Ep 13 - Myths around Morphine and other Meds

There are plenty of myths around about Hospice and use of Morphine – but this episode explodes those myths, and details how meds work at the end of life.
An interview with Dr Chris Hopkins, a palliative care doctor at Otago Community Hospice. 

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Transcript

 Ep 13: Myths around Morphine and other Meds

Kia Ora and welcome to The Ending Life Well Podcast. This podcast series for carers focuses on advice and practical solutions for carers who have been thrown into the deep end looking after a  loved family member or friend in their last days, weeks or months of life. 

Our episode today is Myths around Morphine and Other Meds

Denise
Hi, I'm Denise van Aalst, a palliative care nurse, at Otago Community Hospice. Today I'm going to be talking with Dr Chris Hopkins, a doctor at the Hospice who has been working in palliative care for some time. We're going to be talking about medications, the different medications, the way medications are used in palliative care, and some of the concerns that people have. Hi Chris.  

Dr Chris
Hi, Denise. Thanks for having me. 

Denise
Chris, often people have got real concerns about medications at the end of life. The new medications, maybe they’re ones that they've never had to deal with before, or maybe they're being used a bit differently, so it'd be good to talk about some of those concerns that you've probably met.

Dr Chris
I can think of a couple of things straight away. One thing is that a lot of people have preconceptions about morphine in particular. I guess people are often worried about addiction with morphine – and another problem is that people worry that taking morphine might have bad effects down the line, it might shorten your life, or it might mean that you run out of options for pain relief further on, and I'm happy to say that none of these have ever proven to be concerns for any of my patients in palliative care. 

So I can't think of a single instance where I've been worried that someone's become addicted to morphine that they're taking for pain. And I think, in terms of the question of whether it shortens your life, I think it's the opposite, really. I think morphine definitely doesn't shorten your life, if you're facing a terminal illness with pain, but the pain can, if not shorten your life, then at least reduce the amount of things you're able to do in your life. So morphine is not bad for you, but pain is bad for you, is really the conclusion that I've come to from my experience.

Denise
I think that's a good point, Chris, that that morphine’s not bad, but pain is bad. We don’t need to be trying to live with pain unnecessarily when we have options out there. Can we just go back to the addiction, Chris? Why do people not become addicted to morphine when they're using it at the end of life?

 Dr Chris
Addiction is a complicated term. I mean, there's the medical and physiological aspects of addiction. There's a concept called tolerance which means that you find you need higher doses to get the same effect, and that can happen over months or years, and so that's something that we're aware of, and we've got ways of managing. There's another concept called physiological dependence, which means that if you stop taking the medicine, then you can get a withdrawal effect. And that is a thing that we can see in patients that we're taking care of that we're using morphine for pain. 

Denise
The other concern that people sometimes have is if they take the morphine too soon, there'll be nothing left for later. Now we both know that's not true. 

Dr Chris
I can certainly say from my experience, that's not a phenomenon that I've ever seen. As I say, tolerance is a thing, so if you're taking the same dose of morphine for a long time, it's possible to find that you need a slightly higher dose – and there's always scope to increase the dose of morphine.

Denise
And of course, as the disease progresses it could cause increasing levels of pain that would then need increasing levels of morphine, wouldn’t it?

Dr Chris
More commonly, if we’re increasing the doses of morphine, it's because we're covering a higher level of pain with that morphine. We can increase the doses of morphine up and up and up. At some point, you start to see side effects, and so once we start to see side effects that are causing problems, then we think about other options, whether that's medicine from a whole different family, which will help the morphine work better, that will let us use a lower dose of morphine and get less side effects, or switching from morphine to another medicine in the similar family to a cousin of morphine. And so there are a number of other opiate medicines that we can use to manage pain, which we find at higher doses have fewer side effects.

Denise
So what are some of the alternative medications, Chris?

Dr Chris
Well, the two most common ones off the top of my head, are oxycodone, and fentanyl. Oxycodone is a lot like morphine; it comes in a fast acting formulation that you can take by mouth and in long acting tablets that you can take by mouth. So we can use that as the long acting and the top up medicine. 

Fentanyl is a little bit more tricky, because you can't take it by mouth, but there's a very clever way of giving it which is using a patch on the skin. It's very good because it provides a very constant and stable amount of pain relief over 72 hours, and then you swap the patch and it continues to give you a stable pain relief. And it has the benefit that you don't have to take it by mouth, so if someone's got difficulty taking medicine for whatever reason, maybe vomiting is a problem or the whole tummy area is affected, then we can bypass the oral route altogether and we can use these patches as a way of maintaining a very stable and sometimes very powerful amount of pain relief.

Denise
So when somebody is on a patch Chris, what happens if they need something extra top up that we might give? We've got the fast acting and the slow acting morphine and the oxycodone is the same. So what are the options then if somebody's on a fentanyl patch – how do they get an extra top up?

 Dr Chris
I think this whole concept of having a baseline pain relief and top up pain relief is an important thing just to touch base on. So the way we would usually start that would be by using a fast acting pain relief, so we'd use fast acting morphine, usually liquid and just small doses and we'd see how somebody finds that. And after a few days, we'll have a look at how much morphine is the right dose for that person to control their pain and then we'll look at starting long acting morphine pills, which you can take morning and night, and that gives you a stable amount of morphine in your system day and night to control the pain that you're having. And we would make sure that our patient still has some fast acting morphine in the house, so that sometimes people get pain when they get up and walk around, and so for certain activities, or sometimes you just get breakthrough pain, then you've got some fast acting morphine that you can use as a top up when you need it. 

So when we're using morphine as our long acting pain relief, we'll use morphine for the fast acting. The same goes for oxycodone – if we're using long acting oxycodone tablets morning and night, then our top up pain relief will be oxycodone. But we have to be a little bit more creative with our top up pain relief for fentanyl. So one thing that we can do is we can quite easily use morphine or oxycodone, use the fast acting formulations of those as a top up pain relief, so you might have the patch on constantly for three days at a time giving you your baseline pain relief, and then you take a dose of fast acting oxycodone or morphine, and that will cover your pain if you get more pain when you have a shower. 

If the reason we're using a patch is because the oral route of medicines is not working, then I can think of two options that we would commonly use. There are certain ways you can spray it in the nose or under the tongue and a reasonable dose of the fentanyl can get into your system that way, so that's an option. And that has the benefit of kicking in very quickly, because instead of having to go through your tummy and through the whole bloodstream and get to the brain where it works, it absorbs immediately into the bloodstream from the nose or under the tongue and works very quickly, so that can be helpful. 

Denise
So that's really effective without a long-term effect.

Dr Chris
Yeah, it wears off reasonably quickly, about half an hour as well. And then if we're not able to swallow medicines, then another way we often give medicines is by putting a line under the skin that we can give medicine subcutaneously. So that line looks a lot like an IV line but much smaller. It's like trying to give intravenous medicines but the subcutaneous line is much easier.

Denise
Yeah, the subcut lines are much more tolerated, they're much less uncomfortable, and they last longer. An IV line in hospital that typically only lasts a day, maybe two days, whereas these subcut lines can be in place for a week or even more at times, can’t they, and they’re really well tolerated by people.

Dr Chris
Yeah, they're very good. I mean they're not too technical, we can often train family members how to give the subcutaneous medicines and it's really good. It gives you a lot of power to manage at home, no matter how unwell or how tired somebody gets. If you're able to get a subcut line in, and you're able to train someone how to give medicines through it, then anytime, day or night, any problem, even if it is vomiting. Giving pills for vomiting isn't always the most functional thing to do. But if you've got a subcut line in place, it's great. You can give anti-nausea medicine through that line and you don't have to worry about vomiting.

 Denise
We've touched before on some of the side effects. So nausea may be a side effect of medication, but it may also simply be a symptom of somebody's disease process. There's a lot of different medications available for treating nausea, treating that vomiting. Why are there so many different medications and why do we sometimes use more than one or two?

Dr Chris
The way I look at it is that there are different nausea medicines because there are different parts of the system that cause nausea and vomiting, and each nausea medicine has its own superpower. One that we usually start with is one called metoclopramide and the superpower of metoclopramide is that it gives your stomach a bit of a hurry up. And so one of the patterns of nausea and vomiting we see is that things can linger for a longer time in the stomach and that could be because the stomach is not working very well. If we can use a nausea medicine that gives the stomach a hurry up and helps to clear that food, then that can be especially helpful, and so metoclopramide is a really useful medicine. 

Denise
Cyclizine is another common one, isn’t it?

Dr Chris
Cyclizine is another quite different anti-nausea medicine. The secret superpower of cyclizine is that it's particularly good for motion sickness, which of course is unrelated to the stomach all together, but somehow they connect in the brain, in the vomiting centre, and can cause you to vomit. And so cyclizine is a very different anti-nausea medicine that we also use quite commonly, and that's particularly helpful for people with motion sickness, but works for nausea in general, as well. 

A third anti-emetic that we see quite frequently, because it's very good for nausea caused by chemotherapy or radiotherapy is ondansetron, and that can be a very effective. It's one that we try to avoid in palliative care for the single reason that it can cause quite troublesome constipation. Of course, if the patient is troubled by diarrhoea, then ondansetron could be the ideal medicine. 

And that gives you a bit of insight into how we use medicines – we try and find clever tricks and ways that medicine can help in more ways than one. 

Denise
I'm aware that with some medications, we're almost using them for their side effects rather than the original cause that medications were used for, and I was thinking, haloperidol, we might use for nausea, but it's not its prime purpose as a medication.

Dr Chris
Haloperidol is probably our third go-to medicine for nausea. It's excellent. It hits a lot of different targets in the brain related to nausea, but it was invented as a medicine for mental health problems. So, in that case, we can also use it if someone has a delirium and starts seeing things that are causing them problems. Then, again, we've got a medicine that's good for nausea and good for hallucinations. But we very commonly use it for nausea, because it works and because it's safe. 

Another example of that same kind of concept is a medicine that we sometimes use for pain, for example, nortriptyline – so that it was invented as an antidepressant. And if you think that through, it makes sense, it works on nerve cells, it works on brain cells, and so we use it because it works for pain, and we're using it at quite a different dose from the dose you would use for depression. But we use it because it works, and sometimes it has helpful side effects like it helps you sleep and things like that.  

 Denise
Chris, you mentioned before about the bowels, and constipation is often an issue for people in palliative care, and that can be related to people not moving around as much, as well as their whole system just slowing down. What are your thoughts around treating constipation?

Dr Chris
Yes, constipation is extremely common, I think it would be unusual for me to have a patient who's not had some problems with constipation, which probably isn't the first thing that you think about when you have got a bad diagnosis and somebody talks about referring to palliative care. But in my line of work, I know that it can make people very uncomfortable and it's something that I try to always remember to ask about. 

As you say, there are many underlying causes of the constipation that we see. The medicines are a part of it and we'll commonly see people really notice when they start a certain medicine that their bowels will slow down a lot. Mobility, walking around less, is part of it; the amount that you're eating, and you might be eating less roughage, less bran and fibre, and some other medicines as well as opioids as well. So there are a lot of different things that come together to make constipation a common problem in the patients that we're taking care of.

Denise
And people aren't really aware how unwell simply being constipated can make someone feel, so we really do need to get on top of it.

Dr Chris
What we usually start with is there's a particular tablet called laxsol that has two ingredients. One of them is to make poos softer, and the other one is to give the actual bowel a bit of a hurry up at the lower end, and encourage your bowels to poo. There's another medicine that we can give by mouth for constipation, which comes in a sachet, and so you mix that sachet up with at least 125 mils of water – or you can find a tasty cocktail – I'm sure it doesn't have to be water.

Denise
And that’s a really good point Chris. You know sometimes medicines don't have to be taken just as a medicine. Actually, if it's a liquid form, it's how can we make it palatable so that they can actually get it in more easily and putting it in a smoothie, serving it up mixed with some ice cream, it still gets the medicine in. So it's always worth considering those options.

Dr Chris
An important thing to know about these laxatives is that they don't work immediately. So the laxsol tablets, for example, when we're starting those, we're usually prescribing them at bedtime. They take at least overnight to work. The sachets take two or three days to work. And so when you're finding your way around laxatives, it's important to know that they do take a while to work – and unfortunately, if you find them having a really powerful effect, they take a couple of days to stop working. 

Denise
So it is good to actually keep a record of how their bowels are going. Yeah, are they hard, are they soft, how often are they going? You know, even just being keeping that in a notebook at home can really help to build a pattern, which makes it much easier to get that balance, right, rather than swinging from extreme to extreme.

Dr Chris
Certainly keeping a diary can be really helpful. I'm sure there is an app for that. I know there is a scale, I would encourage our listeners to look up the Bristol stool chart, and you can see poos from type one to type seven, and that can be a very simple way of keeping a note in your diary.

Denise
Absolutely. It's not everyone's cup of tea, but it's a very useful guide.

Dr Chris
Oh, yeah, it's very standardised. There's a reason why we use it because it works. If we're still having problems battling constipation, despite using good doses of laxsol tablets and laxative sachets for the right number of days, then we sometimes find that it's more appropriate to literally attack the problem from the rear end. And then we would be thinking about suppositories usually as the first thing to do. 

There's two different medicines that come in suppositories. One of them is glycerol, which is just a sort of a soft, waxy material, and so if we're dealing with really hard, rock hard poos, then the glycerol is ideal to melt and soften those poos. The other flavour of suppository is called bisacodyl, and that is another medicine that makes the bowel hurry up and squeeze things out. And so we often find they make a very good combination of suppositories. 

I've just reminded myself that there's a thing that we sometimes see when someone's particularly constipated. There might be a hard boulder of poo right at the rear end, and we sometimes see this phenomenon called overflow diarrhoea. And so if there's a big boulder of poo, above that, there's going to be some liquid poo and eventually we find that that liquid poo can squeeze past. And what happens is you find yourself running to the toilet because it's quite urgent, and passing this liquid, and it feels like instead of constipation, your problem has suddenly become diarrhoea, but actually, that's a problem that's caused by really bad constipation. 

Denise
The key difference I think with that sort of diarrhoea, is that one is usually very watery, whereas if somebody has actually got loose bowels, it's usually sludgy to very thin but not watery. And that’s often a key difference between overflow and actual diarrhoea. 

Chris, one of the other medications that we often use and very much using for the side effects is steroids. Now these are not the anabolic steroids, they are not going to body build and give people great big muscles, but there are very useful medication steroids.

Dr Chris
Yes, they are. We're talking about anti-inflammatory steroids, so there are a couple of steroids that people may have seen in day to day medicine. We use anti-inflammatory steroids a lot for things like asthma, and you can have a steroid inhaler for asthma, or steroid creams for eczema, for example, hydrocortisone cream for eczema. In palliative care, we often find that there are problems with inflammation or swelling, especially when we're thinking about cancers, about tumours. So if they're swelling, or if they're putting pressure on somewhere that's causing a problem, then one of our go-to medicines is these anti-inflammatory steroids to reduce that pressure. The steroid that we use the most in palliative care is one called dexamethasone. 

Denise
One of the bonuses we see with that, of course, is people getting a real burst of energy and appetite, you know, so that it’s actually almost really increasing people's enjoyment in life, but it's usually only for a shorter period of time – we're not talking months of benefit in that respect, are we?

Dr Chris
Yes, sometimes we find with the steroids really make people feel better. Sometimes we will try steroids just for the sake of energy and appetite, even if there isn't obvious swelling. And so then again, it's an example of us using the medicine for the side effect, rather than the direct effect. That can be a problem if you take it at bedtime, because it can make it hard to sleep, so we do make sure that we give steroid medicines in the morning, which is the same kind of pattern, the same rhythm that your body also produces steroids in the morning, and the level reduces overnight.

Denise
That's another good point there, Chris, that our bodies do produce steroids, so it's really important that we don't stop taking artificial steroids suddenly. 

Dr Chris
So steroids have a lot of effects, and one of the effects is putting your blood pressure up; another effect is putting your blood sugar up. Those aren't usually things I worry about in palliative care. But the thing is, if you're taking steroids by mouth, then that affects the normal balance of the body's steroids. And if you're taking them for more than a week or two really, we find that the body stops producing the steroids from your own system, and relies on the steroids in the pills. 

That means that your body needs a bit of time to start producing its own steroids again, and the risk there is that your blood pressure can drop, and your blood sugar can drop, and that can actually make you feel very unwell. So that can give you quite a bad withdrawal effect. So if you're taking steroids for more than a week, you must make sure that you don't stop them suddenly – you'd need to reduce them gradually, gradually, and let your body get used to that reduction and start to produce its own cortisone again.

Denise
So if you have been on steroids and you want to stop taking them, you do need to just talk that over with somebody from the medical team as to how you can do that safely.

Dr Chris
They do have side effects and that's important to be aware of. The steroids have their part of the normal body system and they maintain and influence a lot of different systems. But ideally, you'd want to be taking the lowest effective dose. And so we’ll often start with a dose of dexamethasone, like two tablets in the morning, eight milligrams in the morning, but within a week or two, if we can, it would be nice to start reducing that dose, and hopefully, the benefit will remain, but the side effects will be less risky. And as always, it's a balance of benefit and risk and so that's why I say the lowest effective dose. 

Denise

Yeah, that's good advice, Chris. The other probably key medication group that we work a bit with in palliative care is the anti-anxiety medications, the ones that help ease restlessness and a little bit of confusion – perhaps worries. Can you tell us a wee bit about those medications, Chris?

Dr Chris
So I'm thinking of two families of medicines. The first family is very commonly used, and I'm thinking about standard antidepressants. They are certainly helpful medicines. The downside with antidepressants is that they take at least two or three weeks, really, to have their effect. We know they're safe, we know they're effective, but they do take a couple of weeks to have effect. When I'm seeing someone who's having real problems with anxiety and restlessness, I tend to go for something a bit more powerful and a bit more immediately effective, and so then I'm thinking about medicines from the family called benzodiazepines.

Denise
There's a few varieties there, isn't there?

 Dr Chris
That's right. Probably the most commonly known one is diazepam. This isn't one that I use very often, because it lasts for more than 24 hours in your system, so it can be helpful if we need a kind of a baseline medicine. At the other end of the spectrum is one called midazolam, which only lasts for a couple of hours in the system, and so that's useful for something sudden, just like your fast acting morphine – whether that be getting up and moving, if that's going to cause pain, or breathlessness. Really, midazolam for example, is one that we use for any symptom that causes distress, and we use it a lot for breathlessness, because breathlessness is scary, is distressing. And so the midazolam works mostly on the scary. And so it helps to break that cycle of breathlessness and fear. Just like fentanyl, it's not a helpful medicine if you swallow it. It's another one that we use as a nasal spray, and the benefit of that is it kicks in very quickly.

Denise
It would be certainly be the one that I've come across most commonly over the years. But again, there are some other options – lorazepam, clonazepam are available, not used as commonly, and they're both slightly longer acting.

Dr Chris
Clonazepam is one that we use quite often. It comes in a really helpful formulation which is these drops which you just absorb under the tongue, and they absorb very quickly as well. So clonazepam lasts for maybe about 12 hours. The drops are bright blue, which makes them quite memorable. They look like smurf juice. They just help you feel much more relaxed. 

Like everything we use, they do have side effects. The biggest thing with the benzodiazepines is that we find that the more you use, the more you need. So this is one that I wouldn't just use willy-nilly all the time. We can find that with the midazolam spray, because it kicks in quickly and wears off quickly, that can make you feel like you're on a bit of a roller coaster. So I'd normally recommend, try not to use that one too often. Maybe five or six times a day would be would be ideal. 

The other ones, the longer acting ones, we're trying to find the most helpful dose for you. And so you might find that if you can not use it every day, that will give you more benefit than side effects, or just try and keep to the lowest dose that you can. The other side effect, of course, is that they do make you a bit sleepy, so some people don't like that.

Denise
And going back again, to what you said before, it's that balance, isn't it. And for each person, that's individual. For some  being a little more sleepy, but relaxed is a bonus, for someone else they'd rather put up with a bit more pain to be a bit more alert. And we're guided by what that person wants. 

Dr Chris
it's a very important point that our job is not to tell people what to do. Our job is to tell people how we can help and help them decide what's most important to them. So when I say the most effective dose, it’s a question of priorities, what's the most important thing for you at this time. And my job as the doctor, is to recommend the medicine that will hopefully be the most helpful in achieving those goals, those priorities.

Denise
And it's very much a partnership then, isn't it. I think that's a key part of palliative care. It's a partnership between health professionals and the patient and their family, and finding the balance that works the best for everybody. 

Chris, thank you very much. That's been really helpful today. It's been good to talk that through and just to have a bit more of an understanding about medications.

Dr Chris
Thank you, Denise. I hope that helps. 

Denise
Thank you, Chris and thanks to our listeners for joining us today. 

This podcast was brought to you by Otago Community Hospice with support from Hospice New Zealand. If you found this discussion helpful, check out our other episodes at the End of Life podcasts. You can also find more resources for caring for a person who is dying at otagohospice.co.nz/education