Posted by Elizabeth on April 26, 2002, at 19:20:11
In reply to For Bearded and all...., posted by cmcdougall on April 24, 2002, at 20:01:30
> I graduated from college in 1977. What a wonderful time to grow up!
I dunno, some of the styles of dress left much to be desired.... :-}
> Anyway, I knew more than a few junkies - I am still in contact w/ one woman my age who has been addicted to heroin for over 30 years. She is an attorney in DC with a very prominent corporate law firm. To look at her, you would never guess she used. So much for stereotypes...
There are a lot of people out there who are like that (addicts who have good jobs, education, money, etc.). You never hear about them because they have the resources to get their drugs without having to resort to dealing, stealing, etc.; and they only interact with the "drug scene" as buyers. They don't have to spend all their time or money getting drugs. Their lives lack the chaos often seen in the life of addicts who don't have the advantages they have. They provide a picture of what addicts' lives would be like if drugs were affordable and easy to get; and they cast doubt over the assumption that the chaotic lifestyle of many addicts is caused by the drugs themselves.
> My opinion of the safey and effectiveness of heroin is purely anecdotal.
It happens to be right anyway, though. :-)
> Near the end of her life, she was receiving about 4ccs [of morphine] every 15 minutes.
Umm...what was the concentration (how many mg in a cc)? Was it a continuous drip, or did she get discrete injections once every 15 minutes? (People can take surprisingly large amounts of medication on an IV drip. I'm told that at one point when I was in the hospital last February, they had me on 120 mg/day of Ativan.)
> I couldn't understand how we could give my sister so much morphine w/out killing her. The hospice nurse explained that morphine works on pain receptors and as long as there is pain, the morphine will not affect respiration or cardiac function. I do not know if that is true.
Uh, well, morphine works on mu opioid receptors. I'm not sure what the nurse meant. But it is true that tolerance to the respiratory depression from morphine develops more rapidly than tolerance to the analgesia.
> Strangely, she never seemed sedated no matter how much morphine she received. Sis was alert and very cognitive as long as her pain was under control.
Not everybody feels sedated on morphine. I found it moderately activating. But also, pain seems to "eat up" opioids, just as (in my experience, anyway) anxiety eats up benzos. (What I mean, for example, is that if I take 2 mg of Xanax, ordinarily I'd get really groggy, but if I take 2 mg of Xanax when having a panic attack, I feel fine.) Your sister's (no doubt massive) tolerance to morphine may have played a part as well.
> Eventually, the morphine quit working and we augmented w/ Valium.
My god. They didn't even try giving her fentanyl or anything? Every opioid has a limited effect size -- eventually, after you've become tolerant to very high doses, it will plateau and it won't do anything more no matter how much you increase the dose. (Buprenorphine, a "partial" agonist, plateaus at a much lower effect size.) At that point you need to find a stronger drug.
I'm very sorry to hear what happened to your sister. Nobody should have to die in pain, especially in a hospital or hospice.
> In contrast, as my father-in-law lay dying he received sublingual heroin (diamorphine). We never had to increase the dose and we never needed to augment.
Sublingual? Huh. I didn't know it was given by that route. I wonder what the bioavailability is compared with oral (low) and IV (high...so to speak).
> After 6 days, he slowly went into respiratory failure (from the cancer that had invaded his nervous system) and died peacefully.
How long was your sister on the morphine? If your father-in-law didn't become even a little bit tolerant to the diamorphine, that suggests that he was in relatively less pain than she was, and I'm also guessing that he wasn't on it very long. Still, I have little doubt that if it had been available, diamorphine would have been of help to your sister.
Unfortunately, your story isn't at all unusual. Many people suffer in their last days or months because doctors or nurses aren't willing to give them adequate pain medication. My mother, who is on the ethics committee at a teaching hospital, sees it regularly. I hope that I never have to watch someone die that way.
-elizabeth
poster:Elizabeth
thread:103502
URL: http://www.dr-bob.org/babble/20020425/msgs/104239.html