Topical Use of Morphine
by Forest Tennant, MD, DrPH
 The use of topical medication—defined as a pharmaceutical skin
surface application—has gained progressive popularity in recent years. There is now a
wide variety of both non-prescription and prescription topicals available. They include
healing and cooling agents, anti-inflammatory drugs, and those with anesthetic properties.
Physicians and pharmacists have teamed in recent years to compound various prescription
topical agents which include ketamine, ketoprofen, clonidine, and naloxone among others.
Reported here is a summary of the author’s experience and investigation of topical
morphine. Used in the author’s clinic as the premier topical agent, topical morpine
is an indispensable adjunct to standard pain treatment that enhances pain relief, reduces
costs, promotes stretching and walking, and decreases such adverse events as emergency
room visits, disabling pain flares, trigger points, and early refill requests. Morphine
topical is highly recommended as an adjunct in severe, chronic pain patients who take
systemic opioids.
Morphine Background
After initial discovery of central nervous system opioid receptors and the endorphins in
the 1970s, followup studies began to identify opioid receptors in such varied organs as
the ileum, knee joint, pancreas, ovary, and lymphocytes.1-3 Additionally,
endorphin compounds were found in blood raising the question whether endorphins and opioid
receptors have functions other than central nervous system pain relief. A number of
studies clearly document that morphine has direct, peripheral analgesic properties.4-7
Indeed, morphine injected into the knee joint and applied to the skin will provide local
pain relief.5-6 This litany of ground-breaking scientific studies prompted the
author to study the practical, clinical usefulness of topical morphine. Open trials showed
promise and a randomized, double-blind, placebo-controlled study was done which showed
that topical morphine provided localized pain relief.8 Importantly, morphine
was not detected in blood or urine in this study so it is assumed that morphine acts
directly on the skin and does not produce systemic effects. Since this successful study,
topical morphine has been a standard practice in the author’s clinic. It is used as
an adjunct for intractable pain patients who require oral, systemic, opioids.
Topical Formula And Patient Instruction
Standard oral morphine, instant release, 30mg tablets are used to prepare the topical.
Dosage is one to two crushed tablets dissolved in one ounce of cold cream (see Table 1).
Patients are taught to crush tablets and secure their own cold cream for both convenience
and to save money. Admittedly, other bases could possibly be more effective but, when
patients select a cold cream they like, we avoid complaints of skin irritation or allergy.
Patients are initially instructed to use it on an “as needed” rather than on a
“regular” or “around-the-clock” basis. Nevertheless, some patient's
choose to use it on a regular, daily basis. They are instructed on the option to apply
heat or cold with the topical and to massage it into the painful area.
Please refer to the October 2008 issue for the complete text. In the event you need to order a back issue, please click here.
— October 2008
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