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Am Fam Physician. 2000;61(3):836-838

Pain is one of the most feared symptoms for patients who are facing end-of-life issues. Management of this pain often requires high doses of morphine. Unfortunately, physicians are reluctant to prescribe these high doses because of concerns about side effects and causing premature deaths. Bercovitch and associates studied the characteristics of patients requiring high-dose morphine for pain control, the incidence of side effects and the impact on survival for patients at the end of life.

For two years, the charts of all patients admitted to a hospice program were reviewed. All patients and their families were interviewed on admission, and a drug history and complete pain assessment were obtained. Data collected included demographics, site of tumor and metastatic spread, characteristics of pain in association with morphine dose, need for breakthrough pain medications, adjuvant pain therapies and survival time. High-dose morphine was defined as the need for 300 mg or more of morphine per day. This group was divided further into patients receiving 300 to 599 mg per day and those receiving more than 599 mg per day. The morphine dosage was established by the medical director and titrated according to routine pain management parameters.

There were 453 patients who required around-the-clock morphine for pain control. Fifty-five of these patients required dosages that placed them in the range of the high-dose morphine group. The types of tumors that were more likely to require high-dose morphine were breast, gastrointestinal, genitourinary and head and neck tumors. There were no withdrawals of pain medications secondary to side effects in the high-dose group. The most common side effects recorded were constipation and nausea/vomiting. None of the patients receiving the high dose was ever observed by a health care provider to have respiratory depression related to the high-dose morphine. In addition, there were no differences in survival times when high-dose morphine groups were compared with the standard-dose group.

The authors conclude that high-dose morphine is sometimes necessary in the management of patients with advanced cancer pain and is appropriate in hospice patients who do not respond to standard therapy. These high doses of morphine can be used without concern for significant side effects, including respiratory depression. In addition, these high doses can be used when indicated without the fear of hastening the deaths of patients who are at the end of their lives.

editor's note: Despite recent advances in pain control in patients at the end of life, physicians and the public have significant fears and concerns about using pain control medications. This study demonstrates that, despite taking high doses of morphine, patients did not have problems with respiratory depression. The high dosages did not hasten the deaths of the patients being treated. To control pain, aggressive management includes providing the appropriate dosage of medication that can relieve this symptom. Physicians also need to educate patients and family members because of their concerns about morphine use in terminal patients.—k.e.m.

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