Morphine: Forms, Use, Side Effects, and How It's Given

Many people wonder about the uses, forms, and side effects of morphine, and 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 people nearing the end of their lives, different concerns often arise than when morphine is used for surgery or in non-hospice settings. This article explores how and why to use liquid morphine (as well as other forms) at the end of life, and the possible side effects you may expect.

Liquid morphine is often provided in a hospice kit so that family or friends can treat their loved one who is dying. It's important to note that you can always contact your hospice nurse or physician if you have questions about the use of morphine.

Morphine may be used for more than one symptom near the end of life.

Pain

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. Moreover, morphine is readily available in most areas and is usually cost-effective.

Shortness of Breath

Morphine is also effective in treating dyspnea, or shortness of breath, a symptom experienced by well over half of people at the end of life and sometimes more distressing than physical pain. Morphine can reduce the anxiety associated with shortness of breath but actually improves breathing by dilating blood vessels in the lungs and deepening breaths. Other medications in the hospice kit may reduce anxiety, but can actually worsen dyspnea.

Morphine is usually tolerated well, but can also cause some troublesome, and even serious, side effects.

Common Side Effects

Relatively common but not usually emergent side effects include:

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

If your loved one experiences any of these symptoms, it's important to talk to your hospice nurse or physician. Often times these side effects can be controlled or alleviated with other treatments, so your loved one can continue to get the pain-relieving benefit of the drug. Examples include using an anti-nausea medication for nausea and vomiting, or a stool softener with or without a laxative for constipation.

Serious Side Effects

All serious side effects of morphine use should be reported to your doctor immediately, and can include:

• 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

It's important to note that many people appear to hallucinate at the end of life whether they are receiving morphine or not.

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, and often are included in the "hospice kit" provided to loved ones to administer if or when needed.

Advantages

Liquid morphine is relatively easy to give and can be concentrated in order to administer larger doses of the drug using smaller amounts of liquid. In addition, some people are unable to swallow pills because of their illness, due to a decreased level of consciousness, or because of morphine's side effect of sedation. In these situations, people can usually tolerate the smaller amount of liquid needed to alleviate their pain and/or make them feel comfortable.

Time to Onset and How Long it Lasts

Morphine tastes bitter, which is most noticeable in the liquid form in contrast to pill form. Because the concentrated liquid is usually given in small amounts, it is recommended that morphine not be mixed with other liquids. Most people tolerate receiving the medication alone or by "chasing it" with a drink of their choice.

Method of Administration

Oral morphine solution should be given only with a dosing spoon or dropper provided by the pharmacy.

If you are unsure about the right dosing, ask your nurse or another healthcare provider to demonstrate for you. Some hospice nurses carry a "sample bottle" of morphine (without the drug) with them that allows them to demonstrate how to draw up the correct dose and use the dropper. If you have any questions at all, ask your hospice nurse to show you how it is done.

Tablet or Capsule Morphine

Morphine tablets come in both rapid- and extended-release forms.

Rapid Release Tablets

The rapid-release tablets work similarly to an oral/liquid morphine solution in that they have a relatively rapid onset of action but last for only around four hours. Rapid-release tablets can be crushed and mixed with applesauce or pudding for people who have difficulty swallowing tablets. They can also be crushed and administered through a nasogastric (NG) tube.

Extended Release Tablets

Extended-release (ER or XR) tablets can be taken every 12 hours, or even once per day. Extended-release morphine is only used for people who are 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.

Other Methods of Delivery

In addition to liquid and solid forms, morphine can also be delivered as an injection into a muscle (intramuscular injection), as an injection into the fatty tissue just under the skin (subcutaneous injection), or through an intravenous infusion (IV). While these methods of delivery aren't usually the first choice in palliative care or hospice setting, morphine administered in these alternative ways can still prove effective relief of pain.

Morphine can also be delivered as a suppository (inserted into the rectum) for people who need 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, ask your physician or nurse to demonstrate how to administer the suppository.

If you have concerns about using morphine for pain or shortness of breath (dyspnea), it's important to talk to your hospice nurse or doctor. Everyone is different, and your hospice team can help you find the best form and method of delivery to control your loved one's symptoms. Caring for a loved one at the end of life can be challenging, but is one of the most loving and rewarding things a person can do.