Morphine allergy. What are the alternatives?

Factual Questions
1

My Brother was taken to hospital last Thursday with severe exercise induced angina. He’s 50. We both have coronary artery disease. He had angioplasty about 14 years ago but has be fine until recently.

While waiting to be transported to a bigger hospital (Ottawa Heart Institute) he started experiencing unstable angina (he rated it 6-7) for which he was given morphine. His BP plummeted and later he was told that he reacted the morphine.

So now, he’s at the OHI waiting for a triple bypass, (which might be happening today for all I know, the unstable angina having gotten worse over the past couple of days).

I had the CABG a few years ago and I can’t imagine what it would have been like the first few days after if not for copious amounts of morphine I was given.

So what else is there? I tried Google but don’t really want to weed out all the woo. I read something about Tramadol but that seems to be another opioid.

Not seeking medical advise, I’m just curious.

2

First, he’d need to know if the BP drop was a reaction, or an allergic reaction. It’s common for this to occur with an opioid, and not necessarily an allergy.

3

Codine like stuff? I was on hydrocodone after my open heart surgery. I don’t know if it is closely related to morphine.

4

When we spoke yesterday evening, his approximate words were, “They said I can’t have any more morphine. It’s why my BP went so low”.

It’s difficult being so far away. His wife and kids and most of his friends are at least an hour from the hospital. He’s kind of on his own most of the time.

5

if a person can’t use opiates they might get relief from non-steroidal anti-inflammatory drug (NSAID) like Ibuprofen, doses would need to be higher than normal use.

6

It is very rare for someone to be allergic to morphine (and even rarer to have low blood pressure as the only symptom).

Far more likely to be the case is that there is some other problem making your bother’s BP overly sensitive to morphine. Things like aortic stenosis or certain types of heart attacks (e.g. inferior myocardial infarction), or even simple dehydration, and many others, are all possibilities.

7

Morphine is given to patients with chest pain not only as an analgesic, but it had also dialates coronary arteries, thus providing more blood flow. If pain control was the only concern, then fentanyl is a good narcotic analgesic. I’ve never seen it given for chest pain though as it doesn’t effect the coronary arteries like morphine does.

8

There are two types of reactions to opiates, a pseudoallergy and a true allergy. A pseudoallergy is caused by a release of histamine, but is not an IgE meditated reaction. The symptoms of a pseudoallergy are flushing, itching, hives, sweating, or mild hypotension. While a true allergy has severe hypotension, rash, problems breathing, speaking, or swallowing, and swelling of the face, lips, mouth, or tongue.

In the case of a pseudoallergy, the best treatments are avoiding opioids, using a more potent opioid, co-administration of an antihistamine (e.g. Benadryl), lowering the dose, and avoidance of Morphine, Codeine, and Meperidine which have a higher rate of pseudoallergies.

In the case of a true allergy, switch the patient to different class of opioid, and monitor the patient closely in case of a cross reaction.

The different classes are:

[ul]
[li]Phenylpiperidines[/li][li]Meperidine (Demerol)[/li][li]Fentanyl (Duragesic, Actiq, Sublimaze)[/li][li]Sufentanil (Sufenta)[/li][li]Remifentanil (Ultiva)[/li][/ul]

[ul]
[li]Morphine-like[/li][li]Morphine[/li][li]Codeine[/li][li]Hydrocodone (Vicodin, Loratab)[/li][li]Oxycodone (Percocet, OxyContin)[/li][li]Oxymorphone (Numorphan)[/li][li]Hydromorphone (Dilaudid)[/li][li]Nalbuphine (Nubain)[/li][li]Butorphanol (Stadol)[/li][li]Levorphanol (Levo-Dromoran)[/li][li]Pentazocine (Talwin)[/li][/ul]

[ul]
[li]Diphenylheptanes[/li][li]Methadone (Dolophine)[/li][li]Propoxyphene (Darvon, Darvocet)[/li][/ul]

Though, of course Propoxyphene has recently been taken off the market.