MORPHINE SULFATE

Opioid Anlagesic, Narcotic (Opiate) Agonist Analgesic

MORPHINE SULFATE
O Avinza, Kadian, MS Contin, Oramorph SR,

Roxanol, Roxanol T
[Last Revised - 06/15/2011]

Indication
O To relieve acute or chronic moderate to

severe pain; O As adjunct to treat pulmonary edema caused by left-sided heart failure; O And to supplement general, local, or regional anesthesia

Mechanism of Action
Binds with and activates opioid receptors (mainly mu receptors) in brain and spinal cord to produce analgesia and euphoria.

Route/Peak/Onset/Duration
Route P.O. P.O. (E.R.) I.V. I.M. SubQ Epidural Intrathecal P.R. Onset Unknown Unknown Unknown 1030 min 1030 min 1560 min 1560 min 2060 min Peak 12 hr Unknown 20 min 3060 min 5090 min Unknown Unknown Unknown Duration 45 hr 812 hr 45 hr 45 hr 45 hr Up to 24 hr Up to 24 hr Unknown

Frequency/Dosage
Capsules, Oral Solution, Syrup, Tablets Adults. Initial: 10 to 30 mg every 4 hr, p.r.n. Children. Individualized dosage based on patients age, size, and need. I.V. Infusion Adults. Initial: 15 mg (or more) followed by 0.8 to 10 mg/hr, increased as needed for effectiveness. Maintenance: 0.8 to 80 mg/hr. Children. 0.01 to 0.04 mg/kg/hr postoperatively, 0.025 to 2.6 mg/kg/hr for severe chronic cancer pain, or 0.03 to 0.15 mg/kg/ hr for sickle cell crisis. Neonates. Initial: 0.010 mg/kg/hr (10 mcg/kg/hr) postoperatively. Maintenance: 0.015 to 0.02 mg/kg/hr (15 to 20 mcg/kg/hr).

Frequency/Dosage
I.V. Injection Adults. 2.5 to 15 mg injected slowly. Children. 0.5 to 0.1 mg/kg given slowly. I.M. Or Subcutaneous Injection Adults. Initial: 10 mg (based on 70-kg [154-lb] adult) every 4 hr. Maintenance: 5 to 20 mg. Children. Initial: 0.1 to 0.2 mg/kg every 4 hr. Maximum: 15 mg/dose. Epidural Infusion (Preservative-Free) (PreservativeAdults. Initial: 2 to 4 mg/24 hr, increased by 1 to 2 mg/24 hr, as directed. Epidural Injection (Preservative-Free) (Preservative-Free) Adults. Initial: 5 mg into lumbar region. If pain isnt relieved after 1 hr, 1- to 2-mg doses given at appropriate intervals to relieve pain. Maximum: 10 mg/24 hr

Frequency/Dosage
Intrathecal Injection (Preservative-Free) (PreservativeAdults. 0.2 to 1 mg as a single dose. Suppositories Adults. 10 to 30 mg every 4 hr, p.r.n. Children. Individualized dosage based on patients age, size, and need. Indication.To relieve chronic moderate to severe pain that requires opioids for more than a few days E.R Capsules Adults. Individualized dosage given every 12 to 24 hr. E.R. Tablets Adults. 30 mg every 12 hr. Dosage increased based on patients response. Indication: To relieve MI pain

Patient Teaching
Instruct patient to take morphine exactly as prescribed and not to change dosage without consulting prescriber. Explain that patient may take tablets or capsules with food or milk to relieve GI distress and may mix oral solution with juice to improve taste. Urge patient not to break, chew, or crush E.R. capsules and tablets to avoid rapid release and, possibly, toxicity. For patient who has difficulty swallowing, suggest that he open E.R. capsules and sprinkle contents on food or liquids. Urge him to take drug immediately and not let capsule contents dissolve in his mouth. Instruct patient to moisten rectal suppository before inserting it. Urge patient to avoid alcohol and other CNS depressants during therapy. Advise patient to avoid potentially hazardous activities during morphine therapy. Tell patient to change positions slowly to minimize the orthostatic hypotension. Instruct patient to notify prescriber about worsening or breakthrough pain. Explain that morphine may be habit forming. Urge him to notify prescriber if he experiences anxiety, decreased appetite, excessive tearing, irritability, muscle aches or twitching, rapid heart rate, or yawning. Advise female patient to notify prescriber if she becomes pregnant. Regular morphine use during pregnancy may cause physical dependence in fetus and withdrawal in neonate.

 Use cautiously in patients about to undergo surgery of the biliary tract and patients with acute pancreatitis secondary to biliary tract disease because morphine may cause spasm of the sphincter of Oddi. Store morphine at room temperature. Before giving morphine, make sure opioid antagonist and equipment for oxygen delivery and respiration are available. Before therapy, assess patients drug use, including all prescription and OTC drugs. Expect prescriber to start patient who has never received opioids on immediate release form and then switch to E.R. form if therapy must last longer than a few days.

O Keep in mind that when morphine is given by

epidural route, dosage must be individualized according to patients age, body mass, physical status, previous experience with opioids, risk factors for respiratory depression, and drugs to be coadministered before or during surgery. O Give oral form with food or milk to minimize adverse GI reactions, if needed. Solution can be mixed with fruit juice to improve taste. O If needed, open E.R. capsules and sprinkle contents on applesauce (at room temperature or cooler) just before giving to patient. Make sure patient doesnt chew or crush capsules or dissolve capsules pellets in his mouth. O Be aware that E.R. forms of morphine arent interchangeable.

 Discard injection solution that is discolored or darker than pale yellow or that contains precipitates that dont dissolve with shaking. WARNING: Dont use highly concentrated solutions (such as 10 to 25 WARNING: mg/ml) for single- dose I.V., I.M., or subcutaneous administration. These singleadministration. solutions are intended for use in continuous, controlled micro-infusion microdevices. devices. For direct I.V. injection, dilute appropriate dose with 4 to 5 ml of sterile water for injection. Inject 2.5 to 15 mg directly into tubing of free-flowing I.V. solution over 4 to 5 minutes. Rapid I.V. injection may increase adverse reactions. For continuous I.V. infusion, dilute drug in D5W and administer with infusioncontrol device. Adjust dose and rate based on patient response, as prescribed. Avoid I.M. route for long-term therapy because of injection site irritation. During subcutaneous injection, take care to avoid injecting drug intradermally. For intrathecal injection, expect prescriber to give no more than 2 ml of 0.5-mg/ml solution or 1 ml of 1-mg/ml solution. Expect intrathecal If rectal suppository is too soft to insert, refrigerate for 30 minutes or run wrapped suppository under cold tap water.

WARNING: Monitor respiratory and cardio-vascular status carefully and frequently WARNING: cardioduring morphine therapy. Be alert for respiratory depression and hypotension. therapy. hypotension. Monitor patient with seizure disorder for increased seizure activity because morphine may worsen the disorder. Monitor patient for excessive or persistent sedation; dosage may need to be adjusted. If patient is receiving a continuous morphine infusion, watch for and notify prescriber about new neurologic signs or symptoms. Inflammatory masses (such as granulomas) have caused serious neurologic reactions, including paralysis. Expect morphine to cause physical and psychological dependence; watch for drug tolerance and withdrawal, such as body aches, diaphoresis, diarrhea, fever, piloerection, rhinorrhea, sneezing, and yawning. If tolerance to morphine develops, expect prescriber to increase dosage. Morphine may have a prolonged duration and cumulative effect in patients with impaired hepatic or renal function. It also may prolong labor by reducing strength, duration, and frequency of uterine contractions. When discontinuing morphine in patients receiving more than 30 mg daily, expect prescriber to reduce daily dose by about one-half for 2 days and then by 25% every 2 days thereafter until total dose reaches initial amount recommended for patients who havent received opioids (15 to 30 mg daily). This regimen minimizes the risk of withdrawal symptoms.

COMMON SIDE EFFECTS: Nausea and vomiting, light headedness, dizziness, sweating, headache, anxiety, and constipation

Adverse Effects
CNS: CNS: Amnesia, anxiety, coma, confusion, decreased concentration, delirium, delusions, depression, dizziness, drowsiness, euphoria, fever, hallucinations, headache, insomnia, lethargy, lightheadedness, malaise, psychosis, restlessness, sedation, seizures, syncope, tremor, unarousable, unresponsiveness CV: CV: Bradycardia, cardiac arrest, hypotension, orthostatic hypotension, palpitations, shock, tachycardia

Adverse Effects
EENT: EENT: Blurred vision, diplopia, dry mouth, laryngeal edema or laryngospasm (allergic), miosis, nystagmus, rhinitis GI Abdominal cramps or pain, anorexia, biliary tract spasm, GI: constipation, diarrhea, dysphagia, elevated liver function test results, gastroesophageal reflux, hiccups, ileus and toxic megacolon (in patients with inflammatory bowel disease), intestinal obstruction, indigestion, nausea, vomiting GU: GU: Decreased ejaculate potency, decreased libido, difficult ejaculation, impotence, menstrual irregularities, oliguria, prolonged labor, urinary hesitancy, urine retention

Adverse Effects
HEME: HEME: Anemia, leukopenia, thrombocytopenia MS: MS: Arthralgia (Joint Pain) RESP: RESP: Apnea, asthma exacerbation, atelectasis, bronchospasm, depressed cough reflex, hypoventilation, pulmonary edema, respiratory arrest and depression, wheezing SKIN: SKIN: Diaphoresis, flushing, pallor, pruritus, urticaria Other: Allergic reaction; anaphylaxis; facial edema; injection site edema, pain, rash, or redness; physical and psychological dependence; withdrawal symptoms

Jones and Barlett Learning. (2011). (2011). 2011 Nurses Drug Handbook 10th ed. 40 Tall Pine Drive Sudbury, MA 01776