Those receiving stunningly high doses died no sooner than those taking much lower doses.Īnother study, by Luce and his colleagues in San Francisco, looked at 44 patients in intensive care units at two hospitals who were so ill that their doctors and families decided to withdraw life support. But to his surprise, he said, the investigators found no relationship between the dose of opiates a patient received and the time it took to die. The patients had cancer that was "very far advanced," said Portenoy, an author of the paper. Brescia of Calvary Hospital in the Bronx and his colleagues, examined pain, opiate use and survival among 1,103 cancer patients at that hospital, which is for the terminally ill. But Foley and others cite three studies that indirectly support the notion that if morphine causes death, it does so very infrequently. The actual data on how often morphine and other opiates that are used for pain relief cause death are elusive. Patients generally die from their diseases, not from morphine, Portenoy said. He said he was virtually certain that if doctors ever gave antidotes to morphine on a routine basis when dying patients started laboring to breathe, they would find that Lynn's experience was the rule. Portenoy, the other co-chief of the pain and palliative care service at Memorial Sloan-Kettering Cancer Center. "Joanne's experience is emblematic," said Dr. "In every single case, there was another etiology," Lynn said. One man, for example, was having trouble breathing because he had bled from a tumor in his brain, and an elderly woman had just had a stroke. But invariably, she said, she found that the drug was not causing the patient's sudden respiratory problem. Because she did not intend to kill the patient, she said, she administered an antidote. On rare occasions, Lynn said, she became worried when she escalated a morphine dose and noticed that the patient had started to struggle to breathe. So to protect herself in case she was ever questioned by a district attorney, she said, she videotaped the man playing with his grandson while he was on the drug. "Even I was scared," Lynn said, but she found that if she lowered the dose to even 170 milligrams of the drug per hour, the man was in excruciating pain. To relieve his pain, she ended up giving him 200 milligrams of a morphine-like drug, hydromorphone, each hour, 200 times the dose that would put a person with no tolerance to the drug into a deep sleep. She remembers one man who had a tumor on his neck as big as his head. Lynn said she sometimes gave such high doses of morphine or similar drugs that she frightened herself. The standard daily dose used to quell the pain of cancer patients, she added, is 200 to 400 milligrams. "They're taking 1,000 milligrams of morphine a day, or 2,000 milligrams a day, and walking around," she said. Kathleen Foley, who is co-chief of the pain and palliative care service at Memorial Sloan-Kettering Cancer Center in New York, said she routinely saw patients taking breathtakingly high doses of morphine yet breathing well. But even though they end up taking doses of the drug that would quickly kill a person who has not been taking morphine, the drug has little effect on these patients' breathing.ĭr. Lynn said, is that as patients' pain gets worse, they require more and more morphine to control it. The patients, she said, become more tolerant of the drug's effect on respiration than they do of its effect on pain. ![]() Joanne Lynn, director of the Center to Improve Care of the Dying at George Washington University School of Medicine. But something peculiar happens when doctors gradually increase a patient's dose of morphine, said Dr. ![]() No one denies that an overdose of morphine can be lethal. Balfour Mount, a cancer specialist who directs the division of palliative care at McGill University in Montreal, says it is "a common misunderstanding that patients die because of high doses of morphine needed to control pain."
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