Are we doing harm by giving morphine in chest pain?

Subscribe to Resus

Get the latest updates on our Conferences PLUS our Webcasts and Education Newsletters. And it's FREE!

  • We respect your privacy
  • This field is for validation purposes and should be left unchanged.

Register Now:

Sorry, we couldn't find any posts. Please try a different search.

Have you ever given morphine to a patient with chest pain? Have you given it before trying nitroglycerin(GTN)? I know I have and the patient wasn’t hypotensive.

I consider morphine to be the gold standard of analgesia, however, now that I think about it, it really only masks the pain, doesn’t it? It doesn’t really treat the ischaemia. I’ll discuss a study shortly that shows an increased mortality with the use of morphine.

But first……..

I’m looking at the American Heart Association (AHA) guidelines for the use of morphine in Non-ST elevation (NSTEMI) and in ST elevation(STEMI) myocardial infarction and I’m confused. The use of morphine in the NSTEMI patient is Class IIa, and level B evidence, whereas in STEMI it is Class I, level C. What? isn’t the pathophysiological process the same? I need to look at this more closely.

But now here’s the paper: Meine et al. Am Heart J, 2005; 149:1043-1049.

The investigators accessed the CRUSADE registry database and looked at 57,039 patients with NSTEMI and found that those receiving morphine had an increased mortality. They had a 48% higher risk of death!

Now this is a registry study and needs a validation trial, however the point to be made is that unless there is a contraindication to GTN, this is the first drug to give. Morphine should be used if the pain cannot be controlled by GTN. This is the recommendation in the cardiac guidelines. GTN has some significant effects ie decreasing preload and afterload and resulting in vasodilatation. Morphine masks the pain.

I know I’ll be paying more attention.


Peter Kas

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator


  1. jmjanssens on 29/11/2012 at 2:31 pm

    Hi Peter,
    I’m not sure that morphine “only” masks the pain. From it’s pharmacologic properties we can also assume that it reduces sympaethetic stimulus – witness the resolution of tachycardia and other autonomic features in patients with pain of any origin. This should have beneficial effects on myocardial workload and oxygen demand. One way of interpreting the result of the trial you coite is that intractable chest pain is a marker for severity of pathology. Patients with ongoing pain are more likely to need mrophine due to the severity of their underlying disease process. Their demise may be due to this, and not to the admnistration of morhpine per se. Morphine gets the rap though.
    I agree that GTN should be the first drug off the shelf. Faced by severe ongoing pain I would have no qualms about use of morphine or another opioid drug to reduce the suffering of the patient, confident that I am likely to be producing benefit as well.

    • Resus on 29/11/2012 at 7:51 pm

      Thanks for the comment. I agree with all you say. The point here is, and you certainly mention it, not use morphine in place of GTN. Use it as well as. The example I always use is this; If someone has a compound fracture of the femur and we give morphine and enough of it, the pain decreases significantly. It doesn’t treat the femur, but masks the pain.
      In the cardiac patient, it may very well assist in decreasing the workload and I think it does, but it doesn’t result in the vessel dilatation that has the major effect. How much resultant effect does the morphine have? We don’t really know.
      In these cases, I don’t think that the patient has any suffering. If they do, we have to rethink everything( more likely a dissection than cardiac?) It’s usually that we get the pain score down to a 1 or 2 out of 10, so they are comfortable, but have a touch of discomfort. I still think GTN should be the answer here.
      I, like you, believe that the patient in our emergency department should not be in pain, from whatever cause.

  2. how to lose weight on 06/10/2021 at 7:29 am

    I visited a lot of website but I believe this one contains something extra in it.

    my web page; how to lose weight

  3. care products on 06/10/2021 at 8:11 am

    I constantly spent my half an hour to read this web site’s articles or reviews every day along with a cup of coffee.

    Feel free to surf to my web blog; care products

  4. ketogenic diet ulitmate on 06/10/2021 at 8:40 am

    What’s up, all the time i used to check web site posts here in the early hours in the break
    of day, for the reason that i love to gain knowledge of
    more and more.

    Also visit my webpage … ketogenic diet ulitmate

  5. growing indoors on 06/10/2021 at 8:48 am

    hello there and thank you for your info ? I have certainly picked up anything
    new from right here. I did however expertise some technical points using this site, since I experienced to reload the website
    lots of times previous to I could get it to load properly.
    I had been wondering if your web hosting is OK? Not that I am complaining,
    but sluggish loading instances times will often affect your placement in google and can damage your quality score if
    advertising and marketing with Adwords. Well I?m
    adding this RSS to my e-mail and can look out for much more of your respective interesting content.
    Ensure that you update this again soon..

    Visit my blog: growing indoors

  6. getting affordable treatment on 06/10/2021 at 8:57 am

    My spouse and I absolutely love your blog and find most of your post’s to be exactly what I’m looking for.
    Would you offer guest writers to write content for you?
    I wouldn’t mind publishing a post or elaborating on a few of
    the subjects you write in relation to here.
    Again, awesome web log!

    Also visit my blog post: getting affordable treatment

  7. natural skin care tip on 06/10/2021 at 9:02 am

    Regards for all your efforts that you have put in this.
    Very interesting info.

    My web site – natural skin care tip

  8. diets for health on 06/10/2021 at 9:07 am

    I’m so happy to read this. This is the kind of manual
    that needs to be given and not the accidental misinformation that’s at the other blogs.

    Appreciate your sharing this best doc.

    Here is my blog: diets for health

  9. getting affordable treatment on 06/10/2021 at 9:36 am

    I don’t even know how I ended up here, but
    I thought this post was good. I do not know who you are but certainly you’re
    going to a famous blogger if you aren’t already 😉 Cheers!

    Feel free to visit my web page – getting affordable treatment

  10. high fat on 06/10/2021 at 10:03 am

    What’s up, its pleasant paragraph concerning media print, we
    all be aware of media is a enormous source of information.

    Review my web-site :: high fat

  11. natural libido pills on 06/10/2021 at 10:19 am

    I wanted to follow along and let you know how , a great deal I
    treasured discovering your blog today. I’d personally consider it an honor to work at my workplace and be able to make
    use of the tips provided on your blog and also get involved in visitors’
    responses like this. Should a position involving guest publisher become available at your end,
    you should let me know.

    my web site: natural libido pills

  12. simple skin care on 06/10/2021 at 10:30 am

    I am not real good with English but I find this very easy to translate.

    My site – simple skin care

  13. healthy food on 06/10/2021 at 10:32 am

    Hello, Neat post. There’s a problem along with your site in internet explorer, would check this…
    IE nonetheless is the market leader and a large component of folks will pass over your magnificent writing because of this problem.

    Feel free to visit my website healthy food

  14. diets that work on 06/10/2021 at 10:46 am

    Hi, this weekend is pleasant for me, because this occasion i am reading this enormous informative post here at my house.

    Feel free to visit my web-site: diets that work

  15. on 06/10/2021 at 10:52 am

    Hello.This post was extremely remarkable, especially since
    I was browsing for thoughts on this issue last Sunday.

    Here is my blog :: email marketing (

  16. oil pulling teeth whitening on 06/10/2021 at 11:32 am

    I read this post completely about the resemblance of most recent and preceding technologies, it’s amazing article.

    Feel free to surf to my web blog :: oil pulling teeth whitening

  17. on 06/10/2021 at 12:22 pm

    An outstanding share! I’ve just forwarded this onto a colleague who was conducting a little research on this.
    And he boost libido in men over 40 ( fact
    ordered me breakfast due to the fact that I stumbled upon it for him…

    lol. So allow me to reword this…. Thank YOU for the meal!!
    But yeah, thanks for spending the time to talk about this subject here
    on your blog.

  18. quick weight loss pills on 06/10/2021 at 12:35 pm

    Yeah bookmaking this wasn’t a speculative
    conclusion outstanding post!

    Stop by my webpage :: quick weight loss pills

  19. yeast infection on 06/10/2021 at 2:01 pm

    Its such as you learn my mind! You seem
    to grasp so much about this, such as you wrote the ebook in it or
    something. I think that you simply could do with a few percent to power the message home a little bit, but other than that,
    this is wonderful blog. A great read. I will certainly be back.

    Look into my website yeast infection

  20. Luther on 06/10/2021 at 2:03 pm

    Attractive part of content. I just stumbled upon your blog and in accession capital to
    assert that I acquire in fact enjoyed account your weblog posts.

    Anyway I will be subscribing in your augment and
    even I fulfillment you access consistently rapidly.

  21. healthy eating book on 06/10/2021 at 2:35 pm

    Good answers in return of this issue with real arguments and explaining all about that.

    Feel free to visit my homepage; healthy eating book

  22. sexual desire on 06/10/2021 at 2:48 pm

    Wonderful blog! I found it while surfing around on Yahoo
    News. Do you have any tips on how to get listed in Yahoo News?
    I’ve been trying for a while but I never seem to get there!
    Many thanks

    My blog; sexual desire

  23. hotter sex on 06/10/2021 at 3:28 pm

    Hiya very cool web site!! Man .. Excellent .. Amazing ..

    I will bookmark your site and take the feeds also?
    I am happy to find numerous useful info right here in the publish, we’d like work out
    more techniques on this regard, thanks for sharing.
    . . . . .

    Here is my site :: hotter sex

  24. lovemaking ideas on 06/10/2021 at 5:19 pm

    It is not my first time to visit this web site,
    i am visiting this website dailly and get good data from here every day.

    Look at my webpage :: lovemaking ideas

  25. Cristine on 07/10/2021 at 10:08 am

    Howdy! Do you know if they make any plugins to safeguard against hackers?
    I’m kinda paranoid about losing everything I’ve worked hard on. Any recommendations?

  26. on 07/10/2021 at 10:10 am

    I am continually searching online for tips that can help
    me. Thanks!

Leave a Comment