STARTING TREATMENT WITH MORPHINE

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

Now that I am starting morphine, what are the important things I need to know about it?

• Morphine by mouth is usually the best way to take it.
• Solutions should be taken regularly every four hours.
• Long-acting tablets are taken every 12 hours.
• The dose will be adjusted to meet your individual need.
• The main unwanted effects are constipation and vomiting; these can be treated effectively.
• You may need other drugs and treatments as well as morphine.
• Your response to morphine must be carefully monitored, particularly during the first few weeks.

How do you decide how much morphine I need?

Most patients starting morphine regularly by mouth have previously been taking codeine (or a similar drug). In most instances, a patient will be changed to 10mg of morphine solution every four hours.

Occasionally a smaller 'test' dose is recommended in the very elderly or very frail. Sometimes, you will be advised to take an extra 10mg after two hours if the first dose fails to give adequate pain relief, and then to continue on, say, a 15mg dose until reviewed the next day.

On the other hand, if you have been on an alternative to morphine, the starting dose will be higher, possibly 30mg or even 60-100mg.

What if the starting dose does not completely relieve my pain?

If you obtain some relief with the starting dose your doctor knows your pain is responsive to morphine. The aim is to increase the dose step by step until your pain is fully relieved. You should not do this by yourself, but seek direction from your doctor or nurse.

Why every four hours? Wouldn't it make more sense if I just take the morphine when the pain begins to come back?

During recent days or weeks, your pain has proved to be persistent. It may be relieved completely by the recommended dose of morphine but, unfortunately, your pain is going to come back after several hours unless more medication is taken. Think of a similar situation: people with diabetes do not wait until they feel loaded with sugar and unwell before they take their next dose of insulin. With the help of a doctor or nurse they work out how much insulin they need in twenty-four hours to keep things balanced. This is what we aim to do when we treat your pain.

With morphine in solution and with standard morphine tablets, experience has shown that 'every four hours' gives the best combination of good pain relief and least side effects in almost all patients. Very elderly patients (85+) and those with poor kidneys may well be able to take it less often.

If you take morphine just 'as needed', you are prescribing yourself alternating periods of comfort and pain - because the pain has to return before the next dose is taken. The next dose will take up to 30-40 minutes to ease the pain again. That could mean a total of, say, one hour of pain out of every four or five. As this is avoidable pain, it seems crazy to handle things that way. With morphine in solution and with standard morphine tablets, regularly every four hours is the recipe for good round-the-clock relief.

What should I do if I get behind with my medication?

In hospital, it should be possible to be fairly precise about 'every four hours'- 2 a.m., 6 a.m., 10 a.m., 2 p.m., 6 p.m., and 10 p.m. Though, sometimes, nursing restrictions can make the theoretical ideal more difficult to achieve than at home. In practice, most patients do not wake up on the dot of 6 a.m. In consequence, we recommend that 6 a.m. is interpreted as 'on waking', unless you happen to wake, say, after 8 a.m. This means that the 6 a.m. dose might not be taken until 6.30, 7 a.m., or even later. Even so, the next dose should be taken at 10 a.m., and then by the clock for the rest of the day. In short, if you get behind, catch up at the next dose. If you delay, you may find you have difficulty remembering a different time schedule every day. 'On waking, 10 a.m., 2 p.m., 6 p.m.' is easy to handle because it is easy to remember.

At 10 p.m. the same flexibility may be necessary as at 6 a.m. Some patients find that they need to go to bed at, say, 9 p.m. and they are fast asleep by 10 p.m. For this reason, it is best for most patients to regard 10 p.m. and 'at bedtime' as interchangeable. Obviously, if your day does not start till 9 a.m. and you never go to bed until midnight, a more individual timetable may be necessary - but the principle of every four hours by the clock remains the same.

How soon will I become pain-free?

If you have many pains, and if you are depressed or very anxious, it may take three to four weeks to achieve maximum relief.

Immediate total success is a bonus. The first goal will be to get you a good night's sleep and to make you more comfortable during the day. The second goal is complete relief at rest during the day. The final goal is freedom from pain when walking and moving around. This third level of pain control is not always possible with drugs alone, and some people may need to limit certain activities if they find that these continue to bring on pain.

What about the nights? Do I need to set my alarm clock for 2 a.m.?

In theory 'Yes', but in practice the answer is almost always 'No'. If you are elderly and are in the habit of waking in the middle of the night to empty your bladder, a 2 a.m. dose can easily be included. In this case, after you take your 10 p.m./bedtime dose, measure out the 2 a.m. dose into the medicine cup and leave it beside the bed for when you wake. If you are half-asleep when you respond to the call of nature, you won't have to fumble around trying to measure out the correct dose. This can be doubly difficult on a cold and dark winter's night. It also means you will be less likely to disturb your partner.

If you wake again later in the night, the empty medicine cup will tell you that you have already had your 2 a.m. dose, and that all will be well until the morning. There will be no need to rack your brain trying to remember whether or not you have had your middle-of-the-night dose. As with 6 a.m. and 10 p.m., you can be flexible. If you wake to empty your bladder at 1 a.m. - take the 2 a.m. medicine then. If you wake free of pain at 3 a.m. - take it then.

On the other hand, if you do not regularly wake to empty your bladder during the night, there is probably no need to take a 2 a.m. dose. The reason for this is explained in the next section.

A double dose at bedtime? Isn't that a bit dangerous?

Most patients get through the night without a 2 a.m. dose provided they take a double dose at bedtime. (Sometimes in the elderly, one and a half times the normal daytime dose is enough.) Unbroken nights, both for you and the family, are a bonus to good pain control.

By giving a double dose at bedtime, the amount of morphine in the blood will be much higher, and this will cause drowsiness. While this is a disadvantage during the day, it is an advantage at night. By the morning, the amount of morphine in the blood will be back to usual levels before the first daytime dose.

We have information on file to show that a double dose at bedtime is effective through the night and that it is no more risky or dangerous than a single dose at 10 p.m. and another at 2 a.m. For most patients, therefore, 'every four hours', means 'on waking, 10 a.m., 2 p.m., 6 p.m., and a double dose at bedtime.'

Why do I have to take it so often? Couldn't I have a stronger mixture and take it less often?

A larger dose would be effective for longer, but there would be a greater likelihood of troublesome unwanted effects. 'Every four hours' gives the best combination of maximum pain relief and minimum unwanted effects.

Long-acting tablets are available for patients on a steady dose, particularly those who find it difficult to cope with medication every four hours. These need to be taken only every 12 hours. To take a long-acting drug more frequently than this would defeat the purpose of such a preparation. If the dose every 12 hours does not maintain a satisfactory level of comfort, the dose should be increased rather than taking the tablets more often.

Will I need to use other pain relief drugs with morphine?

Many patients do, though not all. You may need aspirin or a similar drug. Morphine and aspirin together are particularly effective in bone pain. Morphine acts on pain centres in the brain and spinal cord, while aspirin acts more locally where you are having the pain.

Cortisone and related drugs are of benefit for certain types of cancer pain, particularly that caused by nerve compression. A variety of other 'helper' drugs may be recommended by your doctor. For example, if your pain is partly caused by muscle spasm, it will be helped by a muscle relaxant.

What will happen to me if morphine does not relieve my pain?

Treatments for cancer pain can be grouped under two broad headings:

• Pain relief drugs.
• Non-drug treatments.

Morphine is one of a range of useful and important pain relief drugs. In practice (and quoting the World Health Organisation again), drugs usually give good relief provided the right drug is taken in the right dose at the right time intervals.

The more important non-drug treatments are:

• Psychological support for you and your family.
• Limiting certain activities (if pain is made worse by them).
• Radiation therapy (particularly for pain in bones).
• Injections to deaden nerves (useful in a small number of cases).

Psychological treatments such as relaxation therapy are helpful for many patients.

Does it matter when I take the morphine in relation to my meals?

No. The times that people eat vary. We have never had to take this into account in patients prescribed oral morphine.

Is there anything I can add to make the morphine solution taste better?

Unflavoured morphine solutions taste bitter. While some people do not mind this (or may even like it), others find the bitterness unpleasant. When this is the case, most people pour the required amount of morphine into a medicine cup and add fruit juice or milk.

Many pharmacies have a flavoured base to which the morphine is added. In other words, the morphine is supplied with a flavour included, and is usually sweetened. Some people, however, find the sweetness less acceptable than the original bitterness.

Will I be able to drive the car if I am taking morphine?

Doctors have a legal responsibility to advise patients if a disability is likely to make them a danger when driving. In many countries, there is an obligation on the driver to report any such disability to the licensing authority, unless relatively short-term (e.g. less than three months).

Taking morphine for medicinal reasons does not automatically disqualify you from driving. Your general alertness and reaction time may however, be affected by your medication.

It is important that you take the following precautions, particularly if you have not driven for some weeks because of ill health:

• Do not drive in the dark or when conditions are bad.
• Do not drink alcohol, however little, during the day.
• Check your fitness to drive in the following way:

- Choose a quiet time of the day when the light is good.
- Choose an area where there are a number of quiet roads.
- Take a companion (husband, wife, friend).
- Drive for 10-15 minutes on quiet roads.
- If both you and your companion are happy with your alertness, concentration, reactions and general ability, then it is all right to drive for short distances.
- Do not exhaust yourself by long journeys.

It is perhaps worth pointing out that many patients receiving morphine are not well enough to drive, and have no wish to do so. To drive or not to drive is therefore an issue only for a minority.