Morphine Sustained Release Tablets Becoming Ghost Pill: A Palliative Conundrum

Dear Sir,

Morphine sustained release tablets are used to alleviate refractory chronic pain.^[1] Sustained release tablet or capsule either disintegrates slowly or remains intact, but the active drug is available for absorption.^[2] Sometimes the shell encasing this sustained release tablet fails to disintegrate leading to the passage of ‘Ghost pills,’ a term coined for such tablets appearing unchanged in faeces.^[3,4] This may lead to severe anxiety and a sense of inadequate pain relief for the patient.

Modifications in the digestive tract secondary to gastrointestinal surgery, especially small intestine stomas (ileostomy or jejunostomy) may compromise the bioavailability of drugs.^[5] This may lead to decreased absorption of oral medications, especially sustained-release preparations.

In this letter to the editor, we describe a case of a patient with jejunostomy with severe abdominal and back pain not responding to morphine sustained-release tablets and also with a history of the passage of ghost pill via the stoma.

A 40-year-old patient of metastatic carcinoma rectum, post exploratory laparotomy for intestinal obstruction with jejunostomy was prescribed morphine sustained-release tablet for refractory severe abdominal pain. His baseline pain was VAS 70/100 which increased to 90/100 during abdominal cramps. The pain was dull-aching in character and radiated to back. The patient was initially prescribed paracetamol, paracetamol/tramadol combination analgesics, and antispasmodics; but there was no pain relief. Nonsteroidal anti-inflammatory drugs were avoided in the patient because of prior history of gastric bleeding. The patient was then prescribed immediate release morphine tablets. After titration of morphine dose as per patient requirement (adequate pain relief), the patient was given morphine sustained-release tablets. However, the patient started complaining of increased pain. The patient and his caregivers noticed the passage of intact morphine tablets or shells of the sustained release formulation through jejunostomy. Considering the issue of anxiety regarding such ghost pill or the decreased absorption of morphine sustained release due to decreased length of intestine, morphine sustained-release preparation was discontinued. The patient was again started on morphine immediate release tablets. There was a decrease in abdominal as well as back pain. This suggests to two possibilities in this patient: - first, the passage of morphine sustained-release tablet through stoma may have led to increased anxiety and a sense of inadequate pain relief in the patient; and second, due to intestinal resection and jejunostomy, there might be decreased absorption of the sustained-release preparation.

We suggest these issues as a possibility in the use of morphine sustained-release preparations in patients who have undergone intestinal resection surgery and are having jejunostomy or ileostomy.