IM Morphine

[Aidey]

Maybe not the best reference, but this doesn't mention opiates anywhere.

http://www.herbological.com/images/SJW_table.pdf


Poking around pub med so far all I have found are studies testing if St. John's Wort can help with opiate withdrawal.

 

[medicRob]

Maybe not the best reference, but this doesn't mention opiates anywhere.

http://www.herbological.com/images/SJW_table.pdf


Poking around pub med so far all I have found are studies testing if St. John's Wort can help with opiate withdrawal.

The Active Constituent of St Johns Wort is a Monoamine Oxidase inhibitor. Some Opiates + MAOIs = Bad Ju Ju.

See the following:

Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. (Gillman PK, 2005)

http://bja.oxfordjournals.org/cgi/content/full/95/4/434?view=long&pmid=16051647

Br J Anaesth. 2005 Oct;95(4):434-41. Epub 2005 Jul 28.

 

[Veneficus]

The Active Constituent of St Johns Wort is a Monoamine Oxidase inhibitor. Some Opiates + MAOIs = Bad Ju Ju.

See the following:

Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. (Gillman PK, 2005)

http://bja.oxfordjournals.org/cgi/content/full/95/4/434?view=long&pmid=16051647

Br J Anaesth. 2005 Oct;95(4):434-41. Epub 2005 Jul 28.

In your article in the conclusion it states specifically:

"In summary, morphine, codeine, oxycodone and buprenorphine are now known not to be SRIs and they do not precipitate serotonin toxicity with MAOIs."

Said drugs are also not listed in Table 1. in the same study describing potential toxicity.

"Table 1 Drugs with clinically relevant serotonergic potency from reference29 with permission. Fatalities from serotonin toxicity involving analgesics have been with pethidine, tramadol and dextromethorphan and, possibly, fentanyl."

I do not see how this study supports the conclusion that morphine would have an interaction with St. Johns Wart.

Thanks for the post though, it was a great read. It knocks Fent down a couple of pegs.

 

[Aidey]

The Active Constituent of St Johns Wort is a Monoamine Oxidase inhibitor. Some Opiates + MAOIs = Bad Ju Ju.

Reference? I've never seen anything claiming that St John's Wort is an MAOI. The literature I've read suggests that it is mosr similar to a SSRI than anything else.

 

[Veneficus]

Then state it like that then. Please dont call me a troll and leave it at that......??? does not ask for clarification does it!

I ask your indulgence. It has been my experience people who post absolute oversimplified statements are usually looking for a fight.

Let me ask you this have you ever had a pt to arrest on you after given MS?

No, and the frequency and doses i often give it at are for the pupose of anesthesia or complete pain mitigation. I suspect that your patient arrested for a cause that was not stipulated and it is being attributed to the administration of a relatively small amount of morphine. (based on common doses used in ems)

it wasnt because they were allergic either....

Doesn't frighten me. Even if they were it is a problem simply solved with some IM epi, and by not using the narcan it not only maintains the analgesia from the morphine, but doesn't block the Mu and Kappa receptors so I can try an alternate formulation.

They took a OTC called St.John Wort(later when they told me they forgotten he took it) and bad stuff happens when the too meet MS and St. Johns Wort.....

That doesn't seem to be supported by the recent article that MedicRob posted. Do you have a more comprehensive or alternate source?

without that line I had could have spelled disaster for this pt, had I not got the NARCAN on as fast as I did.

I must once again ask your indulgence, as this seems to be a rather oversimplified statement. Are you suggested the patient went into instantaneous and simultaneous respiratory and cardiac arrest? If not, and they went into respiratory arrest would positive pressure ventilation and a patient airway have a lesser effect than the narcan?

If this was an undocumented case of a severe interaction, since morphine has a longer half life than narcan and it competes for the same receptor sites, were multiple doses or an infusion of narcan required until the morphine was not biologically available? If not it seems logical to conclude that when the narcan was no longer active the patient would have arrested again. (possibly in as little as 15 minutes)

My personal feeling and comfort zone is having a line started before pushing my drugs. But that is just me.

That seems like a fair opinion. Can I politely inquire what causes you to be uncomfortable with a medication that is prescribed to nonhealthcare providers to self administer for conditions such as Diarrhea, caughing, and home management of pain in chronic conditions?

 

[1badassEMT-I]

Thanks for the advice, but I'm quite capable of holding my own..............I'm not too terribly worried about others "blowing me up".

Many who know me here are aware that I have been properly trained, and more importantly, properly educated.

Your last comment prior to this one actually scares me. It tells me that you will follow any order given by some unknown entity on the other side of a radio. What if the order is wrong? Who do you believe will be the primary defendant when an error in judgement goes to litigation? Do you honestly believe knowledge of your clinical practice holds no importance? Finally, do you REALLY trust the individual on the other end? You have a brain, use it! Think outside of the book. Make your voice heard! Otherwise, the care available to the citizens of your fine State will never change and will not progress with the evolution of medicine. Is that really what you want for yourself, your family, and your community?

Well your WRONG.... I said I can push it but did not said I have or will...but on the other is a Medcial Doctor that is far more highly trained better than me HENCE them being a DOCTOR. Have I argue the fact of some treatments hurting some pts YES.....I have got into trouble over yes.... dont telll me to think outside the box because I do everyday I work....And as in my other post WV state protocol is BS.

 

[1badassEMT-I]

I ask your indulgence. It has been my experience people who post absolute oversimplified statements are usually looking for a fight.



No, and the frequency and doses i often give it at are for the pupose of anesthesia or complete pain mitigation. I suspect that your patient arrested for a cause that was not stipulated and it is being attributed to the administration of a relatively small amount of morphine. (based on common doses used in ems)




Doesn't frighten me. Even if they were it is a problem simply solved with some IM epi, and by not using the narcan it not only maintains the analgesia from the morphine, but doesn't block the Mu and Kappa receptors so I can try an alternate formulation.



That doesn't seem to be supported by the recent article that MedicRob posted. Do you have a more comprehensive or alternate source?



I must once again ask your indulgence, as this seems to be a rather oversimplified statement. Are you suggested the patient went into instantaneous and simultaneous respiratory and cardiac arrest? If not, and they went into respiratory arrest would positive pressure ventilation and a patient airway have a lesser effect than the narcan?

If this was an undocumented case of a severe interaction, since morphine has a longer half life than narcan and it competes for the same receptor sites, were multiple doses or an infusion of narcan required until the morphine was not biologically available? If not it seems logical to conclude that when the narcan was no longer active the patient would have arrested again. (possibly in as little as 15 minutes)



That seems like a fair opinion. Can I politely inquire what causes you to be uncomfortable with a medication that is prescribed to nonhealthcare providers to self administer for conditions such as Diarrhea, caughing, and home management of pain in chronic conditions?

You seem to think I want to fight.....not the case .....I am simply telling you of a case that happen to me......and was told at the hospital by a doctor that the St Johns Wort was the cause of the reaction when I started my push of the morphine......NO FIGHT! oh and for the record there are equally trained on my truck and it was respiratory arrest not full cardiac and my partner had the airway! Due to the hospital location we were at the doors in 2-3 minutes best I can remember with a driver from city FD.....

 

[1badassEMT-I]

Quote:
Originally Posted by 1badassEMT-I
My personal feeling and comfort zone is having a line started before pushing my drugs. But that is just me.

That seems like a fair opinion. Can I politely inquire what causes you to be uncomfortable with a medication that is prescribed to nonhealthcare providers to self administer for conditions such as Diarrhea, caughing, and home management of pain in chronic conditions?


Just my personal preference!

 

[1badassEMT-I]

St Johns wort increases CNS depression - chamonile, hops, Jamaican dogwood, kava, lavender, mistletoe,nettle, pokeweed, poppy, senega, skullcap, valerian. As a interaction with Morphine.

Reference:: 22nd edition 2009 Mosby's Nursing Drug Reference Page 719 under Morphine.

So you saying that it can not happen? Or my story is just out there?

 

[1badassEMT-I]

This doesn't make any sense.

In what sense did they arrest? As far as I'm aware st John's wort increases the side affects of opiates a little. Was it a respiratory arrest? Then you could simply ventilate the person indefinitely. Did they arrest because they were haemodynamically unstable anyway and the vasodilation that comes with morphine pushed them over the edge? If they were so compromised already, having a line in is irrelevant, they shouldn't have been getting the morphine in the first place and narcan won't help with the vasodilation as far as I know.

Besides Narcan can be given IM (and IN as well) so even if it were going to help, you could still give it without a line.

Reference:::: 22nd edition Mosby's Nursing Drug Reference:::::

Naloxone aka Narcan

Actions: Competes with opioids at opiate receptor sites.

Uses : Respiratory Depressions induced by opioids, pentazocine, propoxyphene; refactory circulatory shock, asphyxia neonatorum, coma, hypotension

I just rather have a line/lock in place but like I said thats just me. Oh and it was a respiratory arrest.

 

[1badassEMT-I]

I ask your indulgence. It has been my experience people who post absolute oversimplified statements are usually looking for a fight.



No, and the frequency and doses i often give it at are for the pupose of anesthesia or complete pain mitigation. I suspect that your patient arrested for a cause that was not stipulated and it is being attributed to the administration of a relatively small amount of morphine. (based on common doses used in ems)




Doesn't frighten me. Even if they were it is a problem simply solved with some IM epi, and by not using the narcan it not only maintains the analgesia from the morphine, but doesn't block the Mu and Kappa receptors so I can try an alternate formulation.



That doesn't seem to be supported by the recent article that MedicRob posted. Do you have a more comprehensive or alternate source?



I must once again ask your indulgence, as this seems to be a rather oversimplified statement. Are you suggested the patient went into instantaneous and simultaneous respiratory and cardiac arrest? If not, and they went into respiratory arrest would positive pressure ventilation and a patient airway have a lesser effect than the narcan?

If this was an undocumented case of a severe interaction, since morphine has a longer half life than narcan and it competes for the same receptor sites, were multiple doses or an infusion of narcan required until the morphine was not biologically available? If not it seems logical to conclude that when the narcan was no longer active the patient would have arrested again. (possibly in as little as 15 minutes)



That seems like a fair opinion. Can I politely inquire what causes you to be uncomfortable with a medication that is prescribed to nonhealthcare providers to self administer for conditions such as Diarrhea, caughing, and home management of pain in chronic conditions?

You know what I have read over and over that you are trying to pick me apart....why yes that does bother me to a degree, let me tell you alittle about me.... while I am JUST a EMT-I now and getting my (Paramedic back) , I was once a Paramedic when I got burned out running the busiest truck in a city in NC where I am from I let my card exp.. I have 22 years of EMS exp. NOT CLIAMING to know everything. I know patient care. How I care for a patient may differ from you. I do know what I am doing. I do like to caution on how I care for my patient because this is medicine and I got think of what can go wrong will go wrong. I dont think because I got all the neat tools and toys of the trade that something cant go wrong. SO I use CAUTION on how I do things. Does make me a bad provider? I hope not. Because there are some out there that think just the opposite of that and hurt more than they help. I dont just do a intervention because I CAN, I do it because it is how I am trained and know what it is there for and it uses and it effects. So while you are picking me apart please keep that in mind or maybe consider I am no idiot like from your post that reflects you mite think I am. Just as I have showed my references and reasoning on how and why I treated this patient the position I was in at the time was a good treatment.....At the end of the day that patient was ALIVE! and went home to his family. Now just think of this what if it was your family member that this happen too and I was the one that was treating them would think any thing less of my treatment or would you have been grateful? And I ask that to all of you picking me apart!

 

[1badassEMT-I]

The Active Constituent of St Johns Wort is a Monoamine Oxidase inhibitor. Some Opiates + MAOIs = Bad Ju Ju.

See the following:

Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. (Gillman PK, 2005)

http://bja.oxfordjournals.org/cgi/content/full/95/4/434?view=long&pmid=16051647

Br J Anaesth. 2005 Oct;95(4):434-41. Epub 2005 Jul 28.

None the less you are right = BAD JU JU

St Johns wort increases CNS depression - chamonile, hops, Jamaican dogwood, kava, lavender, mistletoe,nettle, pokeweed, poppy, senega, skullcap, valerian. As a interaction with Morphine.

Reference:: 22nd edition 2009 Mosby's Nursing Drug Reference Page 719 under Morphine.





Reference:::: 22nd edition Mosby's Nursing Drug Reference:::::

Naloxone aka Narcan

Actions: Competes with opioids at opiate receptor sites.

Uses : Respiratory Depressions induced by opioids, pentazocine, propoxyphene; refactory circulatory shock, asphyxia neonatorum, coma, hypotension

 

[MrBrown]

We wouldn't pick you apart if you constructed a well reasoned, logically and medically sound argument instead of a pile of gramatically poor ramblings that show very little understanding of contemporary Ambulance praxis.

You may have 20 years of experience, but do you actually have 20 years of experience or 1 year repeated 20 times?

 

[1badassEMT-I]

We wouldn't pick you apart if you constructed a well reasoned, logically and medically sound argument instead of a pile of gramatically poor ramblings that show very little understanding of contemporary Ambulance praxis.

You may have 20 years of experience, but do you actually have 20 years of experience or 1 year repeated 20 times?

Point noted and taken! And I am working on that. Sometimes my fingers get slower or faster typing what I think i am saying it just dont come across the screen that way. I do have 20+ years. And would like to think I am a DAMN good ALS provider.

 

[Veneficus]

Let's have a closer look at it.

St. John's Wart (SJW) and morphine and narcan.

SJW is listed as a MAOI inhibitor. The stipulated mechanism of action is that it blocks the reuptake of neurotransmitters (monoamines) potentiating their time and effect in the synaptic cleft.

That makes the goal of treatment to increase stimulation and it is used as a last line effort to treat clinical depression.

Morphine inhibits presynaptic neurotransmitter release, acting as a depressant.

With all known effects and excluding some yet unknown or undocumented reaction, taken together, morphine would prevent release and SJW would prevent reuptake. Depending on the half life, affinity, and potency, the reasonable conclusion is one would cancel the other or reduce the effectiveness of one or both.

I have searched the NIH, FDA, both my pharmacology texts, Medscape, and google. I can find no compelling information or even a suggestion there is an interaction at the synapses between morphine and MAOIs. Though several other opioids do have known reactions. (see my earlier post) I did find a study on medscape listing a study done by a manfufacturer of time release PO morphine stating there may be an adverse reaction. However, the link has been removed.

I also found information that demonstrates that both morphine and St. John's wart are metabolized by cytochrome p450 (multienzyme oxidases) and as such inhibit each other's clearance nd potentiate (lenghten) the affects of each other.

High dose or repeated administration could conceivably raise bioavailability of morphine and cause the toxic effects associated. (respiratory depression, hypotension, altered mental status)

Liver damage or infection could also reduce the availability of the CYP further adding to the amount of active drug.

It is also logical that this could be compounded in a patient further with hypersensitivity to opioids.

When adding narcan to the mix, like any competative inhibitor, if the amount of bioactive morphine was elevated, it would increase the probability of morphine blocking the narcan (standard saturation kinetics) reducing the effectiveness and theraputic level of the narcan. A rapid reversal of the opioid without an elevated dose of narcan seems highly unlikely, using anything that is currently known about biochemistry and the properties of the agents involved.

 

[Veneficus]

You know what I have read over and over that you are trying to pick me apart....why yes that does bother me to a degree, let me tell you alittle about me.... while I am JUST a EMT-I now and getting my (Paramedic back) , I was once a Paramedic when I got burned out running the busiest truck in a city in NC where I am from I let my card exp.. I have 22 years of EMS exp. NOT CLIAMING to know everything. I know patient care. How I care for a patient may differ from you. I do know what I am doing. I do like to caution on how I care for my patient because this is medicine and I got think of what can go wrong will go wrong. I dont think because I got all the neat tools and toys of the trade that something cant go wrong. SO I use CAUTION on how I do things. Does make me a bad provider? I hope not. Because there are some out there that think just the opposite of that and hurt more than they help. I dont just do a intervention because I CAN, I do it because it is how I am trained and know what it is there for and it uses and it effects. So while you are picking me apart please keep that in mind or maybe consider I am no idiot like from your post that reflects you mite think I am. Just as I have showed my references and reasoning on how and why I treated this patient the position I was in at the time was a good treatment.....At the end of the day that patient was ALIVE! and went home to his family. Now just think of this what if it was your family member that this happen too and I was the one that was treating them would think any thing less of my treatment or would you have been grateful? And I ask that to all of you picking me apart!

Not trying to fight, trying to see the logic of your position and how you get to your conclusions.

 

[medicRob]

In your article in the conclusion it states specifically:

"In summary, morphine, codeine, oxycodone and buprenorphine are now known not to be SRIs and they do not precipitate serotonin toxicity with MAOIs."

Said drugs are also not listed in Table 1. in the same study describing potential toxicity.

"Table 1 Drugs with clinically relevant serotonergic potency from reference29 with permission. Fatalities from serotonin toxicity involving analgesics have been with pethidine, tramadol and dextromethorphan and, possibly, fentanyl."

I do not see how this study supports the conclusion that morphine would have an interaction with St. Johns Wart.

Thanks for the post though, it was a great read. It knocks Fent down a couple of pegs.

Sorry, didnt see your post at first. I was speculating as to the effect of narcotics with MAOI's, thus why I chose to use the word some before narcotics. Truth be told, I wasn't entirely familiar with the various interactions of St John with most medications, I usually run meds through our interaction checking db at work. However, this post did inspire me to do a bit more research into such things and expand my knowledge, so all in all-it was a good thing. I learn something new every day. I feel that after being made aware of such things that I will be more inclined to ask my patient during my SAMPLE history "Medications taken" section, to include any herbal supplements he or she may be taken as well, especially with regard to Syrian Rue or St Johns Wort.

 

[1badassEMT-I]

St. John's Wart (SJW) and morphine and narcan.

SJW is listed as a MAOI inhibitor. The stipulated mechanism of action is that it blocks the reuptake of neurotransmitters (monoamines) potentiating their time and effect in the synaptic cleft.

That makes the goal of treatment to increase stimulation and it is used as a last line effort to treat clinical depression.

Morphine inhibits presynaptic neurotransmitter release, acting as a depressant.

With all known effects and excluding some yet unknown or undocumented reaction, taken together, morphine would prevent release and SJW would prevent reuptake. Depending on the half life, affinity, and potency, the reasonable conclusion is one would cancel the other or reduce the effectiveness of one or both.

I have searched the NIH, FDA, both my pharmacology texts, Medscape, and google. I can find no compelling information or even a suggestion there is an interaction at the synapses between morphine and MAOIs. Though several other opioids do have known reactions. (see my earlier post) I did find a study on medscape listing a study done by a manfufacturer of time release PO morphine stating there may be an adverse reaction. However, the link has been removed.

I also found information that demonstrates that both morphine and St. John's wart are metabolized by cytochrome p450 (multienzyme oxidases) and as such inhibit each other's clearance nd potentiate (lenghten) the affects of each other.

High dose or repeated administration could conceivably raise bioavailability of morphine and cause the toxic effects associated. (respiratory depression, hypotension, altered mental status)

Liver damage or infection could also reduce the availability of the CYP further adding to the amount of active drug.

It is also logical that this could be compounded in a patient further with hypersensitivity to opioids.

When adding narcan to the mix, like any competative inhibitor, if the amount of bioactive morphine was elevated, it would increase the probability of morphine blocking the narcan (standard saturation kinetics) reducing the effectiveness and theraputic level of the narcan. A rapid reversal of the opioid without an elevated dose of narcan seems highly unlikely, using anything that is currently known about biochemistry and the properties of the agents involved.

This was a pt with a broken tib/fib, pt had slightly increased rr at 22, b/p was good, st on monitor of about 110. o2 at 3l nc. Orders was given for 6mg of Morphine, and to transport. Pt was packaged and ready to go, started pushing iv morphine, pt handling the morphine rr still at 22. After all 6mgs of the morphine was pushed pt went into respiratory arrest. Partner got airway established (ET 7.5 lip line 23) Morphine of course was given for pain mitigation after which was believed by er physician that this was what put pt into respiratory arrest. Afterwards when found out that SJW taken daily from this pt. SJW increases the CNS depression (2009 Drug Reference Nursing). 4mg Narcan was administered b/c it is an opiod antagonist, antidote to be used for respiratory depression induced by opiods. (2009 Nursing Drug Reference) after pushing pt went from respiratory arrest to respiratory depression. pts vs b/p increased, pulse was still tachy at 118 and rr 16. So in short, morphine given for pain which caused a reaction with the SJW which again once mixed or in contact with the morphine can or will cause CNS depression, which occurred when pt respiratory arrested, the narcan is a antagonist and its job is to stop the opiod (Morphine) and to assist with respiratory depression (2009 Nursing Drug Reference)
Other than the above what could i have done. Narcan done its job. Patient is alive.

 

[Sasha]

retracted

 

[1badassEMT-I]

retracted

Please by all means put your input in. I would really like to have know how you would have handle this.