Morphinofobia: the situation among the general population and health care professionals in North-Eastern Portugal

During the last decades, considerable progress has been recorded in the knowledge of the action and the use of opiates in pain management [1‐3]. In spite of this progress, the pain prevalence in general populations and health care institutions remains high, varying from 20 to 80% depending on the region or the country [4‐7].

Why has this knowledge not been applied by HP and did not have the expected effects among the GP? Do morphine frighten so much the GP and HP becoming a public health problem?

Morphinofobia can be defined as a set of false beliefs concerning the negative effects of morphine in the management of pain [8], an inappropriate attitude of professionals in the pain management due to a lack of knowledge [9], a philosophical opposition to the prescription and the use of morphine in pain management [10].

Morphinofobia seems widespread and caused by ignorance, prejudices, false beliefs, economic marketing strategies and limitations in the availability of morphine [8, 10‐16].

In 1960, the studies of Robins et al. [17] and Abeles et al. [18] reported false beliefs of health professionals in the use of morphine: it was related to fears of addiction and abuse, to limited information on legal aspects, a lack of knowledge about the use of opiates by health professionals (physicians) and users (patients) and to the negative image of morphine in general. Similar observations have been reported in a recent study by Zacny et al. [19]: morphine was often associated with advanced disease, imminent death, illicit drug addiction, euthanasia, potential risks of abuse, excessive sedation and fear of pursuit by authorities [5, 7, 10, 14, 20‐25]. Few studies compared attitudes and perceptions related to the use of morphine as an analgesic among GP and HP in a given region.

Musi et al. [26] studied the myths of morphine in the Valley of Aosta in Northern Italy interrogating 380 health professionals and the general population about their fears in using morphine. They showed that despite the availability of morphine, its low costs and its efficacy, the prescription and the acceptance of opioïdes, and more specifically of morphine, in health care institutions was low.

Our study aims to compare morphinofobia among the general population (GP) and health professionals (physicians and nurses) (HP) in a country where the consumption of morphine was multiplied by 4 over the last decade [27], though its prescription is tightly regulated by public health authorities [28].

The survey was carried out between August and November 2005 using two structured questionnaires, developed based on the model of Musi et al. [26]. One of the authors (MF) translated the questionnaires in Portuguese and later conducted the survey. After a translation check by two Portuguese health professionals the questionnaires were pilot-tested among 5 GP and 5 HP in the province of Beira Interior.

The sampling among GP and HP yielded a total of 606 respondents.

This study compared the use of morphine as perceived by GP and HP in the region of Beira Interior in North-Eastern Portugal. There are differences of perception but also common fears. It might well induce some reluctance regarding the use of morphine. This in turn might influence negatively patient care in general and pain management more specifically.

Most studies reporting "false beliefs" regarding the use of morphine in pain management focus either on specific ethnics groups or on health professionals [13, 4, 29‐31]. Studies comparing GP and HP in this field are few. One done by Musi et al. [26] in Northern Italy confirms our results. These authors mention than 39% of GP primarily associate the word morphine with «drugs» and «the risks of somnolence, dependency and the seriousness of the clinical situation». Other studies also support our observations. Weisse et al. [31] report that the physicians' attitude in prescribing analgesics for pain management varies according sex and ethnic group. Bernades [32] reports a difference in perception of pain according to sex. Riley et al. [29, 33] and Robinson et al. [30] show a significant difference in chronic pain management according to age.

In our study morphinofobia among HP seems related to false beliefs on side effects of morphine, risks of addiction and legal constraints in the prescription of morphine. Yet the word morphine is principally associated with the notion of analgesia. Musi et al. [26] reports in his study among HP that the word morphine is associated first with « pain » followed by «analgesia, drug, cancer, death and sedation» which does not differ much from our observations. Other authors report similar data to ours. Seddon et al. [34] mention clearly that the use of morphine in pain management is strongly influenced by the society's perceptions, especially as far as addiction and the legal constrains go. The recent Italian study of Bandieri et al. [13] analysed the consumption of opioids between 2000 and 2008 and showed an increase in the use of opioids in general, but a decrease use of oral morphine. The conclusions of the authors are clear: the behaviour of physicians is still largely contrary to guidelines, suggesting that either cultural or marketing rather than legal factors are mainly responsible for morphinofobia. Staton [35] reports a significant difference in the perception of pain between physicians and patients, especially among certain ethnic groups (Afro-Americans). Nishimori [36] studying opiates abuse among patients at home reported treatment failure by physician in case of opioïde dependency. Ballantyne et al. [37] in a review of literature on chronic pain treatment with opioïdes shows discrimination in prescribing morphine in relation with fears of dependencies.

Many studies report fears and false beliefs concerning the use of morphine in pain management among HP [14, 22, 38‐40]; e.g. Larue et al. [41] report false beliefs of general practitioners and oncologists in France; negative attitudes of nurses in the use of morphine in pain management are reported from Australia [22] from the USA [23] and from Hong Kong [42].

The existence of false beliefs on pain, addiction and abuse of morphine have also been reported by Gilson et al. [21] in a study among 300 American physicians. Furthermore Nwokeji et al. [43] reported that among 267 general practitioners who agreed to prescribe opioïdes to patients suffering from chronic non-cancerous pains, half feared addiction and abuse. White et al. [44] studying the attitudes of hospital physicians on opiate prescription, confirm that opiophobia is often related to fears of dependency. Devi et al. [45] questioning 253 Malaysian physicians reported that 83% of the respondents consider a possible addiction and the fear of exceeding sedation and respiratory depression as the main obstacles in prescribing morphine. Clinical documented experiences have proven that these fears are not justified [3, 46‐49]. Some physicians may also lack knowledge on morphine pharmacokinetics or may be unfamiliar with morphine prescription [50]. Ripamonti et al., [16] concluded in an Italian study of cancer patients that despite the WHO guidelines and EAPC recommendations, there was an inappropriate use of transdermal opioids by Italian physicians in situations where the use of oral morphine was not contraindicated.

Our results showed a rather weak relationship between socio-demographic features and the perceptions of the use of morphine in pain management. Yet morphinofobia was highest among little-educated older men living in rural areas. The cultural and geographic influences on attitudes and beliefs regarding morphine among patients with non cancerous pains have been stressed by Monsivais et al. [51] and Cicero et al. [52]. However a literature review by Turk [53] is cautious in this regard. Ripamonti et al., [16] mentioned that patients were having a problem in taking morphine but they had no cultural problems with other opioids. Most patients knew what morphine meant but do not know the role and the potency of other opioids.

Health professionals play an important role as far as morphinofobia is concerned, be it through a possible lack of knowledge regarding morphine [23, 54], be it out of "more philosophical" reasons as suggested by Covington [10] and Bandieri et al., [13]. Yun et al. [55] and Edwards et al. [22] therefore suggest the necessity to develop more positive attitudes among HP regarding the use of morphine.

There are limits to our study. First a generalisation to the population of Beira Interior of our observations might not be indicated because of the small sample of GP and its opportunistic nature. Second, our study focused on attitudes and perceptions on morphine of GP (potential patient) and HP and did not take in consideration the patients' vision. Third, it should be kept in mind that some of our results are matter of debate in the specialized literature [25, 52]. Last, our study concentrated on the concept of morphinofobia and should not be generalized for other opioids.

This study contributes to a better understanding of "the myths of morphine" among the general population and health professionals in the region of Beira Interior. It suggests that efficient pain management is not limited to the prescription of an adequate analgesic according to « the golden standard ». The success of a morphine prescription is influenced by a multitude of other factors.

Our results are in accordance with the results of the study by Musi et al. [26] done in a similar regional setting. There seems to be quite a misunderstanding of "morphine" as well among GP as HP in North-Eastern Portugal. Such a misunderstanding might well end up in straight forward morphinofobia, thus ultimately compromising an appropriate pain management strategy as recommended by W.H.O. guidelines and EAPC recommendations.

This leads us to suggest that there is a need for information campaigns targeting the general population and for better training programs targeting health care professionals based on the theory of planned clinical behaviour [14] in order to improve acceptance and efficacy of pain management.