Topical Morphine Gel Can Help Ease Pain of EB Wounds, Report Shows
Gel used to treat 3 patients in UK with good results
Topical morphine gel can help to ease pain related to wounds in people with epidermolysis bullosa (EB), a new report suggests.
The treatment was used with good results in three EB patients in the U.K.
“The case studies suggest a positive effect of topical morphine gel on painful wounds across a spectrum of EB subtypes,” the researchers wrote.
The study, “Use of topical morphine gel in epidermolysis bullosa wounds—A series of case studies,” was published in the International Wound Journal.
3 case studies show efficacy of topical morphine gel
Chronic wounds are a characteristic symptom of EB, and managing pain from these wounds is often a challenge.
Morphine is an opioid that can bind to nociceptors — sensory receptors responsible for detecting pain — and result in less pain. The opioid can be administered in a number of ways: orally, via injection, or topically. Topical administration is by local application to the skin.
While topical morphine gel may be prescribed in clinical practice to help manage pain from EB wounds, there is little evidence about its use. In this study, a pair of scientists at Guy’s and St Thomas’ NHS Foundation Trust, in the U.K., reported on the experiences of three EB patients who used morphine gel to manage pain from their wounds.
“The purpose of this paper is to demonstrate the efficacy of topical morphine gel used in a variety of EB wounds as well as patient reported reduction in pain,” the team wrote.
The first patient described in the report was a 28-year-old man with recessive dystrophic EB (RDEB), one of the most severe forms of EB. The man had wounds on the majority of his body; a few large wounds around his ankle were causing him particular problems because they made it difficult to move around and interfered with his sleep.
He was on oral pain meds, including an opioid called tramadol. However, he was reluctant to take a stronger opioid, such as morphine, due to concerns about side effects like cognitive impairment.
The man was started on topical morphine gel, applied by caregivers once daily when the dressings on his wounds were changed. He reported that this helped ease his pain somewhat; his self-rated pain decreased from seven to five on a scale of 10, with 10 being the worst pain.
“The use of topical morphine gel and associated reduction in pain enabled the patient to have improvements in mobility and sleep,” the researchers wrote.
“The advantages of using topical morphine gel for this patient were that he was able to avoid taking strong opioids by mouth, thereby preventing any unwanted systemic side effects from opioid use,” the team wrote, adding, “This enabled improved pain management whilst also taking into account patient preference, which is key for individualised patient care.”
The second case in the report involved a 46-year-old woman with severe RDEB-inversa who had extensive painful wounds, with the most problematic ones located around her groin and rear. Despite a complex system of pain management, the woman consistently rated her pain as eight or higher on a scale with a worst rating of 10. She also had blistering in her esophagus (connecting throat to stomach), which made taking oral pain meds a challenge.
Nurses applied morphine gel to the patient’s wounds once daily during wound dressing. The patient’s pain remained high — usually six or seven of 10 — but nonetheless she reported feeling that the gel was helpful.
“She felt that the topical morphine gel was helpful, and she continues to use it regularly at the same dose and frequency,” the researchers wrote. “She feels more comfortable in the hours immediately following application and reports being able to sit and move around with more ease.”
The researchers noted that, due to the location of the wounds, dressings sometimes had to be changed again after toileting, and the morphine gel is not usually re-applied on these occasions. The patient “reports flare in pain on the occasions when dressings are replaced without the morphine gel being reapplied,” they said.
One man reports immediate improvement with topical morphine
The third case was a 67-year-old man with junctional EB who had a chronic wound on his lower leg. Oral pain meds caused unpleasant side effects like digestive upset. He was given sublingual (under-the-tongue) fentanyl, also an opioid, but still reported pain at eight or nine of a 10-point maximum scale.
After starting on topical morphine gel, the patient “reported an immediate improvement” in pain, with self-rated pain lowering to four or five of 10, the researchers reported.
The team noted that these cases involved only a small number of patients and “clinical evidence is limited.” But they said these studies “do suggest the benefit alongside routine wound care of topical morphine gel.”
Further research is needed into the use of topical morphine in EB to develop evidence-based guidelines for how best to use this medicine to help patients, they concluded.
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