Morphine for cancer pain relief

Published on December 10, 2007 at 10:28 PM · 8 Comments

Cancer patients are suffering unnecessarily because they wrongly believe that morphine and other opioids are only used as "comfort for the dying" and as a "last resort" rather than seeing them as legitimate pain killers that can improve their quality of life.

In a study published online (Tuesday 11 December) in the cancer journal, Annals of Oncology experts in palliative care also say “the belief that opioids hasten death is widely held” amongst patients and this “has a significant impact on pain management, as patients felt that an offer of opioids signified imminent death”. Previous studies have estimated that between 40-70% of cancer patients may not have their pain properly controlled with the right medication for a variety of reasons.

Dr Colette Reid, the lead author of the study, said: “If we are to employ the range of available opioids in order to successfully manage pain caused by cancer, we must ensure that morphine does not remain inextricably linked with death. If this connection stays in place then morphine will continue to be viewed as a comfort measure for the dying rather than a means of pain control for the living.”

Dr Reid, a consultant in palliative medicine at the Gloucester Royal Hospital, Gloucester, UK, conducted in-depth interviews with 18 patients with metastatic cancer, aged between 55 and 82, who were asked to take part in a cancer pain management trial. She wanted to examine how patients reacted when first offered an opioid drug described as similar to morphine. Dr Reid also wanted to understand the factors that influenced patients' decisions whether to accept or to reject morphine. The interviews were analysed along with an experienced social scientist Rachael Gooberman-Hill, and Geoffrey Hanks, professor of palliative medicine, both from the University of Bristol.

The patients interviewed were all white and half of them were women. Their views and experiences about morphine fell into four distinct but inter-related categories: anticipation of death, morphine as a last resort, the role of the professional, and no choice but to commence.

Morphine as a “last resort” was the central theme to emerge from the interviews. The authors write: “We found that patients with cancer who were offered morphine for pain relief interpreted this as a signal that their health professional thought they were dying, because opioids were interventions used only as a ‘last resort'. Because participants themselves were not ready to die, they rejected morphine and other opioids as analgesics, despite the pain experienced as a consequence. Participants' descriptions of the role of professionals indicated that patients value professionals' confidence in opioids. Some patients may therefore become more frightened when offered a choice, since this indicates a lack of confidence in the opioid as an analgesic.”

It could be argued that the patients' belief that the use of morphine represented a ramping up of treatment in the face of approaching death and the associated pain is a reasonably held view, especially as most of the patients interviewed for the study have subsequently died.

However, Dr Reid said: “The World Health Organization guidelines for the management of cancer pain state that analgesic treatment choices should be based on the severity of the pain, not on prognosis. So patients at all stages of cancer could have morphine if their pain is sufficient. In reality, the patients most likely to experience pain, and likely also to have the most severe pain, are those with metastatic disease, i.e. their cancer cannot be cured. These patients may yet have many months to live, but their quality of life is adversely affected by pain, since unrelieved pain leads to social isolation, loss of role and depressed mood. This was the group of patients that we interviewed – patients with metastatic disease and life expectancy measured in months.

“The fear of these patients was that morphine suggested imminent death (and also possibly hastened death) and that once commenced would mean that they would not be able to function normally. However, morphine if used properly, can actually promote quality of life by allowing patients with pain to function better.”

Dr Reid and her colleagues say that the role of the medical professional is crucial in helping to change patients' beliefs and attitudes towards morphine. They write that the study's findings “highlight the importance of the professional in cancer pain management, but also how beliefs about opioids that are communicated to the relatives of the dying may have implications for the pain relief of others in the future”.

Dr Reid said: “During the interviews, patients told us that that when a professional had been confident about opioids, then this had made them feel more able to accept the possibility of taking opioid medication. However, the main source of their fears was either personal experience or stories told by others. If more patients had good experiences with morphine (and other opioids) then the stories will be more reassuring.”

She continued: “Our interviews suggested to us that the patients detected professional ambivalence towards morphine and so this heightened their fears. They also told us that professionals had worried, incorrectly, about hastening death by using morphine and had communicated this fear to relatives. We are getting better at educating medical students about opioids and pain management, but another study we are involved in at the moment suggests that there are definitely educational needs for professionals. I think the role of palliative care teams is crucial here, since we can educate both professionals and patients.”

In an accompanying editorial, Dr Marco Maltoni, head of the Palliative Care Unit, Forlì Local Health Authority and Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola, Italy, agrees. He writes: “Professional competence, correct communication, and a relationship based on trust are the three principle factors taken into consideration by patients when deciding whether or not to start opioid treatment.”

He concludes that the study “which originates from the birthplace of palliative care, is somewhat disturbing in the messages it conveys – extreme fear of opioids and high barriers to palliative care strategies. It suggests that a great many years of health education have not produced the results that might have been hoped for. The problem remains that a number of oncologists today still tend to reserve the use of opioids for the final stages of the disease. A vision of pain management and palliative care that is not solely linked to the end-of-life but rather seen as a positive option, in the less advanced stage of disease as well, needs to be promoted.”

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Comments
  1. Catherine S. Catherine S. United States says:

    I find it hard to have any legitimate respect for this article after reading this section of it: "metastatic disease, i.e. the cancer cannot be cured." Although metastatic cancer severely decreases life expectancy it should not be labeled as a cancer that cannot be cured--especially considering that there is no definite cure for cancer regardless.

  2. Evon jouppi Evon jouppi United States says:

    I don't care what is said in this article.  My sister was alive and talking and fine on Monday night and was dead after the hospice nurse give her six syringes of morphine at a dose of one an hour.  Her breathing stopped on Weds. After the nurse told us to say our good-byes.  She had cancer but we knew that she had a few months left.  She told us how to bake a pineapple upside down cake and fix a pressure cooked roast on Monday night while ignoring the hospice nurse who slipped her an Oxycodone while telling her that he was giving her something for nausea.  Then they proceeded to give her the morphine at one dose an hour saying that she was in pain.  We saw no signs of anything especially pain.  Morphine did this and I am convinced of it.  

  3. Truth Truth Yemen says:

    I have no doubt that palliative care specialists get pressured from coworkers in hospitals, nursing homes and hospices. Comments like "the last specialist didn't have people around for months...they were gone in a week."

    My friend has multiple myeloma and since her surgery, never mentioned any pain. Now, she can't speak, because her specialist is administering so much morphine.

  4. day day United Kingdom says:

    My wife as Lung cancer, primary and secondary its now in her left arm and left leg (bone) She tried Morphine it does not work it makes her sick. All she can take are Paracetamols, no more than 8 per day. After 1.5 hours the pain returns, she cannot take more for fear of going over that amount. It will damaged her liver, god, she dying from cancer for Christ sake.

    Get real all you medical professionals out there, find a better pain relief for people.

  5. Kathryn Rogers Kathryn Rogers Canada says:

    My Baba has been in the hospital for a little over 5 weeks now with lung cancer.  I had gone and seen her on a sunday and she was up and talking, not alot but she was still talking and was able to sit up and eat her supper.  By monday evening she was not eating or drinking or barely talking.  My mom said they are giving her morphine every two hours and has not woke up know for over 24 hours.  What form of quality of life is this it is like she is dead already, maybe morphine does take away some of the pain but she does'nt know where she is and keeps screaming out for help.  If you ask me Morphine has made my Baba into a vegetable.

  6. Carolyn Carolyn United States says:

    I totally agree with all the remarks listed, when Hospice was called in they immediately administered Morphine claiming my cousin was in extreme pain when he complained of none...but, being 84 yrs. old with a little dementia they felt he wasn't being truthful...then more and more till he is now almost a zombie....

  7. lela lela United States says:

    I have metastaic breast cancer, and have been on morphine for one and half years. My children say " we like it when mom is painfree ," And if I was not taking it , I would probably be bedridden, because of the cancer pain. So sorry to hear of others bad experiences, and I do believe if it is adminsitered correctly, it is a very helpful pain medication.

    • warren Hall warren Hall United States says:

      This has been my experience also. I have lung cancer and have had my left lung removed along with 28 limp nodes removed. The morphine allows me to be up and about...having a better life. I don't feel I'm dying from cancer but rather I'm living with it.....Good luck to all.

The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News-Medical.Net.
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