Friday, September 25, 2009

Sister Morphine

This weeks BMJ has the Rolling Stones song reviewed as its "Medical Classic", in a slot generally reserved for worthy tomes like "The Conquest of Pain" or medical novels like "The Citadel". I'm a bit miffed, because I'd already decided on it for the title of this follow on post from the earlier post on heroin. Not actually miffed enough to change it though you'll notice.

The thing is it rather fits what I've got to tell you. Not so much the song as the title to be honest. You see Mick and the boys were rather reinforcing what I had to say last time with their plaintive song about addiction, but this time I want to point out the undoubted therapeutic value of this much maligned drug.

For years Morphine has been a "back of the cupboard" "painkiller of last resort" "fit only for the dying" sort of a drug. True there has been increasing use of morphine drips for post operative pain in recent years (these days even administered at a rate determined by-- of all people-- the poor soul who has the pain). And as suggested, Sister M and her bigger beefier cousin Diamorph' have been the mainstay of end of life pain relief since Hippocrates was in short chitons. Anyone with any involvement in such care will recognize the beatific change in countenance that comes when a pain ravaged patient finally achieves symptom control through their tender mercies.

There's a lot of guff talked about the "Doctrine of Double Effect" that implies it's o.k. to administer potentially lethal doses of opiate to relieve pain. Given methods of administration widely available for at least three decades this has never been a part of my reality or that of my patients. Used correctly opiate analgesics kill one thing and one thing only. Pain. Abuse and overdose are not and have never been therapy and should not be allowed to confuse the issue.

Once every eight to ten years we are sold a new "miracle" non-opiate pain killer. They tend to be derived from some species of anti-inflammatory, are heralded with a vast fanfare, tried with enthusiasm by many of us, and within twelve to eighteen months turn out to be no better than, more expensive than and often more toxic that all non-opiate analgesics that have gone before them. Then they disappear or dwindle to a background, occasional, niche painkiller for when everything else (except morphine) have been tried.

Recently we have had to appreciate that a whole class of painkillers-- the non-steroidal anti-inflamatories, can do bad things to aging kidneys, making them hard to use in severe arthritis (which is precisely where you might want to be able to use them). So the poor punters are left with paracetamol plus or minus a bit of codeine. This seldom works, but it's rare that a patient will welcome the offer of a tiny dose of morphine to help give back their pain control.

Which is a shame.


Nostrumdammit said...

Dr J!!!!
Dr J!!!!!
Once again you hit that nail on the head. We do indeed do a lot of [ unintentional ] damage in these areas when we use NSAID's and the like to manage long term and intractable pain. I have always felt and often sold or recommended opioids as being the simplest solutions. Long term use needs careful management and education allied with very sound monitoring. Sadly not feasible these days given the pressures in terms of patient access and expectations. I once attended a lecture by Dr Tim Hughes [ a crusty old medico codger of my leary generation ] and he very eloquently put forward the case for greater prescribing of opioids. The fact that his retainer was paid by Napp Pharmaceuticals in no way detracted from his elegant presentation. Morphine, Diamorphine and Dihyrocodeine are also relatively cheap, we have a great understanding of them and also now are able to use them with naloxone to reduce the constipation side effects. It has to be the way forward, then we can educate the population appropriately, re-open the opium dens, and send in the Lads to annexe Peking and Kandahar and save time money and kidneys!

Nickynockynoonoo said...

Coproxamol is very effective for RA flares. Pity that's been withdrawn after 20 years. I'd be happy to take morphine on bad days.

hypotemuse said...

"I can't stay on your morphine, cuz' it's making me itch".

Pink, "Just like a Pill".

The LDR was on a post-operative morphine drip fifteen years ago (it provided effective pain relief and didn't make him itch).

ageing student said...

My husband was recently discharged from hospital after orthopeadic surgery with a bottle of morphine syrup, to be taken thre times daily. He was so worried about getting addicted (all those horor stories you read) that he only took it before bed and then only for a couple of nights beause he said it made him dream too vividly! As I don't have any pharmaceutical knowledge, is that a normal side effect of morphine?

Doctor Jest said...

Nostrum'-- as ever I'm indebted to you for your erudite input. As for your parting shot, at last the "War on Ter'" makes some kind of sense. It's not democracy we're fighting for, it's Kidneys.

N-n-n-n -- Welcome. There was something uniquie about Dextropropoxyphene (the opioid in Co-Prox') that didn't just kill pain but truly made people feel better. We're always a bit suspicious of drugs that do that, and sadly rightly so in this case since the overdose death rate from compound analgesics has plummeted since Co-prox was taken off us. But you're not alone in mourning its passing.

Hypotemuse-- I think she meant "itch" rather than itch-- that feeling you get in early withdrawal of restless irritability. Not a problem we see when treating physical pain to a management plan, but in unregulated use for other purposes sadly all too common.

AS-- there's no denying the psychic effects of opiates of all stripes. That's what the "abusers" are looking for after all, so yes vivid dreams are an effect in many, tho' not an unanticipated one. His reaction suggests there was little danger of him developing a habit. Most patients taking opiates for pain are perfectly happy to let them go once the cause of the pain has gone away.

C.A.T-- comment removed. I'm sorry this is a non-commercial enterprise. I sha'nt be linking to you and would prefer you respect my wishes that you not link here. I felt I had to remove your comment, and I do not expect a reply here. Sorry. Dr J.