1. Advocating a Narcotic, Morphine Muhammad Faisal Nadeem

2. Palliative Care ''To cure when possible, to give comfort always''

3. WHO Guidelines: Cancer Pain WHO

4. A Little bit Pharmacology Color Atlas of Pharmacology

5. Systemic Effects

6. Low Consumption United States 45.02 Saudi Arabia 0.5323 India 0.076 9 Pakistan 0.0551

7. Still Growth

8. WHY??????????? Saying that medical community and patients are not inclined to use morphine too much will be misrepresentation of the situation. In reality, both parties dread even by the idea of using morphine. And that is due to some preconceived notions spread by the campaigns about narcotics and exaggerated portrayal of side effects associated with their use.

9. Myths about Use of Morphine

10. Morphine is illegal Facts: Therapeutic morphine is Schedule G drug according to Punjab drug rules 2007 and can be stocked and issued from a pharmacy. Previously, it was Schedule B and controlled drug, only meant for hospitals. Record maintenance by pharmacist and retrieval of empties is mandatory.

11. Manufacturing license can be obtained from federal govt. under form 9. Hospitals interested in palliative care can apply to DG Health Services and a quota of Morphine can be allotted to the hospitals from govt. Medical Store Depot. Or an MS authorized pharmacist can obtain Morphine from manufacturer directly. Empty vials are returned to MSD for next supply. Record maintenance is extremely important. Punjab Drug Rules 2007

12. Oral Morphine is inferior Fact: Although prone to first pass metabolism of liver, morphine is safe, reliable and effective when administered through oral route. Oral route is practical, provides complete relief and is recommended route of administration. Injectable doses can be multiplied by 3 to be given by oral route. Morphine solution can be prepared easily at local pharmacy, or even at home. Should be stored in dark bottle, may be without preservative.

13. Bitter taste might not be as big of a problem. Moreover, patients can mask taste with their own drinks. Adjuvants like prochlorperazine, may be mixed with oral morphine solution. Injectable morphine can also be used orally. Practical Palliative Care, A clinical guide by Pamela M. Sutton

14. Brand and dosage forms Brands Oramorph®; Sevredol®; Filnarine®; Morphgesic®; Zomorph® 10mg/5ml Available as Tablets, slow-release tablet, capsules, oral liquid medicine, sachets and injection

15. Respiratory Depression Fact: Over dosage of morphine causes respiratory depression. At therapeutic doses of morphine, there is no respiratory depression. Due to some unknown reasons, patients with pain do not experience respiratory depression due to morphine even at higher doses when compared to their pain-free counterparts. It seems that pain acts as physiological antidote to respiratory depression. Welshman AWelshman A. 2005 Jul-Aug;71(7-8):439-43.Palliative care. Some organisational considerations.

16. Tachyphylaxis Fact: Contrary to normal beliefs, tachyphylaxis has not been reported in treatment with morphine. Tolerance may develop over time and dose need to be titrated. Increase in dose is more closely associated with increase in pain rather than wearing off effect of morphine. Int J Palliat Nurs.Int J Palliat Nurs. 2000 Apr;6(4):162-9.Issues in effective pain control. 2: From assessment to management.

17. Last Choice Fact: Morphine should be given right from the start when patient has moderate to severe pain. Dose should be increased as the condition worsen. There is no upper limit for the use. Welshman AWelshman A. 2005 Jul-Aug;71(7-8):439-43.Palliative care. Some organisational considerations

18. Addiction Fact: Physical dependence is common. Psychological dependence is observed in less than 11% of patients which require palliative care. Dr Robert Twycross MA DM FRCP, Macmillan Clinical Reader in Palliative Medicine, University of Oxford

19. Drowsiness and Confusion Fact: Although sleepiness and mental clouding are common side effects of morphine but might not be as pronounced as perceived. More important is the fact that these effects are transient and with continuous use disappear. Int J Palliat Nurs.Int J Palliat Nurs. 2000 Apr;6(4):162-9.Issues in effective pain control. 2: From assessment to management

20. Constipation Facts: Constipation may prove itself a limiting factor so it might be managed with aggressive treatment with stool softeners, laxatives, suppositories and enemas. The hand that writes the morphine must also write the laxative. Ignore this at your peril! Practical Palliative Care, A clinical guide by Pamela M. Sutton

21. Use when needed Fact: To manage chronic pains, morphine should be used every 4 hourly. In severe pains, a midnight dose may be necessary. So Morphine should be used around the clock. In painful conditions, analgesia with morphine may be achieved after 3-4 hours so continuous administration may ensure pain free days. Welshman AWelshman A. 2005 Jul-Aug;71(7-8):439-43.Palliative care. Some organisational considerations

22. Giving up HOPE Fact: Morphine use today does not equate with physician’s inability to treat the condition. On the other hands, patients on morphine have better nutrition and rest and experience better mental state comparatively. Welshman AWelshman A. 2005 Jul-Aug;71(7-8):439-43.Palliative care. Some organisational considerations

23. Living Death Fact: When used properly, Morphine increases patient’s mental health, physical independence and is related with higher level of self confidence and dignity. It provides better self care due to tolerable levels of pain. Mayo Clin Proc.Mayo Clin Proc. 1994 Apr;69(4):384-90.Use of orally administered opioids for cancer-related pain.Hammack JE, Loprinzi CL.Hammack JELoprinzi CL

24. Used alone Fact: Due to complex medical status of cancer patients, there may be need of polypharmacy and morphine is compatible with most of drugs. Mayo Clin Proc.Mayo Clin Proc. 1994 Apr;69(4):384-90.Use of orally administered opioids for cancer-related pain.Hammack JE, Loprinzi CL.Hammack JELoprinzi CL

25. What can YOU do? Clarify the negative notions about adverse effects of morphine Persuade official authorities to amend the laws ensuring better supply and access to opioids. Educate health care professionals and patients about benefits of morphine to decrease the social stigmatization of morphine.

26. Thank You!