Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Accidental Extra Strength Morphine

The FDA has notified people that ETHEX Corporation is recalling a single lot of 60 mg extended release morphine tablets. They are concerned about the consequences of OD (OverDose).

First thought to come to mind – the patient might actually experience pain relief with a more appropriate dose, since so many prescribers are more concerned about OD than about effective pain management.

Dr. Marcia Angell once wrote this about pain management:

I can’t think of any other area in medicine in which such an extravagant concern for side effects so drastically limits treatment.[1]

A couple of interesting words here:


1 a obsolete : strange, curious
b archaic : wandering

2 a: exceeding the limits of reason or necessity
b: lacking in moderation, balance, and restraint
c: extremely or excessively elaborate

3 a: spending much more than necessary
b: profuse, lavish

4: extremely or unreasonably high in price

synonyms see excessive


1 : acting rapidly or violently

2 : extreme in effect or action : severe

Dr. Angell makes it sound so extreme. Is it?

Let’s look at an example. These are patients taking a daily does of 60 mg morphine, at least once a day, so this is a relevant example.

If you’re treating patients who have used opiates in the past or who use them chronically to control pain, on the other hand, respiratory depression is not as important. Dr. Jacobson said that these patients often become tolerant to the drugs’ side effects. As a result, he added, these patients are typically unaffected by the drugs’ tendency to depress respiration.

To give an example, Dr. Preodor recalled a patient who was receiving 10 mg of morphine per hour but mistakenly received 250 mg in just over an hour. A sitter monitored the patient through the night to make sure she suffered no ill effects, and the patient was fine. (Her main comment was that she had never slept better.)

While the case was extreme, it shows that patients who are used to opiates and their side effects can handle much higher doses of the drugs without many of the negative side effects. If the patient was unaccustomed to opiates, Dr. Preodor said, the incident could have turned out badly.[2]

There are only a few good articles about pain management, articles that dissect the complications in treating patients, both legal and medical. This is one of the best. Read the entire article. The links are also worth reading.

So, is this something that should be treated with large doses of panic and naloxone (Narcan)?

Naloxone should be titrated to effect, assuming there is any need at all.

Is there respiratory depression?

Are we treating the dose or the patient?

The FDA notice is useful information to have, but unbalanced and extreme. I believe that what Dr. Angell wrote back in 1982 about the extreme responses to pain management is still true. I would add one area, aside from pain management, to the extreme concern for side effects at the expense of the patient – sedation.


^ 1 The quality of mercy.
Angell M.
N Engl J Med. 1982 Jan 14;306(2):98-9. No abstract available.
PMID: 7053494 [PubMed – indexed for MEDLINE]

^ 2 Avoiding trouble when using opiates to treat patient pain.
June 2003 ACP Observer, copyright © 2003 by the American College of Physicians.
By Jason van Steenburgh

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