Dr Edin Lakasing’s article “Palliative care in primary care”1 in the November issue of GM was a concise summary of some of the issues and important points to consider when providing palliative care in the community.
The article dispelled some of the common myths surrounding opioids, but we would like to expand on a point about the myth that they cause respiratory suppression.
Firstly, there is sound evidence to show that when opioids are prescribed for pain and doses are titrated appropriately, the risk of respiratory depression is minimal,2-4 even in those with coexisting airways disease.5 Pain is a natural antagonist to respiratory depression,5 and a study of patients given morphine during the day with a double dose at night time showed no excess mortality.6 Even if a patient with advanced disease is dyspnoeic then opioids can be used to relieve this symptom at doses that do not cause respiratory suppression.7-9
The belief that respiratory suppression may be beneficial in the dying patient is misleading and tantamount to saying that hastening death is a desirable side effect. The doctrine of double effect is often referred to in relation to prescribing opioids. Sadly this serves to perpetuate the myth that opioids given for symptom relief are likely to hasten death.10 This places an unnecessary burden on clinicians who are managing symptoms appropriately but mistakenly believe they may be hastening death by doing so.11 Potentially this could lead to misinformation of junior colleagues, perpetuating reluctance to prescribe opioids when they are needed.12
These myths do not only exist amongst the medical profession but are also common amongst patients and relatives. As clinicians our own uncertainty, misinformation and lack of confidence in this area may be serving to sustain patients’ beliefs that morphine hastens death. This exacerbates the problems of non-compliance and thus results in inadequate symptom control and anxiety.13
Therefore we owe it to the profession and more importantly our patients, to prescribe opioids appropriately and with confidence. The Palliative Care Formulary suggests starting doses of regular Oramorph for pain in patients who have been on weak opioids at 10mg four hourly, or 5mg if patients are frail or elderly14; similarly NICE recommends a starting dose equivalent to 20–30mg oral morphine a day if no renal/hepatic dysfunction.15 Regular review of patients and titrating doses as necessary should allow us to prescribe them with the assurance that the myth of “opioids cause respiratory suppression” is not clinically relevant.

1. Lakasing E. GM 2012; 42 http://gm.olmstaging.com/Palliative_care_in_primary_care_29115.aspx
2. Sykes N, Thorns A, Sykes N, Thorns A. Lancet Oncol 2003; 4: 312–18
3. Mazzocato C, Buclin T, Rapin CH. Ann Oncol 1999; 10: 1511–4
4. Estfan B, Mahmoud F, Shaheen P, et al. Palliat Med 2007; 21: 81–86
5. Borgbjerg FM, Nielsen K, Franks J. Pain 1996; 64: 123–28
6. Regnard C, Badger C. Palliat Med 1987; 1: 107–10.
7. Allen S, Raut S, Woollard J, et al. Palliat Med 2005; 19: 128–30
8. Clemens KE, Quednau I, Klaschik E. J Palliat Med 2008; 11: 204–16
9. Abernethy AP, Currow DC, et al. BMJ 2003; 327: 523–28
10. George R, Regnard C. Palliat Med 2007; 21: 77–80
11. Forbes K, Huxtable R, Forbes K, Huxtable R. Palliat Med 2006; 20: 395–6
12. Larue F CS, Fontaine A, Brasseur L. Cancer 1995; 76: 2375–82
13. Reid CM, Gooberman-Hill R, Hanks GW. Ann Oncol 2008; 19: 44–48
14. Twycross R, Wilcock A. Palliative Care Formulary. 4th ed: palliativedrugs.com, 2011.
15. NICE guidance. www.nice.org.uk/CG140