A comment on the underuse of morphine in the treatment of cancer pain.
THE first inkling of a toothache was on a Friday morning. It was a throbbing pain, but thankfully, it was intermittent. By afternoon it was worse and the pain free intervals were shorter. I downed two tablets of paracetamol. It worked. It was a busy clinic as it usually is prior to a trip abroad (Murphy’s Law at work?). Patients seen and tiresome insurance forms filled out, I made my way to KLIA. I was to deliver a lecture at an oncology seminar in Hong Kong.
The flight took off on schedule at eight in the evening. With the soothing whirr of the jet engines and a glass of vintage Piper Heidsieck champagne, I settled down comfortably to review my lecture notes.
It hit me hard and without warning. My toothache returned with a vengeance. I tried to will it away, but that did not work. They say pain is just a state of mind. It wasn’t then. It was real enough to consume me. It sat stubbornly in my brain, refusing to budge. It bored down nauseatingly and unpleasantly.
Was the pain in my mouth or in my brain? Wherever it was, it was a “I will give anything to relieve my pain” kind of pain. I ceased whatever I was doing. I was bathed in a searing blinding pain.
I rummaged through my medicine kit. The paracetamol was there but I eschewed it. I found two tablets of tramadol and swallowed them. It took 40 minutes before my pain was dulled to half its intensity. It was still sickeningly bad. I could not concentrate on the seminar proceedings. Food was the last thing on my mind although I was in a gourmet’s paradise. I gave my lecture with half a heart and one-third of a mind. The pain of the toothache clamoured for my attention and was sovereign in my consciousness.
And that was just a toothache!
Now, let us talk about cancer pain. I have never experienced it and neither have most oncologists, palliative care physicians and nurses who treat cancer pain. Nevertheless, from what we learn from our patients, it is terrible and wrenching. A serious and thinking approach to cancer pain is required. It has to be scientific and devoid of folklore. I even tell my young doctors that “untreated or uncontrolled pain is a medical emergency”.
Morphine is very effective in controlling most cases of severe cancer pain not relieved by simpler non- opioid measures. And yet morphine is the most misunderstood, underappreciated and underprescribed drug in the medical pharmacopoeia. Patients and carers similarly have lots of misconceptions and myths about morphine.
The first fear about morphine is that it is addictive. This is unfounded. Morphine is not addictive when used properly in cancer patients who require it. It may be addictive in miscreants who are not in pain and who take it in the mistaken belief they will get a high. Most of the time they only end up drowsy and constipated.
The second misconception about morphine is that it leads to respiratory depression, ie patients stop breathing. I have encountered only one case of respiratory depression after three decades of prescribing morphine. In that case, the patient was easily revived with an injection of naloxone, an antidote of morphine.
The third thing I want to strongly say is that there is no fixed dose of morphine. The dose of morphine in any particular patient is the dose required to keep the patient comfortable and pain free. It may be 10mg every four hours or 100mg or 1000mg or any dose from 10 to 1000mg. The question of “why such a high dose, doctor?” should not arise. There is no low or high dose; only the appropriate and correct dose.
Morphine does not shorten life nor is it only for those who are terminally ill. Many cancer patients live for months and years pain-free because of morphine. In the terminal state, morphine provides a blessed relief from the suffering and indignity of impending death.
Apart from relieving pain, morphine allows the patient a good night’s sleep, lightens her feelings of anxiety, curtails chemotherapy and radiotherapy- induced diarrhoea and makes breathing easier. On the downside, morphine causes nausea and constipation. An anti-nausea pill and a laxative are usually prescribed along with morphine.
In Malaysia, we are fortunate to have available two other opioids (morphine-like substances), ie oxycodone and fentanyl. Morphine, oxycodone and fentanyl differ from each other in small and subtle ways. This is fortunate as some patients do better on one preparation than the other.
Palliative care and oncology trainees are taught that a patient is as much pain as she says she is in. I emphasise and reemphasise this teaching. It is not for us to doubt the truth of the patient’s complaint. We must not allow our prejudices and racial stereotyping to influence our patient care.
Some say the threshold for pain is different in different races and cultures. Don’t you believe it! The threshold is the same. It is the willingness to express the suffering that is different.
To doctors, nurses and carers, I say this: The next time you get a toothache or a headache, think of the cancer patient in severe pain. If your suffering is bad, hers is infinitely worse. Learn about morphine and use it wisely and appropriately. Your patients and loved ones will be so much the better for it.
Having cancer is bad enough. Don’t make it worse for the patient by withholding an elixir such as morphine when it is truly needed.
“The aim of the wise is not to secure pleasure, but to avoid pain.” – Aristotle.
● Dr Albert Lim kok Hooi is a consultant oncologist. For further information, e-mail starhealth@thestar.com.my. The views expressed are those of the writer and readers are advised to always consult expert advice before undertaking any changes to their lifestyles. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
"My daughters want me to be there to go to soccer games, to their graduation, if this is the only way that can happen, they're OK with it. More than anything, I'm happy to have a shot at finally being rid of the cancer."
