Fatteh Education: 2 notes on Morphine

We have many patients with neuropathic pain. This study from NEJM suggests that using morphine and gabapentin together is better than either medication alone.

TITLE
Morphine, gabapentin, or their combination for neuropathic pain.

JOURNAL
The New England journal of medicine

DOI
10.1056/NEJMoa042580

Author(s)
Gilron|Ian|I|;Bailey|Joan M|JM|;Tu|Dongsheng|D|;Holden|Ronald R|RR|;Weaver|Donald F|DF|;Houlden|Robyn L|RL|

Abstract
BACKGROUND The available drugs to treat neuropathic pain have incomplete efficacy and dose-limiting adverse effects. We compared the efficacy of a combination of gabapentin and morphine with that of each as a single agent in patients with painful diabetic neuropathy or postherpetic neuralgia. METHODS: In this randomized, double-blind, active placebo-controlled, four-period crossover trial, patients received daily active placebo (lorazepam), sustained-release morphine, gabapentin, and a combination of gabapentin and morphine--each given orally for five weeks. The primary outcome measure was mean daily pain intensity in patients receiving a maximal tolerated dose; secondary outcomes included pain (rated according to the Short-Form McGill Pain Questionnaire), adverse effects, maximal tolerated doses, mood, and quality of life. CONCLUSIONS: Gabapentin and morphine combined achieved better analgesia at lower doses of each drug than either as a single agent, with constipation, sedation, and dry mouth as the most frequent adverse effects.

https://www.focalize.md/find-journals/?a=YZgQOHwBEtb5a2zzCEEI

This article describes a treatment protocol that resulted in better control of pain at the end of life.

TITLE
Impact of a Nurse-Driven Opioid Titration Protocol on Quality of Orders at End of Life.

JOURNAL
Journal of hospice and palliative nursing : JHPN : the official journal of the Hospice and Palliative Nurses Association

DOI
10.1097/NJH.0000000000000716

Abstract
At our community teaching hospital, orders for end of life often lacked instructions to titrate opioids based on evidence-based principles and failed to address nonpain symptoms. An order set and a nursing-driven opioid titration protocol were implemented in August 2016 after extensive education. The purpose of this retrospective preintervention and postintervention study was to evaluate the impact of this intervention on the quality of end-of-life orders. We evaluated 69 patients with terminal illness receiving morphine infusions. After implementation, more morphine infusion orders included an as-needed bolus dose with an objective indication and appropriate instructions on when and how to titrate the infusion compared with before the intervention (94.6% vs 18.8%, P < .0001). Morphine infusion orders were also significantly more likely to include a maximum dose (P = .041) and an initial bolus dose (P < .0001). In addition, prescribers were more likely to order additional medications to manage nausea/vomiting, constipation, anxiety, or pain using a nonopioid (P < .05 for all). In this study, implementation of a standardized opioid titration protocol and symptom management order set led to an improvement in the quality of morphine infusion orders for pain management at the end of life and increased the use of medications to manage nonpain symptoms in dying patients.

https://www.focalize.md/find-journals/?a=UCKhPnwBEtb5a2zzHx3y