When is morphine indicated for pain management in hospice patients?

Morphine Administration in Hospice Patients

Oral morphine is the first-choice opioid for moderate to severe cancer pain in hospice patients, with administration routes and dosing adjusted based on pain severity and patient's ability to take oral medications. 1

Indications for Morphine in Hospice

Morphine is indicated in hospice patients for:

• Moderate to severe pain that hasn't responded to non-opioid analgesics 1
• Pain requiring strong opioid management when alternative treatments are inadequate 2
• Breakthrough pain episodes during regular opioid therapy 1
• Dyspnea in end-of-life care 3

Administration Routes

1. Oral Route (Preferred)

• First-line approach when patients can swallow 1
• Requires two formulations:
  • Immediate-release: For dose titration and breakthrough pain
  • Controlled-release: For maintenance therapy (every 12 hours) 1

2. Alternative Routes (when oral route not possible)

• Subcutaneous: Either as bolus injections every 4 hours or continuous infusion 1

  • Relative potency ratio of oral to subcutaneous morphine is about 1:2 1

• Intravenous: For patients with poor peripheral circulation or requiring urgent pain relief 1

  • Relative potency ratio of oral to intravenous morphine is about 1:3 1

• Rectal: When oral route unavailable 1

  • Bioavailability equivalent to oral route (1:1 ratio) 1
  • Controlled-release tablets should NOT be crushed for rectal administration 1

Dosing Protocol

Initial Dosing

1. Opioid-naïve patients:

   • Start with 15-30 mg oral morphine every 4 hours as needed 2
   • For severe pain requiring urgent relief, use parenteral administration 1

2. Converting from other opioids:

   • Use conservative approach due to inter-patient variability 2
   • For parenteral to oral conversion: 1 mg parenteral morphine ≈ 3-6 mg oral morphine 2

Titration

• Simplest method: Immediate-release morphine every 4 hours with same dose for breakthrough pain 1
• Rescue doses can be given as often as needed (e.g., hourly) 1
• Adjust regular dose based on number of rescue doses required 1
• For nighttime coverage: Double dose at bedtime to prevent pain awakening 1

Special Considerations

Elderly Hospice Patients

• Elderly patients are more vulnerable to opioid side effects 1
• Risk of morphine accumulation, over-sedation, and respiratory depression is higher 1
• Consider starting with lower doses and careful titration

Common Pitfalls to Avoid

1. Underdosing: Fear of addiction or respiratory depression often leads to inadequate pain control 1

   • Clinical experience shows these fears are largely unfounded in hospice settings 1, 4

2. Inflexible regimens: Research shows caregivers administer less morphine with flexible prescriptions (21.84%) compared to structured regimens (39.52%) 5

   • Provide clear instructions to caregivers about when and how to administer morphine

3. Ignoring opioid-induced hyperalgesia: Some patients may develop increased sensitivity to pain with continued morphine use 3

   • Consider opioid rotation if this occurs

4. Failure to anticipate side effects: Proactively manage constipation, nausea, and sedation

Safety and Efficacy

• High-dose morphine (>299 mg/day) can be safely used in hospice settings when needed 4, 6
• Studies show no reduction in survival time with high-dose morphine use in hospice patients 4, 6
• About 9-12% of hospice patients require high-dose morphine for adequate pain control 4, 6

Route Selection Algorithm

1. Can patient take oral medications?

   • YES → Use oral morphine (preferred route)
   • NO → Proceed to next question

2. Is rectal administration feasible?

   • YES → Use rectal morphine
   • NO → Proceed to next question

3. Does patient have good peripheral circulation?

   • YES → Use subcutaneous morphine
   • NO → Use intravenous morphine

Remember that approximately 80% of patients will achieve adequate pain control with these guidelines, while the remaining 20% may require additional interventions such as spinal administration of opioids or adjuvant medications 1.