoms of morphine withdrawal paint an unsettling picture. In short, this potent opioid can bring on addiction, overdose or death. Depending on the individual and the dose taken, typical side effects of morphine use are nausea, vomiting, stomach pain, constipation, dizziness, itchy skin, drowsiness, headache and apathy or anxiety. Other possible side effects range from vocal cord swelling and sexual dysfunction to pneumonia. On the list of rare but severe side effects are seizures, shock, hallucinations, chest pain, circulatory problems and intestinal blockage, but “respiratory depression is the most worrisome side effect of all,” says Damon Raskin, MD, medical director of Cliffside Malibu Treatment Center in California. Respiratory distress can lead to lung failure, coma and death, notes Dr. Raskin.

Symptoms such as hives or pinpoint pupils in low light may not warrant a visit to the ER, but you should call your MD. “However, the other symptoms on the list are cause for alarm,” Dr. Raskin explains, emphasizing the need for immediate ER treatment.

How Does Morphine Work?

poppiesMorphine is in the opiate class of drugs. It was created in 1804 by a pharmacist’s assistant, Frederich Serturner, and derived from the drug opium, which comes from the unripened seed pods of the Asian poppy plant. It was discovered to have tremendous value in pain cessation. By the mid-19th century, its use was widespread in the US, especially among injured soldiers.

Also known by the brand names, Astramorph PF, Avinza, Duramorph, Infumorph, Kadian, Morphine Sulfate Sustained Release, MS Contin, MSIR, Oramorph SR and Roxanol, morphine can be delivered via liquid, tablet or capsule, using an immediate or sustained-release formula. It blocks the perception of pain by attaching to opioid receptors in the brain and throughout the central nervous system. Its dangerous properties are well-documented. Gregory Skipper, MD, director of professional health services at Promises Treatment Centers, in Santa Monica, California, warns, “Any drug that stimulates the opioid receptors is going to be addictive. That’s just the way it works.”

The Trend of Liberal Prescribing

A recent study from George Washington School of Medicine and Health Sciences shows the highest relative spikes in the use of morphine, hydrocodone, hydromorphone and oxycodone in hospital emergency departments nationwide over 10 years, from 2001 to 2010. According to the Physicians for Responsible Opioid Prescribing (PROP), the practice of long-term opioid therapy for non-cancer patients has grown significantly in the past 30 years in tandem with a corresponding rise in addiction, overdose and fatalities.

Previously, morphine was typically prescribed for a limited number of patients — for hospice and palliative care, cancer and postoperative pain, and heart attack or traumatic injuries commonly seen in the ER. In recent years, morphine prescribing has expanded to include a long list of additional ailments, including pancreatitis, kidney stones, appendicitis, fibromyalgia, chronic back pain and even headache. Jane C. Ballantyne, MD, PROP’s president, attributes some of this increased prescribing of morphine to “aggressive marketing by the pharmaceutical industry,” after pain medicine was established as a new specialty in the 1980s and 1990s. Influential palliative care physicians convinced Americans that they needed morphine for pain, notes Dr. Ballantyne. Now, “it’s a cultural thing that often makes us feel that we’re entitled to a fix,” she adds. In her opinion, today’s unwarranted morphine prescribing covers a number of conditions, including fibromyalgia, headaches and sprained ankles.

The World Health Organization’s guidelines for pain intervention states that morphine administration should be limited strictly to ameliorate moderate to severe pain. The risk-benefit scale slides into risky territory when a patient gets involved with chronic, long-term opioid therapy, notes Anna Lembke, MD, Stanford University Addiction Medicine Program Director. “It’s important to realize that opioids are not actually very effective for chronic pain and can, in some instances, even make pain worse by causing a condition called ‘opioid-induced hyperalgesia.'” This is a phenomenon whereby long-term use of morphine and other opioids can cease to manage pain and sometimes cause pain while increasing physical dependence. At this point, the use of the drug should most likely be stopped.

When is morphine safe to use? ‘It’s never safe, not completely… it’s a dangerous drug,’ says Dr. Ballantyne

In the Emergency Room

Morphine treatment is most beneficial for blunting acute pain caused by trauma and serious disease. A severe heart attack, burns and broken bones fit very well into this criteria. However, if someone comes to the ER with a minor injury, “It might be appropriate to treat them with other analgesics or local anesthetics, or no pain meds at all,” says Dr. Ballantyne. She asserts that no patient should walk out of the ER with more than 2 morphine pills in hand.

Jayaram Srinivasan, MD, medical director at Highmark Blue Cross Blue Shield in Pittsburgh, says, “Effective non-opioid pharmacological treatment of pain may include numerous options, such as aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, tricyclics, serotonin-norepinephrine reuptake inhibitors (SNRIs), antispasmodics, topical analgesic agents and others.”

In Palliative and Hospice Care

injectable morphineAccording to the National Institutes of Health (NIH), morphine use in palliative care is appropriate. For patients with COPD, heart failure or Parkinson’s disease, the benefits from carefully measured morphine therapy can improve the quality of life with whatever time remains. Dr. Wetterau comments, “I believe that good pain relief can help a patient want to live, say goodbye to their family and complete other unfinished tasks. If the dose of morphine is increased too rapidly, it could hasten death by decreasing or stopping respiration.” While morphine does slow the body’s systems, the NIH notes that if dosages are increased judiciously, most experts feel that taking morphine for palliative care is not likely to speed death. The decision to use morphine as a tool that provides a patient with more quality time and greater comfort is a deeply personal one, and patients and family members have to make their own decisions in what is ultimately a profoundly philosophical choice.

Factors to Consider

General Dosage Guidelines for Adults

The usual adult subcutaneous or intramuscular dosage of Morphine Sulfate Injection is 10 mg every 4 hours as necessary; dosage may range from 5-20 mg every 4 hours as necessary depending on patient requirements and response.

For intravenous administration, the usual dosage is 4-10 mg administered very slowly over 4-5 minutes. A strength of 2.5-15 mg of morphine sulfate may be diluted in 4-5 mL of sterile water for injection.
Source: NIH’s Daily Med

The risk-benefit analysis of morphine administration is a complex subject with no simple answers. There are drug and disease interactions that should be carefully weighed before a patient agrees to a course of morphine treatment. If you have liver or kidney disease, a traumatic brain injury, severe asthma or COPD, a sluggish gastrointestinal system or a history of substance abuse, you’re not likely to be a good candidate for non-palliative morphine therapy.

According to Drugs.com, of the 770 total potential drug interactions with morphine, 28 are of major concern. One of them, monoamine oxidase inhibitors (or MAOI medications) can result in serious side effects including coma, excitability, low blood pressure, shallow or slowed breathing and shock. Drugs in this classification, including Phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan) or selegiline (Emsam) should be discontinued at least 14 days prior to initiating a course of morphine pain management. Once morphine therapy begins, careful monitoring is critical to patient safety.

When is morphine safe to use? “It’s never safe, not completely… it’s a dangerous drug,“ says Dr. Ballantyne. She maintains that a maximum course of 3 days will satisfy even acute pain intervention needs.

Alternative Pain Interventions

A study conducted in 2013 by the University of Wisconsin-Madison was published in the Journal for the International Society of Psychoneuroendocrinology. While the study subjects were not in pain, the results showed new evidence that mindful meditation can help to provide pain intervention on a molecular level. After several hours of this type of awareness meditation, the subjects were observed to have lowered levels of pro-inflammatory genes, facilitating a more efficient physical recovery from stress events, often associated with disease and pain. In addition, analgesic drugs like morphine work on the same genes. Based on previous clinical studies on inflammatory conditions, the American Heart Association recommends mindful meditation as part of a complete mind-body approach to pain intervention.

Ivy Branin, a New York City naturopath, believes in “getting to the source of the pain first and using the least invasive approach to pain management.”  She advocates dietary intervention for inflammation, which is  often the cause of pain. For example, eliminating nightshade vegetables and glutenous grains and ramping up omega-3 fatty acids can reduce inflammation. (For more information, see Food as Medicine: Osteoarthritis.)  Other natural healing modalities recommended to target pain include acupuncture, biofeedback, chiropractic treatment, cognitive behavioral therapy and yoga.

Over time, certain proactive steps on the part of patients and doctors can help curb the excessive use of morphine in the US. The medical community needs better education for its pain intervention protocols, and patients should have a supportive network for pain management advocacy. The final consensus is that active engagement in multiple pain management modalities are more likely to succeed at achieving the best outcomes.

For More Information

Using vs. Abusing: The Double-Edged Sword of Opioids (MedShadow.org)
Prescription Drug Monitoring Programs Gain Steam (American Society of Health-System Pharmacists)
Hospital Found Responsible for Deaths from Morphine Overdose (Wellsphere.com)

Organizations

Advocates for the Reform of Prescription Opioids
National Institute on Drug Abuse


Robin Vaughn

Robin Vaughn

Robin Vaughn is a multi-disciplinary writer and education specialist. She has written on a wide range of topics for magazines, trade publications and business websites and is happy to be a contributor for MedShadow.org.


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