Rectal Use of Morphine Suppositories and Sustained-Release Tablets
35. Several weeks later, A.J. is no longer able to swallow his medication because of worsening of an existing esophageal stricture. What are alternatives for giving A.J. his required daily analgesic?
In addition to the parenteral routes already presented, morphine can be administered as an oral solution or via a rectal suppository. The absorption of the rectal suppository is at least comparable to, or better than that of, the morphine solution.130,131 If A.J. was stabilized on 240 mg/day of SR morphine, the initial morphine suppository dose also should be 240 mg/day. The duration of action of morphine suppositories is similar to that of morphine solution and therefore must be administered every 3 to 4 hours. For A.J., the starting dose is 30 mg rectally every 3 hours. Other agents, such as hydromorphone (Dilaudid) and codeine, are also available as suppositories. The equianalgesic doses of these agents for A.J. (Table 8-3) would be 6 and 10 mg, respectively. SR oral morphine tablets also can be used for rectal administration. The rectal absorption of SR tablets is comparable to the oral route of administration.132,133 There is no maximal dose for opioid analgesics for the management of pain of a terminal disease, but there is a limit to how many suppositories or tablets the patient can hold rectally.
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