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Untreatable Pain From Osteoporosis Fractures May Be Controlled with Constant Morphine Injection to Spine

Posted on: 07/12/2007
Osteoporosis, thinning of the bone, is a serious disorder because it can lead to fractures, particularly in the spine. The risk of osteoporosis and fractures increase with age. Bone mass peaks in a person between 20 and 30 years old and then it begins to decrease. Vertebral bones, or bones in the spine, deteriorate more quickly than the rest of the body's bones. Women develop osteoporosis more than do men and as they age, their risk of vertebra fractures rises and, considering the growing population and the longer people are living, the incidence of the fractures could multiply by four in the near future.

Another risk is that of having another fracture after already having one. Studies have shown that a woman who has a vertebral fracture has a four to seven times higher risk of having another fracture within six to 18 months, compared with women who haven't had any fractures. Add to this the discomfort and pain that are caused by the fractures, this can severely impact a person's daily activities and quality of life.

While most people can manage the pain with opioids, controlled medications like morphine, some people are unable to take them because of side effects, or they shouldn't take them because of other health problems. Twenty percent of patients who take opioids experience side effects like vomiting, nausea or dizziness.

In this study, researchers wanted to know the effects of intrathecal opioid medications delivered directly to the spine by pump to oral (by mouth) medications. The medication was injected slowly over a long period of time directly to the spine where the pain is concentrated. The researchers treated 19 women and five men who were, on average 74 years old. The patients all had advanced osteoporosis and a history of taking oral and/or transdermal (patch on the skin) medications, and severe side effects or drug addiction.

At the start of the study, the patients underwent a magnetic resonance imaging (MRI) scan so the researchers could see the damage to the vertebrae. The patients were asked to complete two questionnaires: the Visual analog scale (VAS) and the Quality of Life Questionnaire of the European Foundation of Osteoporosis (QUALEFFO). The questionnaires measured their pain levels (VAS) and their ability to manage every day life (QUALEFFO).

The trial started slowly. Patients who were still taking morphine by mouth had their dose cut in half. All the patients were hospitalized for the first three days of the trial. The first dose of intrathecal morphine was a low dose for the first day. The medication, given through a catheter inserted into the spinal area, was increased slowly as the oral morphine was gradually lowered. The right dosage for each patient was reached when the patient reported that their VAS had dropped by half.

Six days after the trial began, the patients returned for the first follow-up. Side effects were treated with the appropriate medication. During the trial five patients complained of vomiting and three complained of itching. When the pump was used alone, only three patients complained of nausea. One patient developed an infection where the catheter was inserted, two had their catheters dislodged. The researchers found that after one year of intrathecal morphine, the patients' VAS dropped around five point, from about 8.7 to 3.6. Their functional scores dropped from about 114.7 to 92.1. What was also noticed was that none of the patients needed any additional pain medication.

The authors conclude that while many patients respond well to oral morphine, there are many who cannot tolerate it or cannot take it. Because chronic pain can have such a significant impact on the quality of life, other methods of pain relief must be found. Using morphine intrathecally seems to reduce the side effects quite a bit. The authors say that by introducing the morphine increases very gradually, the risk of side effects drops. They feel that this use of morphine should be offered as another method of pain control in this population.

References:
Ali Shaladi, PhD, MD, et al. Continuous Intrathecal Morphine Infusion in Patients with Vertebral Fractures Due to Osteoporosis. In Clinical Journal of Pain. July/August 2007. Vol. 23. No. 6. Pp. 511-517.

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