Opiophobia in Palliative Care: Conquering the Last Hill

Opioids are among the most challenging medications. As physicians, we prescribe opioids at least once throughout our careers, including codeine, tramadol, pethidine, methadone, or morphine. At the same time, we continue to have concerns about side effects and fallacies associated with opioids despite years of knowledge and experience. Studies demo-nstrate that cancer patients are often under-prescribed with opioids resulting in preventable and unnecessary suffering.۱ Here is a case report of how the prescription of morphine can cause a complicated situation: Ms. G. was ۶۸ years old suffering from dyspnea for the past three weeks. She was admitted to the emergency department where her severe right pleural effusion was managed by inserting a tube thorac-ostomy. She was a known case of triple-negative breast cancer for two years, and despite all therapeutic interventions, cancer had spread to the bones and lungs. Thoracentesis only slightly relieved her dyspnea. The oncologist referred her to the palliative care clinic for symptom management, specifically pain and dyspnea. She lived with her only daughter (Ms. K.) and preferred staying at home as much as possible. On the day of the visit to the palliative clinic, Ms. K. arrived while pushing her mother in a wheelchair. Ms. K. complained that her mother had been barely eating or drinking anything over the past month. She was in pain, and dyspnea hindered her ability to speak. A palliative care physician prescribed morphine to alleviate her pain and dyspnea. It included ۲.۵mg subcutaneous injection of morphine q۶h and additional injection as needed. The following week, Ms. K. returned to the clinic in a black outfit. Bursting into tears, she shouted at the physician that her mother died the day after receiving morphine and that a paramedic staff who had transported Ms. G.'s body had told her the morphine caused respiratory suppression and death.