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.

Men, Women, and Pain

Rigorous research has concluded that men have a higher threshold for pain.  In a large-scale prospective study of 700 patients conducted by physicians from Tufts-New England Medical Center and San Ignacio Hospital, Bogata, Colombia, researchers examined post-surgical morphine use.  After adjusting for type of surgery and age, women had higher levels of pain intensity throughout the study than men, requiring an average of 30% more morphine on a per-weight basis than men to attain a similar decrease in pain intensity. 

Research results have been mixed, some finding that men required more morphine after surgery than women.  A very large Chinese study found women used significantly less morphine when using patient-controlled analgesia post-operatively, indicating that cultural, ethnic or genetic factors may account for differing research results.  But in animal models, male rats exhibited greater analgesia than female rats to equal doses of opioids.

The researchers wrote that, “Sex differences in pain perception have been attributed to a different socialization process for men and women that influences bodily experience and the willingness to communicate distress. Hormone variations could also in part explain sex differences in pain experience and response to morphine.”