Hospice Patients Alliance: Patient Advocates





Dumb and Dumber




Part One - Misuse of Opioid Medications
by Ron Panzer

Updated May 1, 2016




Chemical formula of Morphine Chemical formula of Heroin also known as Diamorphine

Very, very few people will look at these two chemical formulas and know what chemicals they represent. Almost nobody else will, but we'll get back to them later.

Without qualifying what they are saying, many hospice staff routinely tell patients and families, "Morphine can never harm you." "Morphine is always absolutely safe." And some have even said, "Morphine never killed anyone!"

Ridiculous! Dumb! And, absolute lies!

Of course, responsible physicians, nurses and pharmacists know that morphine and other opioid medications can be used safely if the standards for administering them are followed. And yes, these medications are extremely helpful in relieving certain types of severe pain, but can be completely ineffective for other types of pain.

Unfortunately, the standards for administering these medications are often not followed. What happens if too much morphine is given? What happens if the patient doesn't need an opioid medication at all?

Like any medication, opioid medications have adverse effects as well as the beneficial, intended medical effect. The main adverse effect of morphine is respiratory depression, because opioids effect the respiratory center in the brain. The breathing is made to slow down, and if a severe overdose is given, the breathing stops and death occurs. Death! An adverse effect like death is not something to be ignored!

All of this may sound strange to patients and their families who have been told, "Morphine helps the breathing."

Yes, morphine can calm the patient, slow the breathing, relax a patient, and of course, relieve severe pain. It can even bring them a type of euphoria in some cases. If given in a low dose, it can make them feel they are breathing better. That morphine helps the breathing is something hospice staff are being taught, but trying oxygen or using other basic treatments first is certainly wiser and more helpful.

The last thing hospice staff want patients or families to do is to fear taking morphine or any opioid. In fact, that is number one on the list of things not to do: add to the patients' fear. Having a terminal illness is already quite frightening to many.

Pro-life staff don't want them to fear it, but to respect it. Euthanasia-leaning hospice staff don't want them to fear it while they use it surreptiously to end lives. In fact, hospice staff who read this article will be infuriated that anyone would tell patients and families that in some cases opioids like morphine can kill.

If patients or families do happen to learn that truth, then at least the staff will reassure them that they should not worry. "Don't worry! We are professionals!" "We will keep you safe!" "Trust us!"

Pro-life staff, becoming rarer by the day, assure them that they will use these powerful and effective tools to relieve suffering wisely, within the standard of care — and they will — and the patients will be safe. However, euthanasia-leaning staff will assure them just the same way, yet they do and will betray the patients and their families while violating the standards of care in order to accomplish their goal: death.

Patients and their families entering the healthcare system are walking into what has become, in some situations, a hostile-to-life environment! That is exactly the opposite of what they need and what they want.

In the case of a patient who is experiencing shortness of breath for various reasons, raising the head of the bed so the patient is sitting up higher may be helpful. Using a fan to circulate the air in the room may be helpful.

Giving a nebulizer treatment to an emphysema/COPD patient with constricted airways will be more helpful as a first treatment, especially because many of these patients die very easily from opioid overdoses: they have a poor respiratory effort that is more easily shut down. Yet, some hospice agencies will work to prevent family caregivers from using nebulizer treatments, sometimes telling them, "It's no use now that she's dying." They can be very convincing, even if they're knowingly "mistaken" in what they say.

If the patient has a tracheostomy and fluid is building up in the lungs, removing it by suctioning it out is an obvious and basic nursing intervention. Most experienced nurses who work with these patients have done that thousands of times. But, if there is no tracheostomy, there are medications to give that help at least partially to reduce the fluid buildup in the lungs.

If the patient is quite anxious, a low dose of anti-anxiety medication that does not put the patient into a coma is more appropriate. All of these measures are basic interventions that should be offered first, before opioids are used to "help the breathing."

If the breathing is not rapid, giving morphine to slow the breathing is not appropriate. When there are breathing problems, giving morphine should not be the first choice! However, in many hospice and palliative care settings today, morphine is the first and sometimes only intervention made. If there is a second intervention and only a second intervention, giving a sedative is often what is done.

If staff push to have you agree to administer the morphine, even when it doesn't fit the patient's condition, the patient has a right to refuse that should not be violated. If staff intimidate the patient or the family members, if they try to make you feel guilty that you are not giving the morphine "for the breathing," when the patient doesn't need it, stand up to them. If they tell you that the patient is in severe pain if they wiggle a toe once or simply try to speak, you can know they are manipulating you. Hospice staff should respect the patient's needs and wishes! The problem is too many do not.

Yes, there are ways to discern whether the patient is in pain or not, even when they are not able to communicate, or when they are sleeping, but wiggling a toe is not one of those signs. Furrowing the brow, certain facial expressions, keeping the body tight with muscles flexed and tense (guarding), or moaning, are some signs of pain, but you would need to see the total picture and usually see more than one sign there is unverbalized pain. But moaning could mean the exact opposite: a patient might be objecting to getting the morphine but is too snowed by the morphine and sedatives to be able to speak plainly!

Families know their loved ones. If the behavior or movements you see are normal and not indicative of pain to you, then don't think that all of a sudden these signs are representing pain when you are told, "We must give morphine now!" Listen to your instincts, your intuition, and your knowledge of the patient. Carefully consider what is going on. For the patient's sake, don't allow yourself to be intimidated and manipulated.

Hospice staff are irresponsible if they say that morphine never kills, is absolutely safe no matter how high the dose they give, and never hurt anyone (without qualifying what they are saying). The Nazis perfected the use of morphine to kill patients who were selected for euthanasia. In too high a dose, it puts the patient to sleep, the breathing stops, and the patient dies. Outwardly, it looks very peaceful, but evil can be done in more ways than simply shedding blood!

Think about it: one of the first things the pharmaceutical company's official package insert for morphine says about morphine in its "warnings" section is: "Misuse of narcotic medicine can cause addiction, overdose, or death." It could not be any plainer!

On the one hand, patients need pain relief, and morphine or other opioids are very effective. On the other hand, they are powerful medications and need to be given with care. Truly professional care is needed, and the patient's family as patient advocates must be watching to make sure only medications that are needed are given, and only given in doses that are required by the patient's condition.

Authentic, supportive, end-of-life care professionals will also assure that these medications are only given as clinically needed — that's their job! But tragically, end-of-life care is often not authentic, not supportive, and not professional. That's because the euthanasia industry infiltrated much of the hospice industry a long time ago.1 2 3 4 5

When used properly, morphine is actually very safe. We should understand that opioids are not helpful for all types of pain — severe intestinal spasms, for example. In this case, an antispasmodic medication can make all the difference. Yet, even though increasing doses have no effect, I've walked in on some hospice staff just increasing the dose even more! You could increase the dose forever and simply put the patient to death, but the spasms would never have been addressed. Dumb!

Only the appropriate medication for the patient's clinical condition will be effective. That takes clinical expertise that many hospice staff simply do not have, because in a hospice that is euthanasia-oriented, they are often not trained properly. These staff give everyone the same drug cocktail of morphine and Ativan (lorazepam) — or they fill in the blank and use any alternate opioid or sedative that is on the standing orders list. Too many of them think that that is good hospice care!

If you encounter a hospice or palliative care setting where every patient is getting exactly the same medication cocktail, and every patient is always sleeping (in a medically-induced coma), even though they have widely varying clinical conditions, you can know for sure that there is something seriously wrong. Get the patient out of there as fast as you can! The patient has the right to switch to another hospice once within a certification period (where the physician certifies the patient has a terminal illness). If you can, contact another hospice and have them facilitate the switch.

Sometimes, patients who have little pain or have never taken strong pain medications are given these very potent medications — often with lethal results.

Morphine is a great tool for pain relief that can be used as a blessing or a curse and needs to be respected for what it can and cannot do. Let's take a look at the pictures of chemical formulas again to shed some light on the subject.

Chemical formula of Morphine Chemical formula of Heroin also known as Diamorphine

Do you notice anything about these two chemical formulas? The main part of both molecules (on the right side) is the same. What's the difference? The chemical represented by the left image has two hydroxyl groups (OH) consisting of an O (oxygen) and an H (hydrogen) shown on the left. The chemical molecule represented by the image on the right has two acetyl groups consisting of the H3C or CH3 (a methyl group) and an O (oxygen) shown on the left. That may be confusing but the main idea is that both molecules are almost exactly the same.

The molecule on the left is Morphine. The molecule on the right is Heroin, also called Di-acetyl Morphine or Diamorphine. What happens to heroin when it enters the body? One of the two acetyl groups is removed through metabolic processes and the molecule becomes mono-acetyl morphine and then another acetyl group is removed to form pure morphine.

The "high" that heroin addicts seek is the same as that given by morphine, although heroin crosses into the brain quicker. In fact, heroin has been used medically for quite a while in just the same manner as morphine and is still used this way in the United Kingdom. Both are very effective in relieving certain types of severe pain, and for those who are terminally ill, the question of them being addictive is not relevant. No terminally-ill patient should ever worry about becoming addicted to these medications.

For obvious reasons, patients and their families need to monitor what is happening with the medications. Are the medications given appropriate for the patient's clinical condition? Is the dose given needed? Remember, shortening the time interval between doses is the same as increasing the dose! Increases should only be made if the patient's pain is not controlled.

When hospice staff use these medications appropriately, there is nothing to fear. If the pain is not controlled, then an increase in dosage is appropriate, justified, and adverse effects are much less likely to occur. But let's stop kidding ourselves: these medications need to be respected. Hospice staff who do not show respect for these medications are either dumb, ignorant, or lying about what is going on. They may be intending to impose death without letting the patient and family know what is going on.

If I asked you, "Can heroin kill?" You would know the answer right away. Just think of the hundreds of celebrities who died of overdoses. Heroin, which is one of the most common drugs that have caused death, is morphine once it's absorbed into the body. So, it's obvious that morphine can kill if misused, just like heroin. Other opioids also affect the respiratory center in the brain, so they can cause death in just the same way if an overdose is taken. According to the U.S. Centers for Disease Control and Prevention:

Opioids (including prescription opioid pain relievers and heroin) killed more than 28,000 people in 2014, more than any year on record. At least half of all opioid overdose deaths involve a prescription opioid.6


That number, 28,000, does not include deaths within a hospice or palliative care setting! These deaths are people "on the street," or in their homes, taking opioids with or without a prescription. If opioids cannot kill, as many hospice staff will tell you, have them explain these tragic, untimely deaths!

Of course, some will tell you that heroin is taken intravenously so it has a much faster onset and the effective dose circulating in the bloodstream will be much higher taken this way. That is true. Morphine or other opioids given intravenously also have a double or even triple effect using the same dose if given intravenously compared to if given orally. Nevertheless, that we are dealing with the same morphine molecules (once heroin is absorbed into the body) should be understood, and therefore this medication (and similar opioids) are to be respected.

Even with oral tablet forms of opioids, thousands of people are still dying, because the standards are not being followed, or the patient is not being closely monitored at all, or the individual taking the oral opioid has not even been prescribed that medication and does not need it for symptom relief. When the medication and dose fits the patient's need, and the medication is taken as ordered, and the patient is being closely monitored for adverse effects, it would be a rare occurrence for patients to die from that opioid.

In fact, staff who authentically care for the patient will use a medication like Narcan (naloxone) to reverse the effects of an opioid overdose if one occurred just as might be done in a hospital emergency room. When staff are pro-life, terminally-ill patients' distressing symptoms are managed and the patients are given supportive treatment until they die from their incurable terminal illness, not from any form of stealth euthanasia.

Now, many hospice staff will be infuriated that this has been explained, because they don't want patients and their families to fear the medications being used, or to think some of them may be imposing death, and that is understandable. Many hospice staff also do not know the details explained above about the similarity between morphine and heroin, yet, the patients and family members have a right to know the truth. This is part of the right to informed consent that is basic to the standards of health care.

There are standards of care for everything that is done within healthcare, and administering opioids is one area that especially requires that they be followed. Whether the patient is given morphine, hydromorphone (Dilaudid), oxycodone, methadone, fentanyl, hydrocodone, or any other opioid (short or long-acting), the standards for administration must be understood and followed so that the patient's safety and well-being is assured.7

So remember: if a hospice staff member tells you, "Morphine has never harmed anyone." Or, "Morphine at any dose is absolutely safe," without qualifying what they are saying, you can know that they are either dumb, ignorant, or lying to you.

Any so-called "expert" who tells you that there are very few untimely, imposed deaths within hospice or palliative care settings is either dumb, ignorant, or lying to you! If it is clear that they are not dumb or ignorant, you can be sure they are lying. If they are pro-life leaders, then they are frauds.

Morphine (or other opioid) given in appropriate doses, to those patients who need it, is safe and a blessing at a time of great need!



Next:    "Dumb and Dumber - Part Two: The Age of Lies"







Endnotes:


  1. Ron Panzer, Time to Wake Up to the Realities of Hospice, Mr. Smith!, Feb 7, 2015, Hospice Patients Alliance. Back


  2. Ron Panzer, Getting It Right (Contra Smith and Byock) - Part One, March 7, 2015, Hospice Patients Alliance. Back


  3. Ron Panzer, The Call and the Counterfeit - Getting It Right (Contra Smith and Byock) - Part Two , April 4, 2015, Hospice Patients Alliance. Back


  4. Ron Panzer, Remembering The Religious Foundation of Cicely Saunders' Hospice Mission, April 13, 2015, Hospice Patients Alliance. Back


  5. Hospice Patients Alliance, From Euthanasia Society of America to the National Hospice & Palliative Care Organization (1938 to Present), Hospice Patients Alliance. Back


  6. U.S. Centers for Disease Control and Prevention, Injury Prevention & Control: Opioid Overdose , Retrieved April 29, 2016, U.S. CDC. Back


  7. Hospice Patients Alliance, Clinging to the Original Hospice Mission - Part Three: Standards of Clinical Practice , Retrieved April 30, 2016, Hospice Patients Alliance.
       Hospice Patients Alliance, Hospice Staff Almost Never Use Narcan To Counteract Lethal Overdosages of Narcotics, Death from overdosage can be prevented,,
          Pain Crisis is Not Necessary if Narcan is Titrated , Retrieved April 30, 2016, Hospice Patients Alliance.
       ClinCalc.com, Equianalgesic dosage conversion calculator, Retrieved April 30, 2016, ClinCalc.com.
       Stephen Kishner, MD, MHA; Chief Editor: Erik D Schraga, MD, Opioid Equivalents and Conversions,
          Retrieved April 30, 2016, Emedicine - Medscape. Back




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