title: Patterns of high-dose morphine use in a home-care hospice service: should we be afraid of it?
abstract: BACKGROUND
  Management of cancer pain is one of the most important goals of palliative care. Relieving pain is often problematic. High doses of morphine at home may be required to relieve patients' pain, and is therefore feared. The goals of the current study were to assess the feasibility of high-dose morphine use at home, to characterize the patients, and to examine whether the use of high-dose morphine might affect their survival.
  
  
  METHODS
  The authors retrospectively studied the medical charts of 661 outpatients, which were completed by a home-care hospice team. The authors collected data regarding demographic parameters, medical diagnosis, pain type, morphine dosage, use of rescue doses in addition to regular doses, use of coanalgesics and adjuvant treatments, and survival time as associated with morphine dosage. The authors also compared the data of patients receiving high-dose morphine with those of a group of patients receiving regular doses.
  
  
  RESULTS
  The authors identified 435 patients (65.8%) who received morphine for pain relief. Of these, 396 patients (91%) received a dose of 5-299 mg of morphine per day), 32 patients (7.4%) received 300-599 mg of morphine per day), and 7 patients (1.6%) received very high doses (> or = 600 mg of morphine per day). Overall, 39 patients (9%) received > 299 mg per day. Morphine dosage was found to be inversely correlated (r) with age (r = -0.254; P < 0.001). Male patients required slightly higher dosages than female patients (62.5% of high-dose and 71% of very high-morphine groups, respectively). Primary gastrointestinal (P = 0.015) and lung (P = 0.027) carcinomas, as well as metastatic bone disease (P = 0.001), ovarian carcinoma (P = 0.037), and brain tumors (P = 0.0053) were associated with higher and very higher morphine dosages. Adverse effects were similar in the groups receiving regular, high, and very high doses of morphine. The median survival of patients treated with high doses of morphine was 27 days and was 37 days for those treated with very high doses. Patients treated with low doses of morphine survived for 18 days. Patients not treated with morphine survived for 22 days (P = 0.001 by Mantel-Cox analysis; P = 0.029 by Breslow analysis).
  
  
  CONCLUSIONS
  The use of high and very high morphine doses at home proved safe and did not appear to affect the patients' life expectancy adversely. The use of high or very high-dose morphine should not be a barrier to providing palliative terminal care for home-care hospice patients.
authors.affiliation: Tel Hashomer Hospice, The Chaim Sheba Medical Center, Israel. almi@sheba.health.gov.il
authors.forename: Michaela
authors.initials: M
authors.lastname: Bercovitch
authors.forename: Abraham
authors.initials: A
authors.lastname: Adunsky
mesh_terms: D000368:Aged; D005240:Feasibility Studies; D005260:Female; D006699:Home Care Services; D017051:Hospice Care; D006801:Humans; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D009369:Neoplasms / Q000628:therapy*; D010148:Intractable Pain / Q000188:drug therapy*; D010166:Palliative Care; D012189:Retrospective Studies; D016019:Survival Analysis; D013727:Terminal Care
chemical_list: D009020:Morphine