How addicting is morphine

Palliative medicine : The myth of morphine

It is a good sign that the consumption of strong painkillers has also increased in Germany. After all, our society is getting older and suffering from the consequences of a long life. This includes natural wear and tear, but also chronic diseases that cause pain, the cause of which can no longer be eliminated. Opioids often help. They are descendants of the opium obtained from the seed pods of the poppy plant (main component: morphine). Opioids are used to treat severe pain and severe, otherwise untreatable shortness of breath. Nevertheless, a number of myths prevent opioids from being used where they should, or should be used.

Myth 1: Opioids make death faster

This statement does not apply. Research has shown that opioids, when used in the correct dose, neither accelerate nor delay death. In the eyes of some, “morphine” is associated with the last days in life. But chronic pain patients often cope well with it for many years.

Myth 2: Opioids are addicting

In pain patients, opioids do not necessarily lead to psychological dependence, i.e. what is known as “craving” - the desire to always want more of it. If patients with chronic pain receive short-acting opioids several times a day, however, there is a risk of psychological dependence. This contributes to the fact that patients can no longer get rid of these preparations, such as tilidine or tramadol drops. It therefore makes sense to cease chronic pain patients with opioids, which develop their effects slowly and last for twelve hours. When taken regularly, opioid receptors are continuously occupied, so that the next dose does not suddenly euphoria.

Myth 3: If I am no longer in pain, I can stop taking opioids immediately

Long-term opioid use leads to physical dependence. It causes withdrawal symptoms such as sweating or nausea to set in on abrupt discontinuation. This can be limited by gradually reducing it.

Myth 4: Once I've started with opioids, the dose has to be increased until the medication no longer works

That is another misconception. Nobody has to fear that if the pain situation is stable, the dose of morphine and its derivatives will have to be continuously increased in order to achieve the same soothing effect.

Myth 5: Opioids lead to life-threatening respiratory depression

For fear of harming the patient, in many cases the dose of effective pain treatment is set too low. At the same time, pain plasters seduce “comfortable” pain therapy for patients who have not yet had any opioids. You are quickly overdosed, the result is that the breathing rate drops significantly (respiratory depression). If the need for pain medication increases in the course of the disease, opioids are used cautiously based on experience. If a patient develops a reduction in their breaths even though the dose of the opioid has not changed, this may also be due to changes in organ functions. For this reason, patients and their relatives should be informed about this, and the treating physicians should closely monitor the therapy.

Myth 6: Persistent use of opioids damages the organs

Derivatives of opium in appropriately prepared and medically usable form are among the safest drugs of all. There are no known effects on kidney or liver function or the circulatory system and cognitive performance.

Myth 7: I feel sick and unable to drive on opioids

Opioids only lead to fatigue in many patients for a short time when they are used for the first time or when used in higher doses. As long as the patient is not set in a stable manner, they cannot drive a vehicle. Most of them develop a tolerance for the initial symptoms that accompany opioid therapy. This means that they can then operate machines or control vehicles on their own responsibility. Although road users are generally not allowed to drive a motor vehicle under the influence of intoxicating substances, this does not apply if a corresponding drug has been prescribed to treat an illness. In addition, there are a number of diseases in which driving a motor vehicle is only possible again with the aid of appropriate drugs. There are effective antidotes against the possibly persistent undesirable effects of morphine and its derivatives - such as laxatives against constipation.

Myth 8: If you have severe chronic pain, you cannot do without opioids

So while it is in principle quite possible to treat people who suffer from pain or shortness of breath with opioids, the prescription is now exaggerated in industrialized countries. For example, opioids are given to patients who can manage without such pain relievers. If they don't help, for example with chronic headache or back pain, or for other reasons, patients continue treatment for fear that the pain would worsen if the medication were stopped. Pain is a sensation perceived and expressed by the patient and everyone knows that some people can bear pain better than others. Sometimes a heat pad or distraction is enough. Of course, the cause of the pain should be explored and counteracted.

Myth 9: Opioids are used too often in Germany

You don't know for sure. Of the 500,000 people who would have to receive palliative care every year in Germany, currently only around 100,000 receive outpatient or inpatient palliative care. Two out of three palliative care patients suffer from pain. So far, cancer patients in particular have received palliative medical support and not people with advanced chronic heart, lung, kidney and nerve ailments that can lead to death in weeks or months. These people are also in severe pain. They also need opioid therapy.

Myth 10: Every doctor has mastered opioid therapy

Treating patients with severe pain or shortness of breath requires experience. Not every doctor has the same amount of experience in every area. As a result, patients are not given enough opioids if less experienced physicians change the tried and tested therapy for a patient - for example in hospital, after accidents or when visiting a doctor on vacation. It is therefore advisable for patients who regularly take opioids to have ID with them. There the type and dosage of the opioid analgesics are listed. You can request it from the German Society for Pain Therapy or the German Pain League e.V.

Myth 11: Opioids have to be strictly regulated and their supply regulated

From my point of view, it is still advisable to control the consumption of opioids as with other prescription drugs and to regulate their dispensing. Whether a simple recipe actually promotes abuse is by no means certain and should be tested in model tests. Unfortunately, there are still doctors who do not prescribe narcotics because they shy away from the bureaucratic effort of getting the complicated narcotics prescriptions and filling them out correctly. In doing so, they withhold opioids from their patients.

Myth 12: A patient with severe pain in the nursing home can easily receive opioids

Unfortunately this is not the case. Around every third German currently dies in a nursing home. Pain is a big issue there. However, since nursing homes do not store medicines for all residents in case they need them, but instead only keep them for those for whom the family doctor has prescribed them, many others experience an undersupply of painkillers. In many regions there are no regulations between nursing homes and general practitioners, so that their visits do not take place or only very sporadically. If a family doctor comes to the nursing home for patient A and is confronted with patient B, who is suffering from pain, he unfortunately cannot prescribe opioids because he is not responsible. In the nursing home there is no drug supply due to rigid legal regulations.

It is good when such patients are included in an outpatient palliative care network. The nursing staff can then call in the palliative care specialist on duty. But even he is officially not allowed to leave any opioids in the home for the weekend. If there are no relatives, no one can go to the pharmacy and get the painkillers on the weekend. The dilemma remains. In such cases, nursing homes must be able to have at least a small depot of effective pharmaceuticals ready for basic palliative care for all residents. This is still not allowed and is one of the consequences of insufficient education about the myths that still surround opioid therapy.

The author is a cancer and palliative medicine specialist at the Cecilien Clinic in Bad Lippspringe.

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