Prescribing & Preparation of Topical Morphine Mixture in Palliative Care

For use on any inflamed or open skin lesions causing moderate to severe pain e.g. fungating wound

Cautions
• intolerance to systemic side effects of morphine or other opioid derivatives
• severe renal or hepatic impairment- monitor carefully for signs of opioid accumulation & toxicity over time
• heavy bleeding or exuding wounds

Contraindications
• do not use around eye area
• severe impairment of central nervous system
• acute respiratory depression
• topical management of infected wounds (systemic management permitted

Adverse effects

Very few side effects reported but there is a potential for systemic absorption, especially over larger areas, or with higher concentrations. Closely monitor patient for signs of opioid toxicity.

Some patients have complained on pruritus which may be a sign of hypersensitivity towards either morphine or contents of water based gel with local anaesthetic.

Dosing & Frequency

Any assessment around prescribing should be in conjunction with the specialist palliative care team, NHS Borders.

Start with morphine in water based gel containing local anaesthetic (10mg morphine sulphate injection (1mL) in 6mL water based gel with local anaesthetic mixture once or twice a day. Ensure to review regularly every 3-7 days or earlier if pain score highlights concern.

Can be applied up to 24 hours but as it is a non-sterile mixture it should not be used on an open wound after 24 hours. Depending on response concentration can be increased to:

• Morphine in water based gel containing local anaesthetic = morphine sulphate injection 15mg in 6mL water based gel with local anaesthetic.
• Morphine in water based gel containing local anaesthetic = morphine sulphate injection 20mg in 6mL water based gel containing local anaesthetic.

Note- open wounds can be sensitive to morphine & prescriber should be mindful that increasing concentration &/or frequency of application will increase amount of morphine systemically absorbed.

Topical morphine mixture will be prescribed on drug chart as illustrated in example below:

To prepare morphine in Instillagel® mixture you will need the following equipment:

Procedure for preparing morphine in water based gel containing local anaesthetic (morphine sulphate injection 10mg (1mL) in 6mL water based gel with local anaesthetic) Record pain score

1. Record pain score
2. Prepare clean dressing field using sterile dressing pack
3. Remove old dressing & irrigate wound with sodium chloride 0.9%. Note size, appearance, odour & exudates from wound & document in notes.
4. Record administration of morphine sulphate in as per NHS Borders Code of Practice for the Control of Medicines.
5. Decant full prefilled syringe of water based gel containing local anaesthetic into a sterile plastic Using a 10mL syringe measure 6mL & decant into another sterile plastic tray. Discard excess.
6. Draw up *morphine sulphate 10mg/mL injection & mix with 6mL water based gel with local anesthetic in the sterile plastic tray using plastic probe (ensure relevant controlled drug procedures are followed at all time). 
   *See dosing & frequency information in section 3 for volume of morphine sulphate injection required for more concentrated mixtures.
7. Apply mixture directly to wound bed or onto dressing using spatula
8. Apply secondary dressing to wound (foam or film dressing as appropriate)
9. Dispose of any remaining mixture & items that have been in contact with morphine in sharps bin (see below)
10. Check patient is comfortable & dressing is secure
11. Complete any necessary documentation
12. Record pain score 2 hours after dressing

Secondary dressing

A foam adhesive dressing should be placed over the wound & mixture. If a foam dressing is not appropriate, then apply a film dressing instead. See local wound formulary for preferred dressing choice.

Removal of dressing

The mixture should be washed off the wound with sodium chloride 0.9% solution before reapplying.

Stability

As the mixture is prepared in a non-sterile environment (i.e. hospital ward/ treatment room) once mixed it must be used immediately & not stored. This is due to concerns regarding microbiological contamination rather than instability of mixture.

Disposal of dressing & equipment

For full details regarding disposal of controlled drugs please refer to NHS Borders Policy for Management of Controlled Drugs in Secondary Care.

Any equipment (including part used vials of morphine sulphate injection), used dressing & gel removed from patient should be disposed of in a sharps bin. When ready for destruction the sharps bin should be labelled “contains mixed pharmaceutical waste and sharps – for incineration”.

Initially monitor twice daily using pain scores to measure any improvement from baseline. If pain is reduced consider reducing frequency.

If there is no response after 3-7 days treatment should be discontinued & consider alternative treatment.

Monitor for signs of opioid accumulation & toxicity, especially in patients with renal/hepatic impairment