Topical Use of Morphine
The use of topical medication—defined as a pharmaceutical skin surface application—has gained progressive popularity in recent years. There is now a wide variety of both non-prescription and prescription topicals available. They include healing and cooling agents, anti-inflammatory drugs, and those with anesthetic properties. Physicians and pharmacists have teamed in recent years to compound various prescription topical agents which include ketamine, ketoprofen, clonidine, and naloxone among others. Reported here is a summary of the author’s experience and investigation of topical morphine. Used in the author’s clinic as the premier topical agent, topical morpine is an indispensable adjunct to standard pain treatment that enhances pain relief, reduces costs, promotes stretching and walking, and decreases such adverse events as emergency room visits, disabling pain flares, trigger points, and early refill requests. Morphine topical is highly recommended as an adjunct in severe, chronic pain patients who take systemic opioids.
After initial discovery of central nervous system opioid receptors and the endorphins in the 1970s, followup studies began to identify opioid receptors in such varied organs as the ileum, knee joint, pancreas, ovary, and lymphocytes.1-3 Additionally, endorphin compounds were found in blood raising the question whether endorphins and opioid receptors have functions other than central nervous system pain relief. A number of studies clearly document that morphine has direct, peripheral analgesic properties.4-7 Indeed, morphine injected into the knee joint and applied to the skin will provide local pain relief.5-6 This litany of ground-breaking scientific studies prompted the author to study the practical, clinical usefulness of topical morphine. Open trials showed promise and a randomized, double-blind, placebo-controlled study was done which showed that topical morphine provided localized pain relief.8 Importantly, morphine was not detected in blood or urine in this study so it is assumed that morphine acts directly on the skin and does not produce systemic effects. Since this successful study, topical morphine has been a standard practice in the author’s clinic. It is used as an adjunct for intractable pain patients who require oral, systemic, opioids.
Topical Formula and Patient Instruction
Standard oral morphine, instant release, 30mg tablets are used to prepare the topical. Dosage is one to two crushed tablets dissolved in one ounce of cold cream (see Table 1). Patients are taught to crush tablets and secure their own cold cream for both convenience and to save money. Admittedly, other bases could possibly be more effective but, when patients select a cold cream they like, we avoid complaints of skin irritation or allergy. Patients are initially instructed to use it on an “as needed” rather than on a “regular” or “around-the-clock” basis. Nevertheless, some patient's choose to use it on a regular, daily basis. They are instructed on the option to apply heat or cold with the topical and to massage it into the painful area.
|One or two 30mg morphine tablets (standard oral, instant release) crushed and dissolved in the patient’s favorite cold cream.|
In preparation for this article, the author surveyed 30 intractable pain patients who are on oral opioids and who also use topical morphine. This group excluded any patients who had tried morphine topical but found it useless. Table Two summarizes this anecdotal survey, but some specific points strike the author to be worth additional comment. First, patients report that morphine topical relieves pain within 10 minutes. Some patients report immediate relief. The majority of patients report that pain relief lasts about an hour, but some patients report pain relief that lasts from several hours up to a few days. About half of the patients state they apply heat, or take a bath or shower after they apply it. The majority can better stretch, walk, or exercise after application. Every patient related the ability of topical morphine to accomplish at least one of the following:
- Prevent flares that require an emergency room visit.
- Prevent development of trigger points.
- Decrease early refill requests.
- Reduce required opioid dosage.
Topical morphine has been used by this author as a “rescue” or “last shot and hope” for some very difficult intractable pain cases. Following are brief descriptions of three illustrative cases.