This paper is on the various principles and processes involved in medical management.
Drug chosen is morphine.
Trade names; MScontin, Oramorph
Generic name; Morphine Sulphate
Drug group; Opiate
Morphine is both an Approved, Investigational drug
The reason I have chosen to talk about morphine is due to its significance in pain management and at the same time the risks and consequences that are associated with its abuse.
Morphine is a pain reliever hence used in pain management. The length of medication depends on the persistence or elimination of pain (Ko, 2013).
Pharmacokinetic study (ADME) – Morphine
The preferred route of administration of morphine is oral. However, morphine can also be administered through intramuscular and subcutaneous routes. The oral dose of morphine is 50mg. This is to ensure that it undergoes the first-pass effect to reduce toxicity before it can be circulated to other parts of the body. Morphine is mostly given with food i.e. on a full stomach as food increases its absorption, therefore, resulting in prolonged pain relief when taken on a full stomach compared to administration of the drug to patients in a fasting state. This is because food helps in its absorption in the stomach and small intestines and distribution to other body parts through the bloodstream (Katzung, Masters & Trevor, 2012).
First-pass metabolism or the first pass effect apply to morphine. When morphine is taken orally, it is absorbed in the small intestines and circulated to the liver first through the hepatic portal vein. The liver then acts as a filter such that only part of the drug is circulated in the bloodstream. This drug metabolism reduces the concentration before it can reach the systemic circulation.
After the oral morphine has been absorbed, it is rapidly distributed to all other parts of the body including the brain. Morphine has a large volume of distribution. Morphine oral bioavailability is low since it is about 25 per cent due to the extensive hepatic-first pass effect. The peak plasma concentrations of morphine reach in about 30 to 90 minutes after oral administration of morphine medication. While it takes about 15 to 20 minutes to reach peak plasma concentrations when administered intramuscular or subcutaneous. There are slow releasing oral formulations that have been developed to deliver the required doses of morphine over 8 to 12 hours (MST Continus) or Kapanol that take up to 24 hours (Williams, 2012).
Morphine binds to the blood plasma protein, specifically the albumin and to a very low extent to gamma globulins. Experiments done on morphine reveal that the per cent of morphine bound to albumin and gamma globulins is not dependent on the concentration of the drug in plasma. Between 34 to 37 per cent of morphine is bound to human plasma with a large amount being bound to albumin. This high-level plasma protein binding of morphine makes is less efficient since it cannot traverse the cell membrane or diffuse (Joukar, Atapour, Kalantaripour, Bashiri & Shahidi, 2011).
Morphine drug a very high systemic clearance potential and therefore a very short half-life of about 2 hours. The human liver is the primary site of morphine metabolism where the drug undergoes rapid glucuronidation. However, there are sites of extrahepatic metabolism for the drug and may account for up to 30% of the total morphine drug clearance. In patients with severe liver failure, the extrahepatic metabolism can play an important role in morphine metabolism. The main metabolite of morphine in the liver is morphine-3-glucuronide (M3G) (Katzung, Masters & Trevor, 2012). This metabolite does not have any known pharmacological effect and is excreted in the urine.
Therefore, urine is the main mechanism of excretion of morphine. The other important metabolite of morphine is morphine-6-glucuronide (M6G) which is as potent as morphine. This metabolite has a half-life of about 1-2 hours. This active metabolite is also eliminated in urine and accumulates in high amounts in case of renal insufficiency. Studies done on morphine excretion show that about 10% of the drug is also excreted unchanged in the urine (Williams, 2012).
Morphine is classified as a narcotic agent that is used in pain management. The agent is indicated for the management and relief of pain in individuals who need opioid analgesics for more than just a few weeks. Morphine is thought to interact with the opioid mu-receptors. The mu-binding sites are widely distributed in the brain and have high densities in the thalamus, putamen, nucleus caudatus, posterior amygdala, hypothalamus and some cortical areas. The mu-receptors are also located on the terminal axions of the primary afferents that are within the substantia glatinosa of the human spinal cord as well as the spinal nucleus of the trigeminal nerve. Morphine is known to exert its pharmacological effects on the CNS and the GIT (Katzung, Masters & Trevor, 2012). The prime actions of morphine that have therapeutic value include sedation and analgesia. This drug increases the pain tolerance of an individual and also reduces discomfort, but the presence of pain itself can be recognized. In addition to these; morphine causes alteration of mood, drowsiness, dysphoria and euphoria. Morphine as stated before belongs to the class of opioids which usually produce respiratory depression hence causing brain stem respiratory areas. Therefore mu-receptors, delta-type opioid receptor and kappa-type opioid receptors are agonists (Dragicevic,, Atkinson & Maibach, 2015).
Nursing Considerations When Giving Morphine To Ensure Safe And Effective Management
Drowsiness
A headache
Dry mouth
Stomach pains and cramps
Mood changes
Pain when urinating
Nervousness
Small pupils (black circles in the middle of the eyes)
Agitation, hallucinations
GIT-nausea, loss of appetite, diarrhoea and vomiting.
Morphine should not be given to people with allergies to any of its ingredients. Therefore, one should tell the pharmacist of any allergies who in turn will check the medication guide for the list of ingredients.
The patient should inform the pharmacist or the doctor on other medications being taken as well as herbal products, vitamins and nutritional supplements so as to plan the care to be given.
The physician should be keen to determine herbal products being used by the patient especially tryptophan and St. John’s wort (Katzung, Masters & Trevor, 2012).
The doctor should determine if the patient has paralytic ileus since food and food absorption affects the absorption of morphine hence patients with this condition should not be given this medication.
The patient should tell the doctor if she is breastfeeding or had any blockage in the stomach or intestines.
The effects of morphine are potentiated by most of the alkalizing agents and antagonized by the acidifying agents. The analgesic effect that is produced by morphine is potentiated by methocarbamol and chlorpromazine. Most of CNS depressants such as hypnotics, chloral hydrate, glutethimide and sedatives enhances the depressant effects of morphine drug (Overholser & Foster, 2011).
Morphine is used for long periods in patients with chronic non-cancer pain. The main concern for these prolonged use of morphine relates to the possibilities of cognitive side effects. Studies that have been carried out show that prolonged treatment with oral morphine does not affect the cognitive functions in persons with chronic pain but results into improvements of various aspects of the cognitive functioning such as a consequence of the pain relief and also improvement of mood and well-being.
Advanced respiratory insufficiency
Cranium injuries
Raised intracranial pressure
Legal Framework Underpins Safe And Effective Medicines Management and Administration
General Principles. There are general principles that direct the safe and effective management and administration of medicines in the UK. The medicines that are under these principles include; Prescription Only Medicine (POM), Pharmacy (P) Medication and the General Sales List (GSL). These principles include; (Chartier, 2014).
The Physician dispensing the medicine should be sure of the identity of the patient to whom the medicine is to be given.
The Physician must all the allergies of the patient and ensure that the patient is not allergic to the drug or its ingredients (Hughes, 2012).
The Administrator of the drug should have knowledge and information on the therapeutic uses of the drug, the normal dosages to be administered, precautions to be taken, side effects and contra-indications.
The description, prescription and the label on the medication to be administered are well written with no unambiguity.
The expiry date of the drug to be administered should be checked to ensure that the drug has not expired
The dosage, weight, method of administration, timing and route of delivery should be determined.
Drug interaction should be assessed (Strang et al. 2012).
The physician should immediately make a record of all the drugs that are withheld or even refused by the patient and make sure that the signature of the patient is clear and legible.
In cases of medicine not given, the reason for this should be given.
A physician can administer with just one signature any Prescription Only Medicine (POM), Pharmacy (P) Medication and the General Sales List (GSL) (Appelbe, & Wingfield, 2013).
Controlled drugs should always be administered according to the relevant legislation as well as all the local standard operating processes (Nutt, King & Phillips, 2010).
For one to administer a controlled drug, a second signature should be given.
Local risk assessment should be used to get a signatory for the patient in the home setting for a drug that has already been prescribed and dispensed.
It is advised that a person who gives a second signatory should be a health care professional who has witnessed the whole administration process.
The health care professional should countersign the signature of the nursing student when supervising this student in the administration of drugs (Joint Formulary Committee, 2013).
In Relation to Morphine
Morphine is a controlled drug and categorized as a Schedule 2-controlled medicine. This is because morphine is misused since it is a drug of abuse. These legal controls ensure that morphine is not misused, not obtained illegally so that it cannot cause harm (Gibbons, 2012).
Safe Ordering, Storing, Receiving, and Disposing Medicines
How Morphine is ordered/received;
Morphine is individualized to the patient.
When morphine arrived in the ward, the recipient has to sign. And medicine is given according to the guidelines (Dargan & Wood, 2013).
(Laws) Receiving and storage of drugs is governed by the following guidelines;
When receiving the drug one should ensure that it is the correct formulation.
The receiving person should confirm their identity before receiving the drug.
When storing the controlled safety and security assessment are necessary (Vallerand, 2018).
How Morphine is stored;
Morphine is stored in the fridge at 4 degrees that are fitted with controlled drug cupboards (Handley & Flanagan, 2014).
Guidelines state that these drugs should be stored in controlled cupboards so that the drug cannot fall in the wrong hands since morphine is a substance of abuse.
How Morphine Drug is disposed of;
Disposal of all unneeded morphine capsules, liquid and tablets should be properly done especially the procedure that involves returning morphine back to the pharmacy to be destroyed (Mathur, Patan & Shobhawat, 2017).
In the wards, morphine should be destroyed in a manner that this drug cannot be salvaged and re-used by any other person.
The laws that govern drug disposal states that denaturing kits are used especially in cases where large quantities of the controlled drug are used. Also, when the kits are sent for disposal, they should be labelled according to the Trust Waste Disposal Policy (Mallett et al. 2012).
A Patient Group Direction (PGD) is a written list of instructions for sale, administration and supply of drugs to the various group of individuals who are not normally identified personally before they present for treatment (Working, 2013).
The Patient Group Direction (PGD) works in the manner that the patients are not normally identified with regard to the circumstances, but are given medication for a recurrent condition or process. For instance repetition of a service such as contraceptives where patients are aware of the service or drug is given from a previous episode of care (Anderson & Thornley, 2014).
The Patient Group Direction (PGD) was introduced to enable care specialists to supply and administer a drug directly to an individual for the identified condition without the need for a prescription or instruction.
All the medical practitioners can use a PGD following the guidelines that are outlined in The Medicines Act of 1968 which defines the authorized person to use a Patient Group Direction (PGD) and other policies which guide Health Care Professionals (HCP).
NICE guidelines state that much clinical cares ought to be given on a personal and patient-specific basis. This suggests that the use of PGD is revised to limit the situations to only where this gives an advantage for the patient care and without the compromise of the safety of the patient.
NMC standards for Medicine Management states that the professionals can effectively handle their drugs but a mechanism is needed to limit the Patient Group Direction (PGD) since it breaches safety and security principles.
Patient Group Direction (PGD) application issue: The method is not individual-centred hence it is not that much safe nor secure since the individual needs may be left unattended. This provision is effective especially in instances where the patients are aware of their condition and management from previous care. The challenges facing Application the application of PGD; it does not get support from some major medical organization such as the NICE and the procedure is not as safe as the individual needs are not taken into consideration.
Morphine is not supplied as PGD is the UK since it is a controlled drug that requires a prescription as it can be abused. Having Morphine supplied as PGD will ensure availability of the drug to undeserving people who may abuse it (Parsons, Adams, Aziz, Holmes, Jawad & Whittlesea, 2012).
By use of the inclusion/exclusion criteria; All the healthcare professionals can administer the Patient Group Direction (PGD) where professional regulation is in place.
SAM (Self-Administration of Medicine) means that some patients are selected and allowed to store and administer their own medications while the nurse or the pharmacist educates and supervises this process (Richardson, Brooks, Bramley & Coleman, 2014).
Levels of SAM Scheme by NMC
SAM is compliance, independence and empowerment of the patients as they are given the opportunity to administer drugs to themselves. Therefore, this scheme is favoured by patients.
Disadvantages of SAM
Benefits of SAM
Cultural change
Resistance from General Practitioners
Resistance from the nurses to check medicines
The pharmacists’ resistance to leaving their traditional role.
Morphine is not suitable for use in the SAM scheme in the Local Trust because this is a controlled drug that needs a careful administration to avoid dependence as well as substance abuse.
Safety of Medicines – For a method of drug administration and management to be termed appropriate or successful, safety should be assured. By using SAM to administer Morphine, this will render the drug unsafe since some patients might abuse the drug as they have the access to the drug (Serumaga, 2011).
Conclusion
This article shows drug management mechanisms and processes through the use of Morphine as an example. There are two central principles of pharmacology in treatment which include pharmacokinetics and pharmacodynamics. Pharmacokinetic shows involve the effects that a drug has on the body as well as the mechanisms of action. Pharmacokinetics deals with the processes of drug administration, distribution, metabolism and excretion (Katzung, Masters & Trevor, 2012). There is the legal framework that underpins safe and effective medicines management and administration such as controlling drugs that would be risky to be let for everyone (Rang, Ritter,Flower & Henderson, 2014). Medical practitioners need to properly apply proper mechanisms in ordering, receiving, storage and disposal of medicines such as morphine so as to ensure that no harm to the patient or others. There are principles of supply and administration that are directed towards the Patient Group Direction (PGD) to ensure that this mechanism of giving drugs without thorough personal examination does not harm patients and that the approach succeeds. There are both advantages and disadvantages of working in partnership with patient/clients and careers in relation to self-administration and management of medicines such as those involved in SAMs where patients are allowed to administer drugs to themselves. The ethical concerns include informed consent, beneficence, confidentiality and security.
References
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