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10 Articles in Volume 8, Issue #8
Botulinum Toxin Type-A in Pain Management
Chronic Migraine: An Interactive Case History
Consistent Documentation Drives Compliance
Muscle Physiology, Kinetics, Assessment, and Rehabilitation
Non-surgical Decompression Treatment for Carpal Tunnel Syndrome
The Pseudo-RSD Pain Patient
Therapeutic Laser Evolution: Part 1
TMJ Pain and Temporal Tendonitis with Autonomic Features
Topical Use of Morphine
Toward a Neuroethics of Pain Medicine

Topical Use of Morphine

Used as an adjunct in severe chronic pain patients who take systemic opioids, topical morphine enhances pain relief, decreases pain flares, promotes stretching and walking, and reduces cost of treatment.

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.

Morphine Background

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.

Table 1. Topical Morphine Formulation
One or two 30mg morphine tablets (standard oral, instant release) crushed and dissolved in the patient’s favorite cold cream.

Patient Reports

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:

  1. Prevent flares that require an emergency room visit.
  2. Prevent development of trigger points.
  3. Decrease early refill requests.
  4. Reduce required opioid dosage.
Table 2. Survey of 30 Patients Who Use Topical Morphine
  • Uses daily
  • Uses as needed for flares
  • Provides immediate relief
  • Provides relief within 10 minutes
  • Uses heat or bathes with it
  • Allow walking or stretching
  • Prevents trigger points or flares, early refills, or reduces oral opioids
  • Reduces “burning” pain

Case Reports

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.

  1. A 50-year-old diabetic female who weighs approximately 450 pounds and has legs which are so large and painful that she uses a wheelchair to move. Medications are numerous and include multiple diabetic agents, opioids, and gabapentin. Topical morphine is the only agent that has relieved the burning in her feet and allowed her to walk a few steps at a time.
  2. A 61-year-old male has degenerative spine disease and severe neuropathies of both lower legs. He takes multiple opioids and mexiletine. Topical morphine relieves burning in his lower legs, and he reports that morphine has reduced the discoloration of the skin over his ankles.
  3. A 56-year-old female has had multiple, failed back surgeries, and uses daily opioids, muscle relaxants, and a stimulant. She uses topical morphine about every 4 to 6 hours and claims that she is essentially bed-bound without it. Topical morphine allows her to stretch, walk, and participate in yoga and pilates after it is applied.


Topical morphine has only been investigated and used by this author in severe pain patients who take systemic opioids. The author has no corresponding experience with topical morphine in patients who are not tolerant to opioids or have pain problems other than severe, intractable pain. Also, trials were not done with opioids other than morphine, and it is possible that some other opioids may be more effective than morphine. Morphine applied to the skin does not appear to reach the systemic circulation or, at least, not in any concentration that would be systemically active. This is in contrast to the opioid fentanyl which, when applied to the skin, clearly creates a pharmacologically active systemic opioid with CNS analgesic effects.

One most intriguing aspect of the author’s investigations is that topical morphine almost immediately relieves pain when applied to the skin—despite a pain origination site that is several inches below the surface. This observation has been made by others.6 It is known that there are opioid receptors at the end of sensory nerves, so topical morphine likely attaches to them and somehow relieves deep pain.7 The precise mechanism, however, is unclear and needs to be researched. Further research may show that topical opioids are a viable, safe, non-abusable alternative to some oral opioids.


Basic science and clinical experiences suggests that topical morphine, and possibly other opioids, should be standard, adjunctive therapy in chronic pain patients who have severe enough pain to require systemic opioids. I have found topical morphine to be invaluable in some cases and a helpful adjunct in almost all other severe, chronic pain cases. Topical morphine is a practical addition to today’s pain clinic in that it enhances pain relief and prevents some adverse events such as trigger points, emergency room visits for pain flares, and early refill requests. Topical morphine, with a little cogent research, may be one of tomorrow’s first line treatments.

Last updated on: October 8, 2012
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