QUESTIONS FROM A RELATIVE OR CLOSE FRIEND

by Dr Robert Twycross MA DM FRCP, Macmillan Clinical Reader in Palliative Medicine, University of Oxford
Dr Sylvia Lack, Consultant in Hospice Care, Waterbury, Connecticut

Will it say on the bottle that it's morphine?

The bottle may be clearly labelled 'morphine', or it may simply be called by the brand name. We see, however, no reason for secrecy. In fact, we would discourage it. The reason for secrecy is fear. This false fear is based on false ideas of what morphine is and does.

It often gives people a mental jolt when they learn that morphine is being prescribed. A few days later, though, most patients are very pleased to be taking it - because of greatly improved comfort. As they are more comfortable and sleeping better, they have a renewed interest in life. These and other positives soon outweigh any possible negatives.

Some patients need morphine, either continuously or periodically, for several months or years. To commence morphine does not necessarily mean someone is close to death. Rather, it means that the patient has a severe pain that requires something stronger than codeine.

Is it necessary to keep the morphine locked up?

It is almost unheard of for patients to have an oral solution of morphine stolen by family, friends or intruders. However, as with all medicines, it is advisable to keep morphine out of sight and in a cupboard where young children cannot reach it.

Is it all right to keep the bottle of morphine with the other medicines?

Yes. Morphine solutions almost always have a preservative in them to prevent fungi and yeasts from growing in them. In very hot weather, however, it may be best to keep the morphine in a refrigerator.

Will the morphine mix all right with his other medicines?

It is usually best to link all the patient's medicines to the times that the morphine is taken. Thus a heart tablet taken once a day can be linked with either 6 a.m. or 10 a.m. Laxatives, too, can often be linked with the bedtime morphine. Other tablets may be linked with 10 a.m. and bedtime, or 10 a.m., 2 p.m., and 6 p.m. This will depend on how many times a day the tablets have to be taken, and whether they have to be spaced out around the clock.

Occasionally, because morphine delays stomach emptying in some patients, the combination of morphine and, for example, cortisone may result in acid indigestion, whereas either alone would not. Similarly, the combined use of morphine and certain tranquilisers may together cause troublesome drowsiness, whereas either alone does not. Provided the doctor is alert to such possibilities, the necessary corrective action can be taken. We nevertheless emphasise that, generally speaking, morphine can be given (and taken) in combination with virtually all types of other medication.

Since he has had the pain his appetite has gone completely. Will the morphine help him to eat better?

Many people lose interest in eating and in life generally if their whole horizon becomes one of severe never-ending pain. This is particularly so if sleep has been disturbed and the patient is exhausted both physically and mentally. In these circumstances, better pain control and adequate sleep is likely to result in a renewed interest in eating.

On the other hand, there are many reasons for loss of appetite in cancer. This means that, if the patient continues to be disinterested in food despite good pain control, the doctor will need to assess the problem separately. Nausea and severe constipation are two relatively common causes of loss of appetite.

Will she be safe looking after the baby if she is taking morphine?

Breast-feeding is not possible if the mother is taking morphine, because some of the morphine will be transferred to the child in the mother's milk. This question usually refers to a toddler rather than a baby.

Here, the answer depends on the mother's general stamina more than anything else. Most mothers in this position find the incessant demands of a preschool child very difficult to cope with, and some kind of child-minding has to be arranged.

In short, within the limits of her stamina, there is no reason why a mother taking morphine should be discouraged from caring for her child. Indeed, as she will be more comfortable and sleeping well, someone on morphine is likely to cope better than would otherwise be the case.

What about signing legal documents while taking morphine?

It all depends on the patient's general circumstances. For many patients, the use of morphine brings about a welcome improvement in their general condition. There will also be some who are too ill to sign such documents whether or not they are taking morphine. For those who become very drowsy or muddled when starting morphine, it makes good sense to delay signing important documents for a few days. By doing this, it will be difficult for someone at a later date to cast doubt on the patient's ability to think clearly at the time of signing.

What should I do if he insists on having more than he has been prescribed? Could it kill him?

If left to their own devices, patients are more likely to take too little rather than too much. Assuming that the reason for more morphine is to relieve distressing pain, there are no grounds for refusing the request. Obviously, if more than a double or treble dose is insisted on, there may have to be a certain resistance:
'I'll give you a double dose now, and then ring Dr X. to let him know the prescribed dose is not holding the pain. If he says to give more, or repeat a double dose after an hour or so, that's fine. I just think we need more guidance.'

Should the patient receive too much, it will most probably act like the bedtime double dose (see Section 18). The patient will sleep for several hours and, with luck, will wake refreshed and free of pain.

Is there a danger that she will use the morphine to commit suicide?

Some cancer patients, if caught up in a living hell of unrelieved pain, think of killing themselves. Surprisingly few do. In our experience, when the pain is relieved - often with morphine - the patient no longer thinks of suicide. Moreover, out of several thousand cancer patients, we know of no one who has used a solution of morphine to attempt suicide.

If he has no pain and refuses to take the next dose, do I insist on him taking it?

It depends on the circumstances. If the patient is totally confused, the refusal may be unreasonable. In this case, continued pressure to accept the morphine may be necessary. On the other hand, if the confusion is associated with paranoia (feelings of being threatened persecuted), even gentle persuasion might make matters worse. If in doubt, don't-and seek help from' your doctor or visiting nurse, possibly by phone in the first instance.

If misunderstanding due to confusion is not the cause, he will presumably have a reason for declining the medication. He may be right: it does cause unacceptable drowsiness or nausea in his case. Or perhaps the untreated constipation is merely exchanging one hell for another. There is obviously room for exploring the reason or reasons behind the refusal. Here too, professional advice should be sought.

If she becomes unconscious, should the morphine be discontinued?

No. Mainly for two reasons:

• Unconscious patients in pain tend to become restless.
• 'Physical dependence' usually develops after several weeks of treatment with oral morphine. If this is the case, and the morphine is stopped abruptly, the patient is likely to become restless, If the degree of physical dependence is considerable, she might start to sweat a lot and possibly develop uncontrolled diarrhoea.