Wednesday, February 18, 2015

There is no way I’m taking that %*@$ morphine!

by Kristina Newport, MD

We’ve all heard the multiple reasons why folks are not interested in using opioids for their symptoms…

“They gave my sister morphine and she died the next day”
“He associates that medicine with the war”
“My neighbor’s cousin’s brother was addicted to that stuff”

Lately I have been struck by, not only patient specific stories, but local and national stories about opioids that lead to further stigmatization.  One that really stood out recently was a story about a prisoner who  survived for 2 hours after initiation of the lethal injection procedure.  Of course, this raises issues regarding the death penalty etc., but what I’d like to point out is that the drugs utilized drugs were midazolam and hydromorphone.  The exact same medications that I ordered this morning for a patient in our hospice unit for refractory symptoms. I cringed when I heard the broadcaster name drugs that have so many beneficial uses, knowing that some of our future patients will hear this story and be jaded by it.

Locally and nationally, opioid dependence is in the news regularly, declaring prescription opioid abuse at an all time high, with frequency of overdose deaths tripling in the past 25 years.

Our anecdotal patient stories are supported by numerous published studies revealing patients’ main concerns of:

  • fear of tolerance/addiction
  • perceived hastening of death
  • impairment of cognitive functioning  
So, when we introduce the idea of using opioids to control symptoms, can we blame patients and families for balking?  Here are some lines that I would NOT recommend:

  • “I am going prescribe the same drugs that were used to intentionally kill someone in Arizona,  but I’m definitely not trying to kill your loved one”
  • “2.1 million other people are addicted to this medication, but don’t worry about that at all… you’ll die before that becomes a problem.”
As in many areas of our work, listening to patient and family concerns is key to creating an appropriate plan of care when it comes to opioid use.  In Shinjo et al’s  paper in January’s JPSM, more than 90% of bereaved families whose relatives received opioids reported a preference to receive opioids for cancer pain in the future.  This implies that when people witness the safe use and benefits of the medication, acceptance increases.  We, as providers, also understand the value of opioids, both from a clinical perspective and anecdotally.  We recommend these interventions to those who are suffering because we know that their lives can be better.

We do need to keep in mind, however, that our reasoning does not always speak to what is most important to our patients.   Sometimes the above issues are not just passing thoughts, but strongly held beliefs.  It is our duty to understand these beliefs, just as we need to understand beliefs about other treatments/end of life preferences.  And in some cases, it’s best not to use opioids. While we profess that our goal is to meet the person where they are, we are sometimes as guilty as other specialties- offering the tools that we know and love, even if it is not what the patient wants for him or herself.

So when we hear a line like “There’s no way that I’m taking that evil medicine”, it’s important to pause and ask,  Why?

Kristina Newport MD (@kbnewport) practices Hospice and Palliative Medicine in Lancaster, PA where she also spends time running after her children, 4 and 6.

For more reflections related to this topic, check out the following previous Pallimed posts:

Photo Credits:
Morphine Roche, leaflet cover, 1937 by Atelier Levitt-Him
"MorphineAdvertisement1900 - no watermark" by Venturist. Licensed under PD-US via Wikipedia.

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