morphine myths: important tools for end of life€¦ · morphine myths: important tools for end of...
TRANSCRIPT
![Page 1: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/1.jpg)
Morphine Myths:Important Tools for
End of Life Katheryn J. Lauer, MD/MPH
Virginia Mason Yakima Memorial Compass Care
Hospice & Palliative Medicine
![Page 2: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/2.jpg)
Objectives
• Understanding the cultural context of opiates • Demystifying the use of opiates in end-of-life care• Understanding opiate use for ancillary effects• Treatment of undesired effects of opiates
![Page 3: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/3.jpg)
A Brief History of Opiates• Derivative of the opium
poppy (Papaver somniferum)
● First documented medical use of opium on Sumerian clay tablets (3400 BCE)
![Page 4: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/4.jpg)
A Brief History of Opiates• Opium began being widely
traded in the 1800s for recreational use
● Morphine was first created in 1803 as an extract from opium resin
![Page 5: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/5.jpg)
A Brief History of Opiates
• Heroin first distilled from morphine in 1874
● Abuse potential of heroin recognized in 1924 and made a controlled substance
![Page 6: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/6.jpg)
Regulation of Opiates
● DEA Drug Schedules○ five categories○ based on acceptable medical
use○ takes into account
abuse/dependency potential
![Page 7: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/7.jpg)
Regulation of Opiates
● Schedule I- no currently accepted medical use and high abuse potential (heroin)
![Page 8: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/8.jpg)
Regulation of Opiates
● Schedule I- no currently accepted medical use and high abuse potential (heroin)
● Schedule II- high potential for abuse or dependency, but accepted medical use (most opiates)
![Page 9: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/9.jpg)
Regulation of Opiates
● Schedule I- no currently accepted medical use and high abuse potential (heroin)
● Schedule II- high potential for abuse or dependency, but accepted medical use (most opiates)
● Schedule III-V- lower abuse potential, accepted medical use (low dose formulations of opiates)
![Page 10: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/10.jpg)
A Brief History of Opiates
● Ongoing development of opium derivatives○ morphine/MS Contin○ oxycodone/Oxycontin○ Fentanyl (Duragesic)○ Hydromorphone (Dilaudid)○ Methadone
![Page 11: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/11.jpg)
A Brief History of Opiates
● Ongoing development of opium derivatives○ Codeine/hydrocodone
(Vicodin/Norco)○ Meperidine (Demerol)○ Tramadol (Ultram)
![Page 12: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/12.jpg)
The Opioid Crisis (20th Century)
● In first half of 20th century, pain was considered an existential problem
● Complaints of pain were considered hysterical complaints
● Abuse of heroin led to regulation and increased fear of use of opiates
![Page 13: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/13.jpg)
The Opioid Crisis (1980s)
● Until 1980s, official recommendation was for cancer patients to avoid or wean opiates until their “life could be measured in weeks”
● Studies into the 1990s suggest a fear and avoidance of opiates for any reason by physicians, due to abuse potential
![Page 14: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/14.jpg)
The Opioid Crisis (1980s)
● WHO in 1986 reported under-treatment of post-operative and cancer pain
● Suggested opiates as a valid and effective means to treat
![Page 15: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/15.jpg)
The Opioid Crisis (1990s)
● Studies reported that use of opiates for pain is “unlikely to result in addiction”
● Encouraged use of opiates for acute pain (injuries/illnesses)
![Page 16: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/16.jpg)
The Opioid Crisis (1990s)
● Studies reported that use of opiates for pain is “unlikely to result in addiction”
● Encouraged use of opiates for acute pain (injuries/illnesses)
...And chronic pain
![Page 17: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/17.jpg)
The Opioid Crisis (1990s)
● In 1995, the American Pain Society introduced pain as “the fifth vital sign” with help from….○ The Joint Commission○ Veterans Administration○ Pharmaceutical companies
● Not treating any reported pain was labeled as “inhumane”
![Page 18: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/18.jpg)
The Opioid Crisis (2000s)
● Massive increase in prescriptions for opiates for all indications
● Increase in abuse, dependence, addiction and deaths from overdose
● Management of chronic pain did not improve● Labeled a public health emergency by the CDC in 2017
![Page 19: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/19.jpg)
![Page 20: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/20.jpg)
Risk of Opiate Overdose
● Greatly increased if medications are combined○ Vast majority of fatal overdoses from opiates also had
benzodiazepines and alcohol in their system ● Increased if taking a prescription medication that belongs to
someone else● History of substance abuse● History of depression
![Page 21: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/21.jpg)
Response to Opioid Crisis
● Monitoring prescriptions via Prescription Drug Monitoring Databases
● Teaching physicians alternative methods of treating acute and chronic pain in the community
● Educating community on risks of opioid medication treatment ● Developing interdisciplinary models for chronic pain programs
![Page 22: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/22.jpg)
![Page 23: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/23.jpg)
Response to Opioid Crisis
● NOT avoiding opiates at all costs ● NOT limiting access to appropriate use of opiates in cancer-
related pain or end of life symptom management ● NOT punishing patients or physicians
![Page 24: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/24.jpg)
Opiates in End of Life Care
● Not anticipating long term, chronic use● Not anticipating that pain will resolve or stabilize● Minimal concern for addiction
![Page 25: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/25.jpg)
Opiates in End of Life Care
● Not anticipating long term, chronic use● Not anticipating that pain will resolve or stabilize● Minimal concern for addiction
What is addiction?
![Page 26: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/26.jpg)
![Page 27: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/27.jpg)
Tolerance
An adaptive state that develops from repeated drug administration, which results in increasing doses of medicine being needed to give the same result
![Page 28: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/28.jpg)
Dependence
An adaptive state that develops from repeated drug administration, and which results in withdrawal upon cessation of drug use
![Page 29: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/29.jpg)
Abuse
A pattern of repeated drug or alcohol use that often interferes with health, work, or social relationships
![Page 30: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/30.jpg)
Addiction
A chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain
![Page 31: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/31.jpg)
Addiction
A chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain
![Page 32: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/32.jpg)
Addiction
A chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain
![Page 33: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/33.jpg)
Addiction
A chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain
![Page 34: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/34.jpg)
Opiates in End of Life Care
● Treatment of pain● Use of opiates for ancillary effects ● Variety of effective delivery methods
![Page 35: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/35.jpg)
Opiates in End of Life Care
● Few adverse effects, compared to alternatives○ NSAIDs (ibuprofen, naproxen, aspirin)- limited use in heart
disease, gastrointestinal disease and renal failure○ Steroids (prednisone, dexamethasone)- limited use in
gastrointestinal disease, many potential adverse effects○ Acetaminophen (Tylenol)- limited use in liver disease ○ Adjunct medications (gabapentin, depakote)- many
potential adverse effects
![Page 36: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/36.jpg)
Opiate Formulations
● Oral ● Buccal (through cheek/tongue)● Rectal ● Transdermal (patches)● IV● Intramuscular (ouch!)● Subcutaneous (under the skin)● Intrathecal (into the space around the spinal cord)● Inhaled● Topical and into wound bed
![Page 37: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/37.jpg)
Opiate Formulations
● Long acting○ Oxycontin○ MS Contin○ Fentanyl patches○ Methadone
● Short acting○ Oxycodone ○ Morphine○ Hydromorphone○ Fentanyl (oral/IV)
![Page 38: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/38.jpg)
Opiate Formulations
● Long acting○ Oxycontin○ MS Contin○ Fentanyl patches○ Methadone
● Short acting○ Oxycodone ○ Morphine○ Hydromorphone○ Fentanyl (oral/IV)
● Continuous (IV/subcutaneous )○ Morphine○ Hydromorphone○ Fentanyl○ Methadone
![Page 39: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/39.jpg)
Long acting Opiates
● Constant pain● Frequent use of short acting opiates● Pain that is worse upon waking● Pain that is unlikely to decrease suddenly
![Page 40: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/40.jpg)
Short acting Opiates
● Breakthrough pain (with use of a long acting)● Occasional pain● Pain that is changing/decreasing (injuries, fractures)
![Page 41: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/41.jpg)
Ancillary Effects of Opiates● Decreased respiratory drive● Constipation● Urinary retention● Confusion/euphoria
● Opiate toxicity
![Page 42: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/42.jpg)
Decreased Respiratory Drive
● Effect varies from person to person● Effect varies from drug to drug ● Tolerance can develop● Dose dependent
![Page 43: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/43.jpg)
Decreased Respiratory DriveBenefits
● Very effective in treating shortness of breath (not hypoxia)● Any opiate works (especially short acting)● More effective than lorazepam at treating air hunger● Studies mixed at best showing that inhaling opiates better at
treating shortness of breath than oral
![Page 44: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/44.jpg)
Decreased Respiratory Drive Treatment● Naloxone (Narcan) can be used to reverse this (CAUTION!)● Holding medication also effective● Pushing fluids, if possible/desired● Education of patient, family, staff
![Page 45: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/45.jpg)
Constipation
● 100% of patients on opiates develop this● 100% of opiates cause this ● No tolerance develops● Not dose dependent ● Slows transit (no “push”)
![Page 46: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/46.jpg)
ConstipationBenefits● Can be useful in cases where disease causes fast transit
○ some cancers○ short gut syndrome○ NOT C. difficile
![Page 47: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/47.jpg)
ConstipationTreatment● Does not respond to fiber, diet, increased water● Does not respond to stool softeners (docusate/Colace)● Must use an agent that gives some “push”
○ senna○ bisacodyl○ polyethylene glycol ○ Magnesium
● Can also use methylnaltrexone (Relistor)
![Page 48: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/48.jpg)
Urinary Retention
● Effect varies from person to person● Effect varies from drug to drug ● Tolerance can develop● Dose dependent ● More common in older patients ● More likely when also using benzodiazepines, anti-psychotics,
antidepressants or some hypertension medications
![Page 49: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/49.jpg)
Urinary RetentionBenefits
● Opiates classically used to treat bladder spasms (B&O suppositories)○ Indwelling catheter use○ Bleeding in the urinary tract○ Cancer of the urinary tract
![Page 50: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/50.jpg)
Urinary Retention Treatment
● Indwelling catheter ● Minimize other medications that may cause retention● Ensure constipation is treated ● Decrease opiate dose● Rotate to another opiate
![Page 51: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/51.jpg)
Confusion/Euphoria
● Psychomotor depression (“downer”)● Street value of opiates● Abuse and diversion● Chemical coping
![Page 52: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/52.jpg)
Confusion/Euphoria
● Varies based on route ○ snorting○ injecting quickly
● Tolerance develops● Dose dependent ● Varies based on drug
○ Heroin, hydrocodone more euphoric○ Fentanyl, hydromorphone euphoric when injected○ Methadone, morphine, oxycodone less euphoric
![Page 53: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/53.jpg)
Confusion/Euphoria Treatment
● Likely to abate over time (tolerance)● Encourage fluids● Rotate to another opiate● Minimize other medications that may cause confusion
![Page 54: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/54.jpg)
Opiate Toxicity
● Doses escalated quickly● Started at too high dose● Progressive renal failure
○ very common at end of life ○ may have to decrease dose to make up for kidneys not
clearing
![Page 55: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/55.jpg)
Opiate Toxicity Symptoms ● Escalating pain● Hyperalgesia (pain all over)● Confusion● Twitching
![Page 56: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/56.jpg)
Opiate Toxicity Treatment ● Decrease dose● Switch to another opiate● Fluids● Lorazepam (for twitching)
![Page 57: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/57.jpg)
![Page 58: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/58.jpg)
History
![Page 59: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/59.jpg)
Current Context
![Page 60: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/60.jpg)
Opiates at End of Life
![Page 61: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/61.jpg)
Appropriate Use of Opiates
![Page 62: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/62.jpg)
Ancillary Effects of Opiates
![Page 63: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/63.jpg)
Questions?
![Page 64: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/64.jpg)
References
• Norn S, Kruse PR, Kruse E.[History of opium poppy and morphine]. an Medicinhist Arbog. 2005;33:171-84.
• https://www.deamuseum.org/ccp/opium/history.html• Jones MR, Viswanath O, Peck J. A Brief History of the Opioid
Epidemic and Strategies for Pain Medicine. Pain Ther. 2018 Jun; 7(1): 13–21.
• WHO . Cancer pain relief. Geneva: WHO; 1986.• https://www.who.int/substance_abuse/information-sheet/en/
![Page 65: Morphine Myths: Important Tools for End of Life€¦ · Morphine Myths: Important Tools for End of Life Katheryn J. Lauer, MD/MPH Virginia Mason Yakima Memorial Compass Care Hospice](https://reader033.vdocument.in/reader033/viewer/2022053006/5f0a54947e708231d42b1ffb/html5/thumbnails/65.jpg)
References
• https://www.cdc.gov/opioids/strategy.html• Verhamme KM, Sturkenboom MC. Drug-induced urinary
retention: incidence, management and prevention. Drug Safety, 2008; 31 (5): 373-88.
• D Doyle. Oxford textbook of Palliative Medicine, Third Edition. Oxford University Press, 2005