| Morphine: Preventative Pain Control Amy Smith Biology Senior Seminar 11-17-97 |
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Outline
A. Types of Pain
1. Chronic
2. Post-Operative
A. History
1. Opium, Laudanum, Morphine, Heroine
2. Medical Derivatives
B. Side Effects
A. Hospice
B. Chronic Terminal and Non-terminal
V. Conclusion
VI. Bibliography
| I. Introduction |
Narcotic analgesics, especially morphine are underused for pain control with in the medical field. This underuse is because medical professionals, including doctors, fear patient addiction, side effects and possible lose of their licenses. These fears deny adequate healing and a better quality of life to those who would benefit from a more effective use of these drugs, as done in hospice care.
| II. PAIN: |
Various factors influence the pain a person feels when injured, sick
or recovering from surgery. Different people have different thresholds of
pain. A headache that sends one person to the medicine cabinet for aspirin
may not bother another person. "Nonphysical factors, such as fear,
anxiety, depression, and fatigue," (Backer, 1994) are also variables
which influence reactions to the threshold pain. If an adolescent complains
of a headache, and the parents' ask if she took something for it, she will
more than likely take pain medication before complaining next time. Cultural
values also play a part in pain response. Our culture admires "Stoicism
and tolerance," (Backer, 1994). Pain is not inevitable and can be treated.
To live a life hampered by pain when treatment is available, is to cheat
one out of the full quality of life that is possible.
Pain effects the body through the nerves. The phenomena of pain is conveyed
from a peripheral part of the person, through afferent nerves to a part
of the brain, similar to sight, touch, and hearing. These signals are then
interpreted by the brain as pain (Murphy, 1981). The nerve cells used to
relay pain messages to the brain are specific nerve cells called nociceptors.
These nerves do not send messages until "the stimulus reaches noxious
levels," (McClesky, 1992).
Pain can be acute or chronic. Acute pain is intense, short in duration
and generally a reaction to trauma. Chronic pain does not go away, and can
range from a dull ache to excruciating agony. Terminal and non-terminal
illnesses can both be causes of chronic pain. Tissue damage is not always
found in chronic pain, but those who suffer from it are rendered "nonfunctional
by incapacitating pain," (Murphy, 1981).
| Chronic Pain |
Chronic pain has four mechanisms. Nociception is a neural signal of threatened or damaged tissue, and is the classical pain pathway. Central pain states are thought to be caused by abnormal activity in neurons in the afferent pathway. The mechanism for this is not completely understood, and a person may perceive pain where there is no tissue damage. Behavioral pain is communicated by a word, grimacing, posturing, and other behavioral signals. These signals indicate that a person is in pain, (Murphy, 1981).
A person suffering from chronic pain may undergo a change in personality becoming irritable and moody. The pain is responsible for this change in a formerly good natured person. Pain is emotionally and physically, draining. These dual effects not only take a toll on the ill person but also on her, family and friends. The person with the pain deals not only with the agonizing pain, but also with the guilt and frustration of not being the person she was before the pain.
| Post-Operative |
Post surgical pain is an acute pain rather than a chronic pain. It is due directly to the fact that an incision was made, creating tissue damage. Depending on the surgery, the pain can diminish quickly within a day or two. However recovery can take a bit longer, and postoperative pain is very common in the recovery room.
The severity and reason for this pain has many factors. Age is important.
The two extremes of very young and very old, seem to have lower instances
and less pain than those patients in the middle of life. Fear of pain and
some neuroses also seem to increase the postoperative pain. Preoperative
medication can affect postoperative pain. Barbiturates and some other medications
seem to worsen post-Op pain. Narcotics on the other hand delay the need
for a painkiller in the recovery room. The site of the incision and procedure
also have a significant influence on post-Op pain. A surgery in the thoracic
region seems to be the most painful type of operation, and lower abdominal
surgery the least painful. The technique of the anesthetic, such as the
presurgical use of narcotic analgesics is important, but not the type of
anesthetic (Murphy,1981).
| III. OPIATES: |
Chronic pain and post-surgical pain can both be alleviated by the use
of opiates. Opiates are a type of drug extracted from the pod of the Asian
poppy. These drugs have been used medically and non-medically for centuries.
Laudanum has been used since the 16TH century to stop coughing and diarrhea,
and to calm nerves. In the 19TH century morphine was extracted in its pure
form and became an injectable solution with the use of the hypodermic needle.
In 1898, heroin was introduced. At first heroin was thought to be a remedy
for morphine addiction. It turned out to be not only a more potent pain
killer, but also much more addictive than morphine. Heroin is the only opiate
more liable to create dependence than morphine. Only two natural opium products
are still used today for clinical use, morphine and codeine. The synthetic
opium products are generally called opioids. These drugs were developed
to produce the same type of analgesic uses, but with out the drug dependence
(Addiction Research Foundation,1995).
| Morphine |
Morphine is a strong narcotic analgesic used in the management of moderately
sever to severe pain.. It is not a very popular street drug, but its availability
in the hospital has created some abuses by health professionals. Morphine
can also relieve certain types of difficult breathing, suppress coughs,
and cholera produced diarrhea. Its typical dosage is between 5-20 mg every
four hours for an intramuscular injection and 8-20 mg orally. If used intravenously
it is usually 4-10 mg used for postoperative pain. The intravenous effect
is almost immediate.
| Codine |
Codeine is the other natural opiate used in the medical field, and like
heroin, it synthesized from morphine. This opiate is used more for mild
to moderate pain, rather than sever pain, and is typically combined with
Tylenol. This combination is sold as Tylenol #3 w/ codeine and provides
relief from a cough and diarrhea, similar to morphine.
| Other Derivatives |
Hydrocodon, hydromorphone, meperidine (Demoral), and Oxycodone (Percodan)
are all semi-synthetic opioids used in the medical field. These medications
are also used as narcotic analgesics and have some dependency potential.
The effects of all of these last three to four hours and are used for moderate
to severe pain,.
Synthetic opioids are Fentanyl, methadone, propoxyphene, and pentazocine.
Fentanyl is used for moderate pain relief and as a surgical anesthetic.
The effects of these medications last one to two hours. Propoxyphene is
used as a mild pain reliever, and methadone is used mostly in the treatment
of opioid withdrawal (Mdh@debug.cuc.ab.ca,1994).
| Side Effects |
Dependence is a side affect common to all opiates, natural and synthetic
alike. Opiates have specific withdrawal and dependence characteristics,
Prolonged use causes both psychological and physical dependence. Chronic
opioid users may also develop endocarditis, an infection in the lining of
the heart. Drug users may use contaminated needles, increasing their risk
for AIDS and other diseases which are transmitted through the sharing of
unclean hypodermic needles (Mdh@debug.cuc.ab.ca,1994). The withdrawal from
opioids is not a painless event, but neither is it life threatening. Withdrawal
symptoms include uneasiness, yawning, tears, diarrhea, abdominal cramps,
goose bumps, runny nose, and a craving for the drug (Addiction Research
Foundation,1995).
A slightly reduced respiratory rate is one of the side effects for the
medical use of morphine, and other opiates. This side effect worries some
doctors of cancer patients, because as the cancer metastasizes the pain
becomes worse and therefore a higher dosage of morphine is needed. The higher
dosage may ultimately reduce respiratory rate to the point where a person
is not breathing, although this is not as common as it may sound at times.
Other side effects are constipation, nausea, loss of appetite and decreased
gastric motility (Mdh@debug.cuc.ab.ca,1994).
| IV. PAIN CONTROL: |
| Hospice Care |
Hospice is probably the best example of effective pain control using
morphine, and other opiates. The concept of hospice has its roots in Christianity.
In the beginning of Christianity, places for the care of the sick, poor
and dying were called Hospitia and were run by religious orders. Current
hospice care also stems out of a history of religious affiliation. The Irish
Sisters of Charity founded Our Lady's Hospice in Dublin in the 1800s, and
St. Joseph's hospice for the dying poor in England was founded in 1902 (Backer,
1994).
Just as Jesus showed care and compassion for those in pain, sick and
dying, those people who founded Hospice clinics and charity hospitals had
strong Christian beliefs, gifts of healing, and felt the need to do the
same. Today's Christian health care workers should feel a similar need to
ease the pain and suffering. A physician cannot use the same techniques
that Jesus used to help those in need. It would be impossible. It is with
the gifts God has given that a physician may help those in need. Medicine,
including morphine, is one of those gifts.
| Chronic Pain Control |
" It is scandalous that in almost every case suffering was largely
preventable and unnecessary, inflicted not by the disease, but by shocking
medical ignorance, arrogance, complacency and pride," (Dixon,1997).
Dr. Ilora Finlay gives a six step guide to obtaining adequate pain relief.
Backer gives a list of "Ten Commandments" for the health
care profession which is appropriate to the problem of inadequate pain control.
1. Thou shalt not assume that
the patient's pain is caused by the malignant process.
2. Thou shalt take into consideration the patient's feelings.
3. Thou shalt not use the abbreviation p.r.n. (meaning as needed).
Continuous pain requires regular preventative pain management.
4. Thou shalt not prescribe inadequate amounts of any analgesic.
5. Thou shalt try nonnarcotic analgesics in the first instances.
6. Thou shalt not be afraid of narcotic analgesics.
7. Thou shalt not limit thy approach simply to the use of analgesics.
8. Thou shalt not be afraid to ask a colleague's advice.
9. Thou shalt provide support for the whole family.
10. Thou shalt have an air of quiet confidence and cautious optimism.
Although these commandments were used in reference to hospice, many other
medical areas can benefit from these ideas. Health care providers, especially
Christian ones, have an obligation to provide the best care possible to
their patients,. The duty to follow Jesus by giving comfort and compassion
is inherent in the profession chosen by the Christian. This does not just
mean to give of your time, but also of you talents and knowledge. Health
care providers need to educate themselves on the benefits of more effective
morphine use in the treatment of chronic pain, for both terminally ill and
the nontermially ill.
| V. CONCLUSION: |
The gift of healing is important and should be used to help others. The
duty of a Christian health care worker, be it the position of nurse, physician,
pharmacist, or other, is to not only use their own personal gift, but to
enhance it through education, and a thorough search for the best possible
treatment. In the case of chronic pain, morphine works better and with fewer
side effects than most drugs (Herrera, 1997). Not only does morphine relieve
pain, it also helps prevent pain (Gorman, 1997). Morphine should not be
given indiscrimanently. A doctor prescribing any opiate should be aware
of any and all side effects, and explain them to the patient and family.
Pain is a common human experience. Dying is also a common human experience.
For those who have a terminal illness, dying in pain does not need to be
experienced. Doctors need to be educated on how to properly use narcotic
analgesics for the terminally ill. They also need to be allowed access to
adequate use of narcotic analgesics, especially morphine, for those with
chronic pain who are not chronically ill. Once the physical pain is alleviated,
emotional pain and negative coping mechanisms may be address through a collaborative
effort of different health care workers.
People trust their doctors and nurses to do what is best for them. It
is a violation of trust, and a misuse of a God-given gift to not find the
best available method and use it to help the patient. If the best option
is not available because of societal fears, such as morphine, The doctor,
and other health care workers should become advocates to help obtain access
to the treatment. A health care worker should follow the example of Jesus
when caring for those in pain. He took away the physical pain first, knowing
that the person would then be able to focus on faith.
| VI. Bibliography |
Addiction Research Foundation. 1995. "Facts about...Opiates"
http://www.arf.org/isd/pim/opiates.html. Sept. 25, 1997.
Backer, Barbara, Natalie Hannon, Joan Yong Gregg. 1994. To Listen, To
Comfort, To
Care: Reflections on Death and Dying. Delmar Publishers Inc. Albany, NY.
Dixon, Patrick. 1997. "Pain Relief in Cancer"
http://people.delphi.com/patrickdixon/painreli.htm. Oct. 7,1997.
Gorman, Christine. 1997, April 28. "The Case for Morphine: If Nothing
is Better for
Pain than Narcotics, Why Don't More Doctors Prescribe Them?" Time.
64-66.
Herrera, Stephan. 1997, May 19. "The Myth of Morphine." Forbes. 258-59.
Kohler, Steve. 1992. "Hard Cases" Outlook. 14-16,18-19.
Martin, Edward W. 1996, April. "Pharmacological Management of Cancer
Pain"
http://biomedcs.biomed.brown.edu/RIMedicine/MARTIN.HTM. Sept. 25, 1997.
McClesky, Ed. 1992. "The Root of Pain" Outlook. 17.
Mdh@debug.cuc.ab.ca. 1994, Jan. 30. "Opioid FAQ"
http://www.paranoia.com/drugs/opiate/FAQ-Opioid. Sept. 25, 1997.
Moulin, Dwight, E., et al. 1996, Jan. 20. "Randomized Trial of Oral
Morphine for
Chronic Non-cancer Pain" The Lancet. 143-148.
Murphy, Terence M. 1981. "Treatment of Chronic Pain" Anesthesia,
vol. 2. Ed. Ronald
D. Miller. Churchill Livingstone: New York, NY.
National Cancer Institute. 1980. Coping with Cancer: A Resource for the
Health Care
Professional. National Institutes of Health: Bethesda, MD.