Morphine Labeling

New Look

For many years now the most common concentration of oral morphine solution used in hospice has been 20 mg per mL.   Although the concentration is exactly the same, you may begin seeing different labeling.  It may now read 100 mg per 5 mL.

The Food and Drug Administration worked with Roxane, the largest manufacturer of oral morphine solution to change the labeling and the look of the product to reduce the possibility of errors.  The intent of this labeling is to help differentiate this product from another product with a concentration of 20 mg per 5 mL.

The volume of liquid is unchanged:

• 5 mg = 0.25 mL
• 10 mg = 0.5 mL
• 20 mg = 1 mL

Although the label prominently says 100 mg per 5 mL, you will also see (in smaller letters) 20 mg per mL. 

The new labeling may mean a little change in our mathematics, but remember that the concentration has not changed. 

If you have any questions about the concentration or labeling, call Pathways (1.888.755.7855) and we will be glad to double check your calculations with you. 

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

How Morphine Can Help in Heart Failure at the End of Life

Morphine is most often used as a pain reliever.  But for heart patients, it is often used for shortness of breath.  There are several ways that morphine interrupts the cycle of breathlessness.

• Morphine lowers the breathing rate in the brain’s respiratory center. This means the heart doesn’t have to work so hard to supply blood to the chest muscles for breathing.  It reduces excessive breathing drive.
• Morphine widens blood vessels in the arms and legs.  Pooling blood in the extremities reduces the amount of blood that returns to the heart.  This means the heart doesn’t have to pump as often—it can rest more.  When the heart doesn’t have to pump so hard, it also needs less oxygen—so the resident doesn’t have to breathe as hard.
• It eases anxiety, and when a resident is less anxious, he or she will breathe more calmly.  If you breathe more slowly, you are less anxious.
• When we are in pain, we tend to breathe faster and harder.  So relieving pain also reduces respiratory rate.

Used correctly, morphine is safe.  Addiction is very, very rare.  The chance of becoming addicted is so small that it is considered unethical to withhold morphine because of a fear of addiction.

But if we don’t know how opioids like morphine, fentanyl, Vicodin or Dilaudid work, we may mistake initial responses.  If an opiod is new to a person, he or she may be sleepy for the first 2 or 3 days—especially if they have not been sleeping well (maybe because of shortness of breath or pain).  When symptoms are relieved, the resident may want to “catch up” on sleep.  After a few days, the sleepiness wears off.

At the end of life, morphine is the most important medicine for providing comfort to heart patients.  It reduces the breathless feeling that can be so frightening to people at the end of life.

Managing Pain Without Medication

In addition to medication for pain, there are other things we can do to reduce pain.  Usually these are used in addition to medicine or while waiting for the medicine to work.  But if a resident refuses pain medication, using these techniques may help.

Alternatives to Try

Distraction:  This is an effective technique.  It’s as though the brain can only pay attention to one thing at a time.  Talking, watching TV, playing games or looking at photo albums are some examples.  If the pain is severe, these will not work.

Deep breathing / relaxation exercises:  Guide the person in deep, slow, rhythmic breathing.  There are many relaxation recordings available that are easy to follow.  You can suggest to family members that they purchase relaxation recordings and furnish a listening device.

Cold:  A cold pack (gel pack, ice pack, or zip bag with crushed ice) helps inflammation or muscle ache.  Wrap the pack in a towel; do not put the ice pack directly on the skin.  Even if this does not relieve all pain, it may help to numb the area somewhat.

Warmth:  A warm tub bath or warm packs can relax muscles that have tightened due to pain.  A warm, wet washcloth applied directly to the affected area may help.  Covering the cloth with plastic will help retain the heat longer.

Massage: This is an excellent way to distract from pain and relax tense muscles that make the pain worse.  Lotion may reduce friction.  You do not have to massage the painful area.  Massaging another area of the body may distract the mind from pain.

Prayer / meditation: Some people find this very comforting and perceive less pain during prayer.  There may also be rites or rituals that could comfort the resident.  Ask family members about this.

Music: Music is another form of distraction that research has shown relieves pain.  It does not matter what kind of music, whatever the resident likes will work.  Again, family members can help provide information about musical tastes and recordings and a CD player.

Energy work / therapeutic touch: These are hands-on techniques in which the practitioner places his or her hands on the resident’s clothed body to achieve a transfer of energy.

Acupressure / acupuncture: These techniques apply pressure or needles to specific points on the body to relieve discomfort in other areas that are associated with those points.

Reflection / life review: Those nearing the end of life often want to reflect on the events of their lives and the people they knew.  Asking about family members or the resident’s youth or birth place may assist in starting this kind of life review.

Pets: Research shows that pets improve mood, lower blood pressure and heart rate, and may serve as a good distraction from pain.

Innovative Program at Pathways

Pathways Hospice patients can take advantage of our well developed Integrative Therapies program.  It provides innovative therapies such as guided imagery, comfort touch, music therapy, aromatherapy, massage, and pet therapy.  These therapies are shown to reduce agitation in residents.

If you are interested in learning more about the Integrative Therapies program at Pathways, talk to Pathways staff, or visit our website:  www.pathwayshealth.org.  The Resources section includes downloadable information and simple tips for incorporating Integrative Therapies in your daily life too!

Power of Positive Thinking

A series of lab experiments conducted in Europe found that those patients who expect their analgesics to work get relief from their pain.  Those who were told their painkillers had been discontinued had more pain, even though they were actually continuing to receive the same dose. A patient’s expectations about the effectiveness of a pain drug appear to override the properties of the drug itself.

Scans Illustrate Phenomenon

Patient MRI scans conducted during the research show that, “volunteers had more activity in areas of the brain involved in memory and anxiety when they were expecting pain versus when they were expecting relief.  When the volunteers were told the drug would work, there was a boost in brain activity in areas associated with fighting pain,” says study author Dr. Ulrike Bingel, from the department of neurology at the University of Hamburg Medical Center in Germany.

Although the placebo effect is well documented, there is less research on the “nocebo” effect, in which patients have negative experiences when warned about the side effects or lack of effectiveness of a treatment, even if they are taking a placebo.

“This tells me that when we’re talking to patients and presenting therapy, the more positive we are about how the therapy is going to impact them, the better outcomes we’re going to have,” says Carla Rubingh, a pain management specialist and assistant professor of pharmacy practice at the University of Nebraska Medical Center in Omaha who was not involved in the study. 

Benefits of the Mind-Body Connection

Pathways is home to an innovative Integrative Therapies Program that includes guided imagery and meditation to help patients find comfort and relief.  Relaxation techniques use the mind-body connection to achieve relaxation. Using simple suggestions, the practitioner guides the patient or family member to make the changes they wish to achieve in their physical or emotional state. This is very effective in reducing stress and anxiety, and is helpful in pain management.

For more information about Integrative Therapies at Pathways visit our website and Integrative Therapies resource page for caregivers.