Morphine

What Kind of Drug Is It?

Morphine is a natural product of the opium poppy plant. Of the many mind-altering compounds in the opium poppy, morphine is the strongest. The drug has many important medical uses, all having to do with pain control. It is never used to treat emotional or psychological problems.

For many people recovering from painful surgery—and for even more people facing the daily agony of end-stage cancer—morphine can dramatically improve their quality of life. The drug, called an opiate, has been used for pain relief for many years, in many different cultures worldwide.

When prescribed for a patient by a physician, morphine can help speed recovery from operations, ease the pain and trauma of childbirth, and give dying people relief from incurable pain. When used illegally as a recreational drug solely to get high, morphine is highly addictive with many unpleasant side effects. When purchased on the street, it is usually found in the form of heroin, a substance that turns to morphine in the brain. (An entry on heroin is available in this encyclopedia.)

Whether used legally or illegally, morphine is a very dangerous drug. Overdoses can cause fatal breathing problems. Even those who use it for pain relief can develop a dependence or physical need for the drug. Doctors tend to be very conservative when they prescribe it for pain because they are aware of its risks and drawbacks. Since the beginning of the twenty-first century, patients' rights groups have urged the medical community to use morphine more freely to control pain. They believe that patients in severe pain would be more likely to contemplate or commit suicide if they were unable to use the drug.

Official Drug Name: Morphine sulfate,morphine hydrochloride (for injection); Duramorph (spinal injection); MS Contin, Oramorph, Kadian, MSIR (pill and tablet forms); Roxanol (liquid for oral use)

Also Known As: M, Miss Emma, monkey, morph, white stuff

Drug Classifications: Schedule II, opiate

Overview

Morphine is derived from a flowering poppy called Papaver somniferum. This plant can grow in many environments, but it thrives in a soil that contains some sand and loam, in higher elevations with cooler temperatures. Opium poppies were first grown by people

6,000 years ago in the area that is now Iran and Iraq. A manuscript from the ancient Egyptian city of Thebes, dating to 1552 bce, mentions opium as a cure for more than 700 illnesses.

From Plant to Drug

Although the leaves and stems of the opium poppy plant also contain opiates, it is the sticky sap in the bulbs that has the most strength. The bulbs begin to ripen after the flower petals fall. As the bulbs ripen, skilled farmers cut them, and the sap flows out. Once collected, the sap is dissolved in boiling water. The twigs and other plant material float to the surface, and the boiled opium is strained. It is then cooked a second time, this time to remove the water. Once the water has evaporated as steam, what remains is a putty-like substance called "smoking opium." After this simple process, users sometimes smoke or eat the opium to get high.

More commonly, though, the cooked opium goes through another chemical process. Again it is boiled, this time with lime. The lime converts the opium from a non-water soluble morphine alkaloid into the water-soluble calcium morphenate. Ammonium chloride is added to the solution, and this causes the morphine to settle to the bottom of the cooking pot. The solution is poured through a straining cloth, and what remains is chunks of morphine that are dried in the sun. Legally, these morphine "bricks" are processed into prescription painkillers. Illegally, they are smuggled into laboratories and turned into heroin.

Addictive Effects

None of this chemistry was known to opium farmers in the era prior to modern medicine. In the Middle Ages (c. 500–c. 1500), opium was mixed with wine or other alcohol and called "laudanum." Crude opium was also smoked, particularly after the introduction of pipes from the Americas after Columbus (1451–1506) reached the New World in 1492. When opium smoking became widespread in Asia—and particularly in China—the destructive and habit-forming effects of the drug began to be revealed.

In 1803 German chemist Friedrich Sertürner (1783–1841) experimented with opium and isolated morphine for the first time. He named his discovery after the Greek god Morpheus, who is often depicted in ancient statues sleeping among opium poppies. Within thirty years of Sertürner's discovery, it was possible to buy medicines with morphine from any store that sold remedies. Both morphine and opium cost less than alcohol, and the substances were abused by famous and common people alike. The users of morphine and opium-laced medicines were aware of the dangers. As early as 1821 author Thomas de Quincy wrote Confessions of an English Opium Eater, describing his personal experiences of addiction and drug-induced mental breakdown.

Morphine, a painkiller that can be dissolved in water, came to the forefront in 1848, when an inventor perfected the hypodermic needle. This allowed the substance to be injected right into a vein, producing pain relief (and euphoria) in minutes. Surgeons welcomed this new tool, since it enabled them to perform pain-free operations. But the medical community quickly learned that morphine was habit-forming. In his book Illegal Drugs: A Complete Guide to Their History, Chemistry,

Use and Abuse, Paul M. Gahlinger estimates that 400,000 soldiers became addicted to morphine during the American Civil War (1861–1865). Morphine addiction was so common among returning veterans that it was called "the soldiers' disease."

Discovery of Heroin

Doctors and chemists continued to experiment with morphine, hoping to create a product that would be less habitforming but would still control pain. Codeine was isolated in 1832. It was not as strong as morphine but was used in cough formulas and diarrhea medications. Soon it was found to be addictive as well. Another experiment on the morphine compound occurred in 1874, when British chemist Alder Wright created diacetylmorphine (DIE-uh-SEE-tuhl-MOR-feen), marketed as heroin.

With the introduction of heroin, morphine users and opium smokers hoped they had found a cure for their addictions. Many tried heroin to wean themselves off the other substances. In doing so, they traded a bad addiction for an even worse one. By that time, over-the-counter medicines containing codeine, morphine, heroin, and cannabis (marijuana) could be bought for problems as varied as toothaches, headaches, and fussy babies. (Entries for codeine and marijuana are available in this encyclopedia.) At that time, people did not realize the dangers of using such products.

Dealing with the Growing Abuse

China had long struggled with large numbers of opium addicts. As Chinese immigrants came to the United States to work, some brought the habit with them. By the late 1800s, almost every major city in the United States had at least 1 opium "den"; New York had more than 300. Opium dens were darkly lit establishments where people went to smoke opium. Many dens had beds, boards, or sofas upon which people could recline while experiencing the effects of the drug.

On February 1, 1909, China and the United States led a meeting called the International Opium Commission. Eleven other countries participated. Three years later, a convention in the Netherlands produced the first international agreement on the regulation of narcotics—especially opium and heroin. Gahlinger wrote: "This began a process whereby the United States took a global leadership in controlling the international narcotics trade, even while its own domestic use of addictive drugs was rampant. One hundred years later, this situation has not changed."

The Harrison Narcotics Act of 1914 made it illegal to sell medicines containing heroin, morphine, or opium without labels warning of the presence of the drug in the product. In 1926 heroin was made completely illegal. Morphine remained legal but only when prescribed by a doctor.

The twentieth century was marked by enormous progress in surgery, medications, and treatments of all sorts of diseases. Scientists

developed synthetic painkillers based on the properties of morphine, such as oxycodone and fentanyl. However, they made no progress in removing the habit-forming effects of the substances. (Entries on oxycodone and fentanyl are available in this encyclopedia.) Morphine is still widely used in hospital settings and is prescribed as pills and liquids. It is also available in a pump implanted in the body, for use in the most stubborn, ongoing, and incurable pain. Except in the case of surgery, doctors use morphine as a drug of "last resort," after all other painkillers have failed. It is most often used when a patient is dying. At the last stage of life, the fact that morphine is addictive is no longer significant.

What Is It Made Of?

Morphine is an alkaloid, the chemical class to which many drugs belong. It is also an organic product, meaning that it is derived from a plant. The process of extracting morphine from opium is so simple that farmers can do it alongside their fields, with few other tools than cooking pots, lime (an ingredient in fertilizers), and ammonium chloride (also found in fertilizers). In its basic form, the morphine alkaloid is not soluble in water. Once it has been treated with lime and ammonium chloride, however, it becomes the water-soluble compound calcium morphenate. Further treatments produce morphine sulfate, morphine hydrochloride, and morphine. All of these are used in medicines.

After having gone through chemical processing, morphine salts appear as a bitter white powder. Some people take this powder by mouth, while others snort it or dissolve it in water and inject it. Morphine products are not as fat soluble as heroin. A highly fatsoluble drug like heroin enters the bloodstream quicker and moves to the brain faster, no matter how it is taken. As such, morphine products do not work as quickly to produce the intense high that is experienced with heroin use. Injected morphine does work quickly, in about five to ten minutes, whereas heroin works almost immediately.

The vast majority of legal morphine is converted to codeine, a milder painkiller and cough suppressant used in great quantities worldwide. The remainder of legal morphine is processed as a painkiller. More than 1,000 tons of morphine are produced legally every year, from poppies grown on government-regulated farms in India, Turkey, and the Australian province of Tasmania. Illegal opium production is widespread in the highlands of Burma, Laos, Vietnam, Thailand, Pakistan, Afghanistan, Colombia, Mexico, and Lebanon.

How Is It Taken?

Prescription morphine comes in many forms. As morphine sulfate and morphine hydrochloride, it is a liquid injected into veins. As Duramorph, it is a liquid injected into the fluid surrounding the spine. This type of injection is called an epidural. Duramorph is used in childbirth and some forms of surgery that can be performed while a patient is awake. Morphine pills of various strengths are also available and are prescribed for cancer pain, back pain, recovery from surgical procedures, and occasionally migraine headaches. The drug can also be found in rectal suppositories. The latter form of morphine is usually given to people suffering from nausea. A liquid form of morphine is available for oral use among patients who have difficulty swallowing pills.

Some patients use morphine pumps. These come in two forms. Either the patient is hooked up to a needle (IV) and can press a button to increase the flow of morphine through the needle, or a morphine dispenser is implanted under the skin, releasing a set dose of the medicine at hourly intervals. The pumps are usually programmed so that a patient cannot receive too much morphine and overdose. Too much morphine can lead to death by stopping a patient's breathing.

Morphine is usually sold illegally on the street in its pill forms. Users crush the pills and snort, smoke, or inject them.

Are There Any Medical Reasons for Taking This Substance?

Morphine is used most often to ease the pain of dying from cancer. Cancer causes tumors (abnormal growths) in just about any organ in the body, from the brain to the limbs. These tumors can cause intense pain that never goes away. Morphine does not shrink tumors. Rather, it causes the brain not to respond to the pain that the tumor causes. Patients know they are in pain, but they feel more comfortable. Their anxieties are also eased by the relaxing components of the morphine.

Newspapers and magazines report cases of end-stage cancer patients who, with high doses of morphine, are able to take care of themselves around the home, do tasks such as gardening and attending family functions, and even work on projects they want to finish before death. hospice workers who try to make dying patients as comfortable as possible report a greater sense of calm and less trauma for the patient and family when morphine is used to sedate and control pain.

Recovery from surgery without morphine would be a terrible ordeal for many patients. Even though the drug is often used only for the first few days, it greatly eases the pain and trauma the patient feels after a procedure. Used in this way it does not promote addiction. As the body recovers, doctors reduce the doses of the painkiller, eventually switching to over-the-counter products such as aspirin, acetaminophen, or ibuprofen.

Morphine's Not for All Patients, Though

For chronic, or ongoing, conditions such as back pain and migraine headache, morphine is never used as the first drug for treatment. Typically the drug is only prescribed for people who have used other opiate or opioid painkillers, or other prescription drugs, with disappointing results. Morphine's side effects—tolerance, constipation, nausea, drowsiness, and dizziness—make it a drug of last resort for people in pain.

Some people suffer pain that does not respond to morphine. This kind of pain, known as nerve damage, is particularly frustrating both for patients and their doctors. If nerves are damaged, they cannot read the chemical message morphine sends them.

Terri Schiavo

One of morphine's main uses is in end-of-life situations where doctors try to control pain and suffering. In March of 2005, after a long legal battle, Terri Schiavo—who was diagnosed with severe brain damage and no hope of recovery—was removed from the feeding tube that had kept her alive for fifteen years. As she perished from starvation and dehydration, doctors administered morphine to ease any suffering she might have felt. Terri Schiavo died on March 31, 2005.

Doctors who prescribe morphine must be certified to do so by the U.S. Drug Enforcement Administration (DEA). Morphine prescriptions require extra paperwork to determine how much medicine each patient receives and whether or not the doctor is

over-prescribing it. In response, doctors tend to under-prescribe morphine for two reasons. First, doctors do not want to be seen as dispensing drugs without good reason. Second, doctors do not want to take the chance that a dose they deem safe for a patient might actually lead to a fatal overdose.

Usage Trends

Morphine enters the illegal market in two ways. Most of it is transformed into heroin in illegal laboratories in Asia, Mexico, and South America and smuggled into the United States. The rest is diverted from its legal use through theft from pharmacies or through "doctor shopping" for prescriptions. An illegal practice, doctor shopping occurs when an individual continually switches physicians so that he or she can get enough of a prescription drug to feed an addiction. This makes it difficult for physicians to track whether the patient has already been prescribed the same drug by another physician. Additionally, some morphine fatalities can be tied to people legally taking the drug, but taking it in higher doses than recommended, or combining it with other painkillers, alcohol, or cocaine.

People of all ages and income levels abuse prescription painkillers, sometimes with fatal results. Users often start taking the prescription drug for a painful condition and wind up abusing it for the mental effects. It is difficult to determine the number of deaths caused by morphine every year because heroin shows up as morphine on drug tests. Sometimes the cause of death is simply listed as "opiate overdose," and this could also include codeine or other prescription painkillers.

According to the "2003 National Survey on Drug Use and Health (NSDUH)," an estimated 119,000 teenagers between twelve and eighteen had tried heroin at least once. If given a drug test, these teenagers would test positive for morphine. Emergency room mentions of pure morphine are much lower than those for heroin, OxyContin, and Vicodin. The strength of morphine, the difficulties doctors face prescribing it, and the close watch kept on supplies in hospitals and pharmacies tend to keep illegal supplies low. Plus, the higher purity of illegal heroin makes that drug more attractive for abuse.

Effects on the Body

Morphine floods a group of receptors in the brain and spinal column that take in endorphins and enkephalins. Biologists think that endorphins and enkephalins work together naturally to dull pain or to ease anxiety when someone is hurt or close to death. Morphine replaces these natural molecules, and in a much greater quantity than the body can supply. Pain signals surging from an injury or a cancerous tumor cannot relay their messages to the brain because morphine has blocked the receptors that register the pain, while rewarding the receptors that enhance pleasure. Patients may still hurt, but the pain will not bother them as much, and they will be able to concentrate on other aspects of life.

Not Typically Abused for a High

Morphine is not as fat soluble as heroin, so even when injected it does not produce the instant rush of pleasure that makes heroin attractive as an abused drug. Nevertheless, morphine does induce a dreamy state of happiness, drowsiness, and relief from anxiety that can last from four to six hours, depending on the dose and the way it was administered. Most people taking morphine for pain learn to live with the drowsiness and confusion. Some opt to live with the pain instead so that their senses are not dulled by the drug. Usually patients will work closely with their doctors to monitor doses so that a balance can be achieved.

Scientists are finding that patients in pain can become tolerant to very high doses of morphine—doses that, if taken recreationally, would kill a person outright. Tolerance, or needing higher doses of a drug to achieve the same results, is a standard side effect of opiate use.

All opiates produce similar side effects in the body. Morphine users will typically develop constipation because the drug slows muscle movement in the bowels. Breathing may be slowed as well. The drug can affect coordination—users must adjust to the medicine before driving or operating machinery. Other side effects include nausea and vomiting, loss of appetite, loss of sexual function, and pinpoint pupils. Some people develop a mild allergic reaction in the skin that causes itching or prickling.

Even when used as directed, morphine can cause withdrawal symptoms if a dose is missed or the medication is stopped suddenly. These symptoms include sneezing, runny nose, muscle aches, insomnia and anxiety, diarrhea, muscle twitching, sweaty and clammy skin, and goose bumps.

Reactions with Other Drugs or Substances

Because morphine can slow breathing and reaction time, it is much more dangerous when taken with alcohol, tranquilizers, sedatives, anti-anxiety medications, antidepressants, or even over-the-counter allergy medicines. Doctors must also monitor patients who take the pill form of morphine for reactions with other medicines metabolized in the liver, including medicines for tuberculosis, such as Rifampin, and medicines for seizures and epilepsy, including Dilantin. Some antibiotics can increase the level of morphine retained in the bloodstream.

Cancer patients on chemotherapy may have difficulty taking morphine because the drug can upset the stomach. These patients sometimes experience relief by using rectal suppositories or by using

pumps that bypass the stomach. However, doctors must evaluate the loss of appetite that results when morphine and chemotherapy are combined.

Some drug abusers combine morphine and cocaine. This can be particularly deadly, especially in terms of addiction. The two drugs work differently in the brain, causing high levels of disorientation, and both are habit-forming. Addicts who use opiates and cocaine at the same time find it hard to free themselves completely of both drugs.

Treatment for Habitual Users

Morphine use can lead to addiction. Even after years of not using the drug, opiate users can still crave the drug because they remember how they felt when they were taking it. Withdrawal from morphine and other opiates is a difficult task that lasts three to five days, if the user quits "cold turkey." More commonly, addicts seek treatment with methadone or buprenorphine, medications that will curb the withdrawal symptoms and block the effects of morphine in the brain. (An entry on methadone is available in this encyclopedia.) A morphine overdose that has caused breathing to stop can be treated with naloxone (Narcan), a drug that quickly rids the body of opiates. However, many opiate deaths occur in private settings. The user stops breathing, and no one is present to call for emergency care.

Health professionals advise anyone wishing to end morphine dependency to work closely with doctors and a psychiatrist or other therapist. If the dependency was brought about by morphine's use as a painkiller, a doctor may taper the dose so that the patient gradually becomes free of the drug. If the dependency comes from recreational use, the addict must learn strategies to live free of the drug's influence, often including finding new friends and staying away from the people and places associated with the drug use. Doctors and nurses who take opiates recreationally often lose their jobs—jobs they had trained for over many years.

Narcotics Anonymous (NA) is a self-help group that allows recovering addicts to meet and obtain assistance from other people who have lived through drug abuse. The nonprofit organization has a telephone helpline and group meetings in most cities and towns in the United States. Opiate dependency is one of the toughest addictions to beat, and the support of a group of peers is extremely helpful during moments of craving, anxiety, or depression.

Consequences

One of the most serious consequences of a heroin or morphine addiction is the long-term profile a person creates for his or her future health care. Doctors are reluctant to prescribe powerful painkillers to people who have no history of drug abuse. They are much less likely to prescribe these drugs to people who have abused opiates in the past.

Morphine Chronology

4000 bce      Opium poppies are cultivated in the Fertile Crescent (now Iran and Iraq) by the ancient cultures of Mesopotamia.

1552 bce      An ancient Egyptian papyrus text from the city of Thebes lists 700 uses for opium.

600-900 ce      Arabic traders introduce opium to China.

1524      Swiss doctor Paracelsus mixes opium with alcohol and names the product laudanum.

1803      German scientist Friedrich Sertürner isolates morphine as the most active ingredient in the opium poppy.

1848      The hypodermic needle is invented, allowing for quicker delivery of morphine to the brain.

1861–1865      An estimated 400,000 soldiers return home from the American Civil War with addictions to morphine.

1874      British chemist Alder Wright uses morphine to create diacetylmorphine (heroin), in an effort to produce a less addictive painkiller.

1914      The Harrison Narcotics Act ends over-thecounter purchases of medicines that do not have a full list of ingredients on the label.

1970      The Controlled Substances Act names morphine as a Schedule II controlled substance, recognizing its uses in pain relief and surgical settings.

1974      The first hospice facility opens in the United States.

2005      Terri Schiavo receives injections of morphine as her feeding tube is removed and she is allowed to die, after spending fifteen years in what doctors called a persistent vegetative state.

Advocates for the terminally ill point to another consequence of recreational opiate use. Some people in pain view prescription painkillers as dangerous and addictive, products that will make them crazy, or make them sleep all the time, or turn them into criminals. Such people suffer needlessly because of the negative perception attached to opiates. Doctors feel this too. They feel they are being monitored by the government and their jobs may be in jeopardy if they prescribe too much pain medication. As a consequence, they under-prescribe, even for dying patients. The bottom line: Many people suffer pain because other people abuse painkillers.

The Law

The Controlled Substances Act of 1970 placed morphine on the Schedule II list of controlled substances. This means that the U.S. government deems morphine to be a drug with medicinal uses that also carries the potential for abuse and addiction. Doctors who wish to prescribe morphine must register with the U.S. Drug Enforcement Administration (DEA). Morphine prescriptions are not like the typical slips of paper issued for most prescription drugs. They are more complicated and must be filed with the DEA, where records are kept on each doctor and how much morphine he or she prescribes. If the DEA determines that a doctor is prescribing too much morphine, that doctor can face criminal prosecution and possible jail time.

Illegal possession or sale of morphine, or any Schedule II drug, carries serious penalties, even on a first offense. Anyone caught with the drug can expect fines of as much as $10,000, mandatory drug testing, loss of driver's license, loss of federal government college financial aid, and a permanent criminal record. Judges often order opiate abusers into detoxification clinics. Second offenses almost always carry jail time and very heavy fines.

Because morphine is so habit-forming, its use can lead to other sorts of crime. People craving the drug are more likely to rob homes in search of cash or valuables. They are more likely to break into pharmacies or to commit armed robbery. They may resort to prostitution to pay for their habits, making themselves vulnerable to the human immunodeficiency virus (HIV) and other sexually transmitted diseases. An arrest for any of these offenses will result in jail time, where the addict will receive little treatment as he or she faces drug withdrawal.

For More Information

Books

Arsenault, Kathy. In the Arms of Morpheus: The Tragic History of Laudanum, Morphine, and Patent Medicines. Somerville, MA: Firefly Press, 2002.

Gahlinger, Paul M. Illegal Drugs: A Complete Guide to Their History, Chemistry, Use and Abuse. Las Vegas, NV: Sagebrush Press, 2001.

Hodgson, Barbara. Opium: A Portrait of the Heavenly Doom. San Francisco, CA: Chronicle Books, 1999.

Periodicals

"Beware of Morphine Overdoses." Drug Topics (October 20, 2003): p. 8.

Girsh, Faye. "Death with Dignity: Choices and Challenges." USA Today Magazine (March, 2000): p. 62.

Harvey, Kay. "As Her Condition Deteriorates, Gwen Frazier Faces the Loss of Her Independence." St. Paul Pioneer Press (April 28, 2000).

Hopkinson, Tom. "Morphine Produced in the Human Brain." Chemistry and Industry (October 4, 2004): p. 8.

Hurley, Mary Lou. "New Drug for Postop Pain Is Now Available." RN (October, 2004): p. 76.

McAlpin, John P. "Pakistani Paramilitary Troops Seize Morphine, Weapons Near Afghan Border." America's Intelligence Wire (August 13, 2004).

"Nine Days in June: Drugs Claim Two Sports Stars—and 147 Others." Life (January, 1987): p. 83.

O'Neill, Terry. "Morphine, Murder and Mercy: New Painkilling Guidelines Clarify Issues Surrounding Treatment of the Terminally Ill." The Report (October 21, 2002): p. 42.

Ostrom, Carol M. "Oregon Doctors Concerned with Improving Quality at the End of Life." Seattle Times (May 14, 2000).

Rauch, Sharon. "Living, Dying with Pain." Knight Ridder/Tribune News Service (February 20, 2002).

"Schiavo Denied Communion as Parents' Legal Battle Reaches Desperate Point." Detroit Free Press (March 27, 2005).

Shnayerson, Michael. "The Widow on the Hill." Vanity Fair (May, 2003): p. 122.

Web Sites

"2003 National Survey on Drug Use and Health (NSDUH)." Substance Abuse and Mental Health Services Administration (SAMHSA).http://www.drugabusestatistics.samhsa.gov (accessed July 30, 2005).

"Husband Seeks Autopsy on Terri Schiavo." CNN.com, March 29, 2005. http://www.cnn.com/2005/LAW/03/28/schiavo/ (accessed July 31, 2005).

"Morphine." U.S. Drug Enforcement Administration.http://www.usdoj.gov/ dea (accessed July 30, 2005).

See also: Cocaine; Codeine; Fentanyl; Heroin; Hydromorphone; Methadone; Opium; Oxycodone