Morphine Query

[LeaningOnTheEverlastingArms]

My mum (88) has been prescribed 1 mg morphine x 6 doses in 24 hours for secondary metastatic cancer in her pelvis, spine, sacrum & skull.

She refuses to take it unless she is in a lot of pain, when it is often ineffective.

Am I wrong in thinking she should take it every four hours to build up her tolerance so she can have a stronger dose?

She is concerned she is going to become addicted to it.

That's a very small amount each time, why was it prescribed like that. A lot of people fear getting addicted, the pain control is the priority though. Is she on any other painkillers.

To answer a few of your questions .
Morphine is addictive but this is of no concern in patients who will never need to wean off the drug .
You do not need to take it to " build up " tolerance . The problem with many drugs such as Morphine is that , over time , you do develop a tolerance and a higher dose is needed to achieve the same therapeutic effect .
The dose you quoted seems very small( if it is an oral dose ) . Are you quoting the strength of the medication , eg 1mg/ ml , if so please check the dose/ number of mls your mum should be take otherwise she will get no benefit from the drug .

She’s got a lidocaine patch during the day. Volterol gel and paracetamol. That’s it.
I think it’s a tiny dose.

Palliative care nurse said she can’t progress to 2 x 5mg tablets per day until she takes the 6x 1mg dose. Nobody will tell her she’s not going to get better and other family members are adamant she mustn’t be told the truth. Hence her worry about addiction.

This is what’s on her notes.

Is it an injection or oral liquid. Who prescribed it.,the 2 x 5mg tablets are not equal to 6mg. Does she want to know her prognosis, I'm surprised she doesn't know. There are buttons patches and oramorph which might help.

it’s an oral liquid. Prescribed by doctor in general medical ward in hospital. She has since moved to a nursing home while a care package is arranged for her to go home (she lives alone).

Occasionally she takes it during the night but often is seeking further pain relief within two hours.

she is confused and has told various relatives

1. they don’t know what’s wrong
2. they think it might be cancer
3. it is cancer

This dose is very small. Doses as small as this are sometimes initially , correctly , prescribed to check side effects eg drowsiness/ confusion etc and also if there is renal impairment, but in my experience it usually needs to increase steadily but significantly until the patient is getting the required effect without delibitating side effects . If your mum isn't getting pain relief when taking the dose discuss it immediately with her prescriber/ GP .

Oral morphine has a short duration of action and can lead to peaks and troughs of pain and relief. If your mum is needing it consistently then she may be better on a longer acting preparation/ or a patch.

Thanks for your advice.
I’m going to phone the palliative care team on Monday and also her new GP (she’s had to be registered with a new GP as the nursing home is in a different area than her home).

Once the pain builds up too much, it is much harder for the meds to get on top of it. Ideally she should be taking the morphine as soon as the pain starts, if not, by the clock is also fine.
I agree. That is a tiny dose, maybe needs reviewing by the GP. A long acting slow release morphine would be ideal, with the liquid used for breakthrough pain.
She will not get addicted. Tell her that it is being used up on the pain and is being used in correct way so none left over for dependence.
If she wants to.know about her health nobody should be hiding it from her.
I hope.her pain is well managed very soon and I hope you are OK OP.

Thank you for this. I appreciate the advice and support very much x

Sounds like she is on 5mg BD for background pain. Then the oramorph is to take for breakthrough pain. Once she is taking a lot of this the background pain dose will be increased.

The breakthrough dose should be approx 1/6 th of the maintenance dose so once that goes up the breakthrough dose will increase.

That prescription is to take when required, it's not even a regular dose so the staff may not be giving it to her unless she asks for it or they ask if she is in pain and if it's only lasting 2 hours then it's not effective. Plus I doubt see is being woken up during the night to take it. How long has she been taking it for. Like pp suggest she might be more comfortable on a patch or slow acting capsules or tablets with liquid on top if it's needed, the nurses or palliative team needs to monitor how much pain she is in before and after each dose so they can get the doses right.

Is she prescribed the 2 x 5mg tablets? Have you got a copy of her whole prescription

I'm not medically qualified but I've nursed a family member through cancer. In our case everyone agreed that the palliative care team were the absolute experts in pain control and they were also very experienced in explaining to the patient what they needed to take and why. I would make sure the palliative care team has all your comments, observations and concerns. They will make recommendations to the GP who will probably prescribe accordingly.
If there's any way you can speak to the palliative team before Monday I'd try to do that, because Monday seems like quite a long way off.

I couldn't see the screenshot showing the BD/ regular dose but agree that if pain isn't being controlled doses need adjusting .
Another poster mentioned morphine isn't addictive at the correct doses . Unfortunately this is not correct and if given regularly , over time , will be addictive at all doses. However , OP you should reassure your mum that it is being monitored, is safe , and is necessary.

All pain and relaxant medicines are potentially addictive but that should never be a barrier to them being prescribed for symptom control

I have her whole prescription and there’s no 2x 5mg tablets
@MissMoneyFairy yes, it is only given if she asks for it, and she is very reluctant to do so, even when in pain.
@MontyDonsBlueScarf I will try to get the palliative care team tomorrow.

Thanks everyone for your contributions. Really helpful xx

Yes speak to them but it may need a doctor to prescribe it, the nurse may also if she's a nurse prescriber. I'm not sure where she got the 2 x 5mg dose from then if it's never been prescribed. Good luck getting it sorted.

I work in palliative care. This is a very small dose. If she's often in pain she needs a medication review from a doctor, get in touch with out of hours, someone with what sounds like advanced disease and symptoms shouldn't be waiting over the weekend till Monday morning. And if she has pain she needs to tell the staff so they can try giving her medication and see if / how well it works.

Morphine is addictive and you can develop tolerance but in this context you don't need to worry about that, doses can be increased as needed and there isn't a set maximum. If she's getting side effects with the morphine then there are alternatives that can be used instead (also if her kidney function isn't great etc).

Hoping her symptoms improve soon - with good palliative care input she shouldn't need to be struggling significantly with pain.

https://www.macmillan.org.uk/cancer-information-and-support/impacts-of-cancer/pain/painkillers-frequently-asked-questions

This is a good link for more info x

Thank you, @Violetmouse xx