Doctor Pharmacy

Morphine Sulfate:

An opioid analgesic.

Indications:

It is prescribed for relief of moderate to severe pain, including that from myocardial infarction and dyspnea caused by left heart failure, and as a preanesthetic.

Contraindications:

Drug dependence or known hypersensitivity to this drug prohibits its use.

Adverse Effects:

Among the more serious adverse effects are increased intracranial pressure, cardiovascular disturbances, respiratory depression, and drug dependence. Nausea, vomiting, constipation, and xerostomia are common.

Morphine Sulfate:

n brand names: Duramorph PF, MS Contin, Roxanol;

drug class: narcotic analgesic (Controlled Substance Schedule II);

action: depresses pain impulse transmission at the central nervous system by interacting with opioid receptors; use: severe pain.

Morphine Sulfate: Warning - High-alert drug!

Astramorph PF, Avinza, Duramorph, Epimorph (CA), Filnarine (UK), Infumorph, Kadian, Morphine H.P. (CA), Morphogesic (UK), MS Contin, MST Continus (UK), MXL (UK), Oramorph (UK), Rhotard (UK), Sevredol (UK), Statex (CA), Zomorph (UK)
Pharmacologic class: Opioid agonist
Therapeutic class: Opioid analgesic
Controlled substance schedule II
Pregnancy risk category C
FDA Boxed Warning
• Avinza (morphine sulfate) capsules are modified-release form indicated for once-daily P.O. administration to relieve moderate to severe pain requiring continuous, around-the-clock opioids for extended time. Instruct patients to swallow capsules whole or sprinkle contents on applesauce. Warn them never to chew, crush, or dissolve capsules or consume alcoholic beverages or use prescription or nonprescription drugs containing alcohol during therapy, as this may lead to rapid release and absorption of potentially fatal dose.
• Intrathecal dosage of morphine sulfate injection is usually one-tenth of epidural dosage.

Action:

Interacts with opioid receptor sites, primarily in limbic system, thalamus, and spinal cord. This interaction alters neurotransmitter release, altering perception of and tolerance for pain.

Availability:

Morphine hydrochloride

Rectal suppositories: 20 mg, 30 mg
Syrup: 1 mg/ml, 5 mg/ml, 10 mg/ml, 20 mg/ml, 50 mg/ml
Tablets: 10 mg, 20 mg, 40 mg, 60 mg

Morphine Sulfate

Capsules: 15 mg, 30 mg
Capsules (extended-release): 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 90 mg, 100 mg, 120 mg, 200 mg
Capsules (sustained-release): 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 100 mg
Oral solution: 2 mg/ml, 4 mg/ml, 20 mg/ml (concentrate), 10 mg/5 ml, 20 mg/5 ml, 100 mg/5 ml
Rectal suppositories: 5 mg, 10 mg, 20 mg, 30 mg
Solution for epidural injection (extended-release, liposomal): 10 mg/ml, 15 mg/1.5 ml, 20 mg/2-ml vials
Solution for epidural or intrathecal use (preservative free, for continuous microinfusion device): 10 mg/ml and 25 mg/ml in 20-ml vials
Solution for epidural or I.V. injection (preservative-free): 0.5 mg/ml, 1 mg/ml
Solution for I.M., I.V., or subcutaneous injection: 1 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml, 10 mg/ml, 15 mg/ml, 25 mg/ml, 50 mg/ml
Solution for I.V. injection (for patient-controlled analgesia [PCA] device): 1 mg/ml, 2 mg/ml, 3 mg/ml, 5 mg/ml
Tablets: 15 mg, 30 mg
Tablets (controlled-release, sustained-release): 15 mg, 30 mg, 60 mg, 100 mg, 200 mg
Tablets (soluble): 10 mg, 15 mg, 30 mg

Indications and dosages:

Severe to moderate pain
Oral use -
Adults: 5 to 30 mg P.O. (immediate-release) q 4 hours p.r.n. Or 20 mg P.O. (controlled-release, Kadian) once or twice daily p.r.n. Or 200 mg P.O. (MS Contin) in opioid-tolerant patients who require daily morphine-equivalent dosages above 400 mg.
I.M. or subcutaneous use -
Adults: 5 to 20 mg/70 kg I.M. or subcutaneously q 4 hours p.r.n.
I.V. use -
Adults: 2 to 10 mg/70 kg I.V. p.r.n. given slowly over 4 to 5 minutes. As a continuous I.V. infusion, 0.1 to 1 mg/ml in dextrose 5% in water delivered by controlled-infusion device.
Rectal use -
Adults: 10 to 30 mg P.R. q 4 hours p.r.n.
Epidural use -
Adults: Initially 5 mg (Astramorph PF, Duramorph) injected in lumbar region (may relieve pain up to 24 hours). If response isn't adequate within 1 hour, carefully give incremental doses of 1 to 2 mg p.r.n., up to 10 mg/24 hours. For continuous epidural infusion, 2 to 4 mg/24 hours. For epidural injection (DepoDur) before orthopedic leg surgery, recommended dosage is 15 mg; before lower abdominal or pelvic surgery, 10 to 15 mg. For cesarean section after umbilical cord clamping, recommended dosage is 10 mg.
Intrathecal use -
Adults: Usual intrathecal dosage is one-tenth of epidural dosage; 0.2 to 1 mg as a single injection in lumbar area may relieve pain up to 24 hours.

Dosage adjustment:

Adults weighing less than 50 kg (110 lb)
Elderly patients
Children

Contraindications:

Hypersensitivity to drug, tartrazine, bisulfites, or alcohol
Acute bronchial asthma
Upper airway obstruction
Respiratory depression
GI obstruction, paralytic ileus

Precautions:

Use cautiously in:

• head trauma; increased intracranial pressure; severe renal, hepatic, or pulmonary disease; hypothyroidism; adrenal insufficiency; prostatic hypertrophy
• elderly or debilitated patients
• pregnant or breastfeeding patients.

Administration:

• For best response, give at pain onset.
• Give oral form with food or milk to minimize GI upset.
• If desired, crush immediate-release form and mix with food or fluids.
• Don't crush or break extended-release form; remind patient to swallow it whole.
• If desired, open sustained-release capsules (Kadian) and sprinkle entire contents onto small amount of food (such as applesauce). Have patient consume mixture immediately without chewing, crushing, or dissolving pellets.
• When giving by direct I.V., dilute in at least 5 ml of sterile water for injection or normal saline solution. Give 2.5 to 10 mg over 4 to 5 minutes.
• For continuous I.V. infusion, use infusion pump or PCA pump. Titrate dosage to provide adequate pain relief.
• Don't use parenteral form if it's cloudy or contains visible particulates.

Route    Onset    Peak    Duration
P.O.    Unknown    60-120 min    4-5 hr
P.O. (extended)    Unknown    Unknown    8-24 hr
I.V.    Rapid    20 min    4-5 hr
I.M.    10-30 min    30-60 min    4-5 hr
Subcut.    20 min    50-90 min    4-5 hr
Epidural    6-30 min    Unknown    Up to 24 hr
Epidural (ext., liposomal)    Unknown    Unknown    Unknown
Intrathecal    Rapid (min)    Unknown    Up to 24 hr
P.R.    Unknown    20-60 min    4-5 hr

Adverse reactions:

CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, nightmares
CV: hypotension, bradycardia
EENT: blurred vision, diplopia, miosis
GI: nausea, vomiting, constipation, dry mouth
GU: urinary retention
Respiratory: apnea, respiratory depression, respiratory arrest
Skin: flushing, itching, sweating
Other: physical or psychological drug dependence, drug tolerance

Interactions:

Drug-drug. Antihistamines, barbiturates, clomipramine, sedative-hypnotics, tricyclic antidepressants: additive CNS depression
Buprenorphine, butorphanol, dezocine, nalbuphine, pentazocine: decreased analgesia
Cimetidine: decreased morphine metabolism and increased effects
MAO inhibitors: severe, unpredictable reactions
Mixed opioid agonist-antagonists: precipitation of withdrawal symptoms in physically dependent patients
Warfarin: increased anticoagulant effect
Drug-diagnostic tests. Amylase, lipase: increased levels
Drug-herbs. Chamomile, hops, kava, skullcap, valerian: increased CNS depression
Drug-behaviors. Alcohol use: increased CNS depression

Patient monitoring:

• Monitor vital signs. Contact prescriber if respiratory rate is 10 breaths/minutes or less.
• Assess pain character, location, and intensity.
• Monitor fluid intake and output. Stay alert for urinary retention.
• Monitor bowel elimination pattern. If constipation occurs, intervene as appropriate.
• Assess neurologic status. Implement safety measures as needed to prevent injury.
• Evaluate patient for signs and symptoms of physical or psychological dependence. Be watchful for drug hoarding.
Patient teaching:
• Tell patient he may crush immediate-release form and mix with food or fluids.
• Advise patient not to crush or break extended-release form. Instruct him to swallow it whole.
• Tell patient he may open sustained-release capsule (Kadian), sprinkle entire contents of capsule onto a small amount of food (such as applesauce), and consume immediately. Stress importance of not chewing, crushing, or dissolving pellets.
• Advise patient to take drug at the first sign of pain, because continuous dosing is more effective than p.r.n. dosing.

☞ Tell patient and caregiver that drug may cause respiratory depression. Instruct them to immediately report respiratory rate of 10 breaths/minute or less.
• Inform patient that drug may cause constipation or urinary retention. Encourage high-fiber diet and high fluid intake.
• Stress importance of taking drug only as prescribed. Point out that drug may cause psychological or physical dependence.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, vision, and alertness.
• Teach patient and caregiver about appropriate safety measures to prevent injury.
• Caution patient to avoid alcohol and other CNS depressants during and for 24 hours after therapy.
• Advise patient to avoid herbs, which may worsen adverse CNS effects.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.