In order to appreciate the present and prepare for the future, you must understand the past. If we look back in time, we see Dame Cicely Saunders as the modern-day founder of hospice. The journey begins with the death of David Tasma in 1948 and Saunders opening of St. Christopher’s Hospice in 1967. During that time, we see the rise of many “cocktail” creations for the treatment of end-of-life symptoms, including the Brompton Cocktail. The Brompton Cocktail contained a variety of ingredients, such as Morphine/Cocaine/Alcohol/Chloroform/Heroin etc. and we see Cicely Saunders praising this cocktail in the 1950’s for easing suffering at end of life.

We flash forward to the 1970’s and early 80’s, a physician by the name of Robert Twycross asks the question, is the idea of a cocktail needed or are all of these ingredients causing too much sensory impairment. This idea of “keeping people comfortable” vs. “symptom control, with quality of life” came into question. Sensory impairment was high with these cocktails, I mean they contain cocaine & chloroform! Twycross set out to do research on this topic and discovered in multiple studies that using morphine alone was therapeutically equivalent to the cocktails, but caused less impairment and more quality of life. In response to these studies, Cicely Saunders in an interview said “everyone changed from heroin to morphine and the only impact was the prescriber who had to write the order”. Here the concept of Morphine Elixir was born.

That led to the transatlantic hospice movement, where knowledge sharing between Europe and the west (United States) began and you start to see influence from the likes of Elisabeth Kubler-Ross ‘On Death and Dying’ 1969, Connecticut Hospice 1974 etc. That transatlantic movement walks us up to 1978 where a pharmaceutical company by the name of Roxane Labs had just been purchased and then onto the 90’s where this idea that ‘concentrated solutions’ could replace elixirs and could be given sublingually, a real benefit at end if life. With wind in the sail, Roxane Labs gave birth to their first child and named them “Roxanol”. That family grew and gave us many other siblings, two popular concentrates, Lorazepam 2mg/mL & Haloperidol 2mg/mL.

So, at least at a very high level, you know how Morphine Concentrate 20mg/mL (Roxanol) came to be the backbone medication for hospice, a medication that you probably find yourself talking about, educating on, ordering, each and every day.

Note: This is part 1 of the morphine mini-article series.