Morphine's Forms, Side Effects, and How to Administer the Drug

Of all the medications used to treat pain, morphine sulfate is perhaps the most misunderstood and the most feared. Commonly used in hospice and palliative care settings to treat patients nearing the end of their lives, this article explores how and why to use liquid morphine in end-of-life situations, as well as morphine in other forms, and the possible side effects of this pain-relieving drug.

In palliative care and hospice settings, morphine is often considered the "gold standard" of pain medications because it generally treats pain effectively and is usually well-tolerated by patients. Moreover, morphine is usually cost-effective and readily available in most areas. In addition, morphine is also effective in treating dyspnea, or shortness of breath, which some patients might experience because of their illness/disease.

As noted above, morphine is usually tolerated well by patients, but the drug can also cause some troublesome, and even serious, side effects. Some possible side effects of morphine include:

• Constipation
• Diarrhea
• Dizziness
• Drowsiness
• Feeling lightheaded
• Upset stomach
• Vomiting

Because of the possible side effects of morphine, you should tell your healthcare provider about any or all of these symptoms if your loved one is receiving this drug to alleviate his or her pain. Some of the morphine's side effects can be alleviated with other treatments, such as using an anti-nausea medication for nausea and vomiting, or a stool softener for constipation.

All serious side effects of morphine use should be reported to your doctor immediately, such as:

• Slow, shallow or irregular breathing
• Blue or purple color to the skin
• Fast or slow heartbeat
• Seizures
• Hallucinations (seeing things or hearing voices that do not exist)
• Blurred vision
• Fainting
• Hives
• Rash
• Itching
• Tightness in the throat
• Difficulty swallowing
• Swelling of the arms, hands, feet, ankles, or lower legs

Morphine comes in several forms, including liquid or tablet form, which makes it the pain-relieving drug of choice in many end-of-life situations. The forms of morphine can include:

Oral Morphine Solutions

Oral (liquid) morphine solutions are commonly used in palliative care and hospice settings because it's relatively easy to administer. Morphine can be concentrated in order to administer larger doses of the drug using smaller amounts of liquid. In addition, some patients unable to swallow pills because of their illness or decreased level of consciousness, or because of morphine's possible side effects, can usually tolerate the smaller amount of liquid needed to alleviate their pain and/or make them feel comfortable.

An oral/liquid morphine solution typically starts working quickly -- usually within 15 minutes -- and lasts for roughly 4 hours, although some patients might find they require morphine more often. Morphine tastes bitter, which is most noticeable in the liquid form versus pills. Because the concentrated liquid is usually given in small amounts, it is not recommended to mix morphine with other liquids. Most patients generally tolerate taking the medication alone or "chasing it" with a drink of their choice.

Oral morphine solution should be given only with a dosing spoon or dropper provided by the pharmacy. Because it is highly concentrated, it's important to get the dose as accurate as possible. If you are unsure about the right dosing, ask your nurse or healthcare provider to demonstrate for you. I carry a "sample bottle" of morphine with me when I visit my patients. While the bottle doesn't contain the actual drug, this sample bottle allows me to demonstrate how to use a dropper to draw up the correct dose.

Tablet or Capsule Morphine

Morphine tablets come in rapid- and extended-release forms. The rapid-release tablets work similarly to an oral/liquid morphine solution in that they work relatively quickly but only last for roughly four hours. Rapid-release tablets can be crushed and mixed with applesauce or pudding for patients with difficulty swallowing tablets or crushed and administered through a nasogastric (NG) tube.

Extended-release (ER or XR) tablets can be taken every 12 hours, or even once per day. Extended-release morphine is only used in patients experiencing continuous moderate to severe pain. You should always check with your healthcare provider or pharmacist before crushing an ER tablet or opening an ER capsule. Otherwise, you might administer a dose that is much too high.

Other Delivery Methods

In addition to liquid or solid forms, morphine can also be delivered as an injection into a muscle, as an infusion intravenously (IV) or subcutaneously (into the fatty tissue under the skin). While these forms of delivery aren't usually the first choice in a palliative care or hospice setting versus the forms described above, morphine administered in these ways can still prove quite effective, less painful and carry less of a risk.

Morphine can also be delivered as a suppository (inserted into the rectum) for patients needing a longer-acting dose but who are unable to swallow morphine in liquid or tablet form. If this is the form of delivery your healthcare provider recommends, then your physician or nurse should demonstrate how to give administer it.

Finally, if you have concerns about using morphine for pain or shortness of breath (dyspnea), then you should talk with your healthcare provider. He or she can help you find a solution that is right for you and your loved one.