A randomized controlled trial by Harris et al. From the second day, the patients were treated with oral slow-release morphine. They concluded that dose finding with intravenous PCA may be appropriate for a small minority of patients with severe pain. The systemic availability of morphine by the oral route is poor and this contributes to a sometimes unpredictable onset of action and great inter-individual variability in dose requirements and response.
Some types of pain do not always respond well or completely to morphine, notably neuropathic pain. Addition of proper adjuvant analgesics makes a lot of difference in these patients. However, none of the alternatives to morphine has so far demonstrated advantages, which would make it preferable as the first-line oral opioid for cancer pain. In patients with deranged liver and kidney function, dose of oral or parenteral morphine should be carefully titrated to avoid unnecessary effects due to morphine overdose as a result of accumulation of morphine metabolites.
The role of conventional analgesic is limited in neuropathic pain. Certain adjuvant analgesics like gabapentine and pregabalin have been proven to provide definitive role in these types of pain.
Providing sustained analgesia is an important aspect of cancer pain management. Medications should be administered on an around-the-clock basis because regular administration of doses maintains a constant level of drug in the body and helps prevent recurrence of pain.
The titration of opioids should always be accompanied by the monitoring of pain and sedation scores and ventilation. In patients with tumor progression, the increase of the analgesic medication might be due to the changing in the clinical situation and disease progression.
Dose titration with a potent opioid may be considered as safe and efficient in clinical practice. Nevertheless, the high morbidity and the reduced performance status and compliance, in combination with the analgesic medication, may lead to complications, requiring fast intervention from the medical staff.
Our patient also behaved in a similar manner and the high morphine requirement might be the result of progressive nature of the disease. Admission to palliative care units for dose titration with morphine is required for few patients in their old age, advanced malignancy, bony and neuropathic pain. However, a small minority of cancer patients suffers from pain exacerbations so severe that intravenous dose finding with proper selection of adjuvant drug is necessary for assessment of pain syndromes, planning of the analgesic regimen, and adequate pain management.
Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Indian J Palliat Care. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. Shiv Pratap Singh Rana; E-mail: moc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract Morphine has been used for many years to relieve cancer pain.
Keywords: Adjuvant analgesic, Cancer pain, Dose titration, Oral morphine. Footnotes Source of Support: Nil. Oral morphine for cancer pain. Cochrane Database Syst Rev.
Adjuvant analgesics in cancer pain management. In: Systemic opioids for the management of cancer pain: An updated review. Cancer pain relief.
The pain tends to get worse as the cancer progresses. Morphine taken by mouth has been used since the s for controlling cancer pain. In the World Health Organization recommended taking an oral solution of morphine every four hours.
Morphine is now available in a number of different formats that release the morphine over various periods of time. Morphine immediate release is rapidly absorbed, and would usually be taken every four hours. Modified release tablets are available that release morphine more slowly, so that they can be taken only twice a day or even only once a day.
In this updated review we set out to estimate how well morphine worked, how many people had side effects, and how severe those side effects were — for example, whether they were so severe that participants stopped taking their oral morphine. We found 62 studies with participants. The studies were often small, compared many different preparations, and used different study designs. This made it difficult to work out whether any one tablet or preparation of oral morphine was better than any other.
There did not seem to be much difference between them. More than 9 in 10 participants had pain that went from moderate or severe before taking morphine to pain that was no worse than mild when taking morphine.
More than 6 in 10 participants were very satisfied with the morphine treatment, or considered the result to be very good or excellent. Only about 1 person in 20 stopped taking morphine because of side effects. Morphine is associated with some unwanted effects, mainly constipation, and nausea and vomiting.
At one level these are good results. On another level, the quality of studies is generally poor and we could wish for more consistency in study design, and especially in study reporting, which should include the outcome of pain reduced to tolerable levels — no worse than mild pain — so that people with cancer are not bothered by pain. The conclusions have not changed for this update. The effectiveness of oral morphine has stood the test of time, but the randomised trial literature for morphine is small given the importance of this medicine.
Most trials recruited fewer than participants and did not provide appropriate data for meta-analysis. The review demonstrates the wide dose range of morphine used in studies, and that a small percentage of participants are unable to tolerate oral morphine.
Recruitment was undertaken at eight general practices across urban and rural areas of Victoria, Australia. Eligible individuals were aged 18 years or older, able to sufficiently comprehend English, and presented at a GP clinic.
The questionnaire was distributed in the waiting room of each of the practices for a two-week period between November and February Participation was voluntary, all data were non-identifiable, and project information and consent statement were included with the questionnaire.
Demographics and experiences of morphine use were collected. Data were analysed using R 3. Exploratory factor analysis EFA , with an ordinary least squared OLS extraction method, was used to examine the latent structure of the data.
Direct oblimin rotation was used so that multiple factors, if found, would be allowed to correlate. This approach to EFA is robust to data outliers and data heterogeneity. Parallel analysis, 21 a Monte Carlo test for retention of factors based on the magnitude of eigenvalues, was used to determine the number of factors to extract.
Because of the tendency of parallel analysis to overestimate the number of factor to retain, the 95th percentiles of the random eigenvalues were used. Internal consistency — a measure of reliability — was calculated for each factor once the EFA was finalised. This refers to the extent to which all of the items in a scale or factor measure the different aspects of the same attribute. Of the questionnaires administered, were returned giving a response rate of Participant demographic results are presented in Table 1.
The majority of participants Participant responses to selected items of clinical relevance are detailed below in ternary form Table 2. Items with strong agreement include:. Questions exploring the association of morphine with imminent death scored with a high proportion of participants disagreeing:.
Cases with missing values in the questionnaires were omitted, resulting in a sample size of for the EFA. Together, these indices suggest that the MCD correlation matrix was appropriate for factor analysis. Factors and factor loadings for this EFA and the descriptive statistics for each item are detailed in Table 3. Group differences were analysed dependent on demographic variables, using a two-sample t-test to compare the responses of participants.
There were no significant differences in responses according to age, sex or education level. Experiences of morphine use showed some between group differences Table 4.
Participants who had previously known someone with cancer, or had personally been given morphine, had significantly higher scores on the efficacy scale, thus perceiving it to be less efficacious. This study has documented important findings on perceptions of morphine and its use for patients with cancer as held by a general practice population.
Importantly, the widely reported barriers and concerns so prevalent in patient and health practitioner populations were not so expressed in this study. In contrast to previous studies, this population view morphine as providing good pain relief, which has significant utility in treating cancer pain despite being potentially addictive.
The lack of a perceived association between morphine and shortening life in this study deserves specific comment, particularly as it contrasts with discussions by other authors. It is reassuring that such a view is not widely supported in this population; however, it raises questions as to why healthcare professionals continue to believe such views exist.
This understanding may represent a more complex phenomenon and, indeed, may reflect deeply held views of healthcare professionals. In place of communication based on patient understanding, health professionals may arrive at this conversation with pre-supposed beliefs that are then superimposed on patients and their family.
It is important to note the findings from the EFA that show a reduced perception of the efficacy of morphine among those with prior experiences of its use. This survey reveals largely positive perceptions about morphine and its role in cancer care.
Indeed, these perceptions are more positive than anticipated, given the extensive detailing of concerns and barriers in the pain literature. Perhaps rather than assuming that barriers and concerns exist when initiating morphine prescription, an open exploratory approach should be taken.
The aim of the approach should be to initiate a discourse that is relevant to the patient or their family, discussing their experiences or beliefs. While this is a seemingly basic component of clinical care, in the busy clinic it is easy to digress to assumptions, which may or may not be relevant to that individual.
This study has a number of limitations that are primarily related to the participants. They were predominantly female, Australian-born, tertiary-educated and represented a large proportion of people who were previously given morphine, or had a shared experience of morphine in cancer care, rates of which have not previously been documented and may have occurred in a range of settings.
Steps were taken to minimise population bias by involving general practices in a range of socioeconomic, geographical and cultural areas of Victoria. The findings of this research are singularly relevant to morphine and do not attempt to explore attitudes to the growing number of opioid medications available.
Future work may concentrate on mapping perceptions from the general population to the cancer population to determine if such attitudes change as circumstances change, or with the provision of patient information about use of morphine.
This study may provide guidance for the clinical consultation, to identify those views that are widely held and form the basis for discourse. Past experiences of morphine use either personal or through family and friends should be discussed and related to the clinical indications for present use. It is significant to demonstrate the wide diversity of views surrounding morphine, especially those positive associations that support its ongoing place in cancer care.
Competing interests: Matthew Grant was previously employed as a pharmacovigilance physician for MSD in , but has had no relationship with the company since that period. Funding: This study was supported by a grant from General Practice Education and Training, which was wholly funded by the Australian Government.
Ari Dyball for data entry. Australian Family Physician. Search for: Search AFP. Filter Relevance Date. Issues by year. Volume 46, Issue 10, October Morphine use in cancer care: A survey of attitudes and perceptions in general practice patients. Background Morphine is widely prescribed for patients with cancer, although a number of attitudes have been cited as barriers to its use, including fear, addiction and associations with death.
The aim of this study was to explore the nature of these beliefs, and assess the extent to which these attitudes exist in a general practice patient population that may require morphine in the future.
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