We’ve covered some history and some myths in previous articles, so let’s spend a little time on morphine the medication.

Morphine is a really effective pain reliever and is still considered to be first line by the world health organization (WHO) for end-of-life symptom management. There is no data that globally supports one opioid is better than another. Granted there are patient considerations which may make one agent a better choice, hence hospices number one principal for creating individualized plans of care. Morphine currently holds that #1 spot as a ‘pure opioid’, meaning it is not mixed with another agent like acetaminophen etc.

Many ask, and you often see this echoed by patients and families on social media, why does hospice jump right to morphine? Frankly, it has to do with the idea it’s a pure opioid and you are not limited in dosing, aka a ceiling, like you get with combination products- example things that contain acetaminophen where there is a max dosing limit. The goal in hospice is to manage symptoms and create comfort as quickly as possible, so avoiding that messy aspect of having to change medications, begs one to just start with the end in mind. Morphine also comes in multiple dosage forms (tablets, liquids, injectables, short acting, long acting), various strengths, well tolerated orally, rectally, via PEG, subcutaneous, intravenous, etc. and is generally very cost effective.

Like all medications there are some known concerns, one being the use of morphine long term and in renal impairment due to the metabolites M3G and M6G. M3G is the one that more often leads to myoclonus, neuroexcitation and hyperalgesia, though all opioids can produce hyperalgesia, with methadone being one of the least likely. Remember besides just the metabolite, time and dose plays a role here. Often, someone might be concerned even though they already have morphine in the home, the patient has renal insufficiency so therefore morphine shouldn’t be used. Remember, if your patient is in the active stages of decline and not expected to live for more than a couple of weeks or is not on a trajectory to use high doses, the acute/short term use of morphine will be fine. However, if your patient has significant renal insufficiency and months to live and you’re starting an opioid, then picking another agent could be warranted. Oxycodone, Fentanyl, & Methadone are better choices with renal impairment, remembering that Hydromorphone (Dilaudid) is metabolized similar to morphine to the D3G and D6G metabolite and is associated with similar concerns.

Note: This is part 3 of the morphine mini-article series.