Monday, November 27, 2006
Morphine side effects
For those of you who celebrated it, I hope you had a fine Thanksgiving last week.
I'm trying to slowly dig through my backlog of un-blogged articles I had flagged and thought I'd mention an interesting article from the American Journal of Hospice & Palliative Medicine. It's a prospective study of morphine related side effects in (mostly advanced) cancer patients chronically on morphine, who were cared for by the Cleveland Clinic palliative medicine team (median age 64 years, half had ECOG's of 3 or 4 at the start of the study, median daily oral morphine dose was 144mg, most were also receiving non-morphine analgesics/adjuvants). The subjects answered a 32 item questionnaire about their symptoms once weekly for 4 weeks (42 patients answered at least one questionnaire; 30 answered all 4). The prevalence of symptoms at the time of the first interview had some surprises: 90% had dry mouth, 69% sedation, 64% myoclonus, 60% constipation, 48% flushing, 38% urinary hesitancy, 36% dysphoria, 26% nausea, 24% nausea, 21% nightmares. The symptoms that were present for an entire month in those who answered all 4 questionnaires were dry mouth (77%, although only 20% moderate to severe), 23% had constipation (3% mod-severe), 13% sedation (10% mod-severe), 43% myoclonus (0% mod-severe), 23% had urinary hesitancy (3% severe), 10% nausea (0% severe), 10% itching (0% severe).
A couple things about this. First, the authors noted this was the first prospective study of morphine related side effects in this patient population which was initially shocking to me, but on further reflection seemed congruent with the general poor state of symptom research in the cancer patient (outside of Epo/fatigue & 5HT3 inhibitors/chemo-nausea studies). The other point is that these are symptoms of advanced cancer patients who are chronically on morphine, not necessarily symptoms due to morphine (this was a straight-forward descriptive study without a control or comparison group, and clearly much of this symptom burden is from other drugs/processes). That aside, what surprised me (and the authors too) was that certain symtpoms such as dry mouth and myoclonus were pretty common (and 20% reported moderate to severe dry mouth for the entire month!), as were urinary retention symptoms--these were reported much more than I am noticing in my practice. On the other hand nausea was not very common and thankfully persistent moderate to severe nausea was absent from this group. This supports the idea that patients quickly become tolerant to morphine's nauseating effects. On the other hand sedation was quite common and 10% complained of persistent moderate to severe sedation for the entire month. Again, how much of this is due to morphine is unclear, but it is consistent with observations that a certain percentage of patients never get fully tolerant to the CNS toxicity associated with opioids. Personally, this study has raised for me the need to more aggressively look for these maybe-more-frequent-than-previously-suspected side effects such as myoclonus, xerostomia, and urinary hesitancy.
5 Responses to “Morphine side effects”
November 30, 2006
One of my favorite teaching points is to go through with residents/medical students/nurses, etc. and pimp them about the side effects of morphine.
Usually respiratory depression gets mentioned first (which I usually talk about proper dosing pretty much avoids respiratory depression), then sedation (same thing about proper dosing) then a pause for a while and someone finally says constipation (and then we talk about proactive bowel regimens).
After that it is commonly blank stares, and no answers. But myoclonus, xerostomia (I love that word!) and urinary hesitancy are great teaching points and make it easy to demonstrate there is some real and critical knowledge about pharmacology and medicine that is so important to end of life care. It is not as simple as just turning up the morphine and ativan! I don't know how many more times I can say that.
November 30, 2006
"Addiction" is always mentioned up there with respiratory depression as a common side effect.
November 13, 2009
For readers finding this site via Google, this happens to be one of our more popular posts. If there are questions you have about the use of opioids appropriately in hospice and palliative care please feel free to comment and we will try and find the right info for you.
Obviously none of this is intended as medical advice as per our disclaimer, but if we can do some general education that is always a good thing.
June 05, 2010
My father has undiagnosed primary CA (tumor path looks like pancreas); he has a normal chest/abd/pelvis CT. He had an initial T7 metastatic lesion. He underwent 2weeks of RxTx but got worse with repeat MRI showing multi level vert. body mets and cord compression. He underwent tumor debulking and rod placement. Prior to the discovery that the T7 lesion was cancer he had already been started on percocet and was "taking it like candy". Once he got to the oncologist he was quickly put on MScontin at 160 mg per day; as pain got worse, fentanyl patch was added and was up to 75 mcg/day. When he had surgery he went to a dilaudid drip at a paultry dose of 1mg/hr and he went thru withdrawal. He was completley obtunded most of the time and had bizarre myoclonic activity. I emphasized to the medical team that I was worried he was withdrawing but no one really thought he was. We ended up sending him to a hospice facility where he was put on a "healthy" dose of morphine and found that he was back to himself at 9mg/hr morphine. Now he is in a nursing home and on oral morphine at 160 mg TID with a prn dose of 45-60 every 4 (not getting much of that). About 5 days ago he was decreased on his TID dose to 130mg. Now I am seeing him clammy, sweating, tremors, very dry mouth, runny nose, and bizarre behavior. I seem to be getting the brush off by the staff. I don't think they recognize he is withdrawing. Call into the MD but they are not there every day and won't be back til Monday. My question is whether we should just let him withdraw so we can get him off of as much of the morphine or should we increase his dose again and wean him more slowly; he was functioning decently before the change. Still was pretty sleepy but could participate in PT/OT and have a conversation. Right now he is having a very difficult time even taking a sip of water without someone holding the cup for him.
Any information would be greatly appreciated. No one seems to have much knowledge about drug withdrawal in elderly (77yo)cancer patients.
Alison
P.S. I am an emergency room pediatrician
June 06, 2010
Allison,
Since it is out Pallimed policy not to answer direct clinical questions (legal reasons, obviously), I cannot directly address your question.
Regarding the broader issue of opioid withdrawal, it is a significant issue in hospice patients especially when considering switching routes or opioid medications. Making sure you are working with a board certified palliative medicine doctor should be a good first step. Not all hospices use HPM board certified medical directors and I think it is a good basic check on the knowledge base of the medical director.
As far as research, there is not a whole lot on opioid withdrawal in hospice patients, although it should be considered with symptoms like delirium, anxiety and sympathetic drive.
I hope this is of some help. I figure I had to say something since my wife is also a peds ED doc.
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