Brand Name
Astramorph
PF, Avinza, DepoDur, Duramorph, Epimorph (CAN), Kadian, M-Eslon (CAN), Morphine
Extra-Forte (CAN), Morphine Forte (CAN), Morphine H.P. (CAN), Morphitec (CAN),
MS Contin, MSIR, MS/L, MS/L Concentrate, MS/S, OMS Concentrate, Oramorph SR, Rescudose,
RMS Uniserts, Roxanol, Roxanol 100, Roxanol UD, Statex (CAN)
Class,
Category, and Schedule
Chemical
class: Phenanthrene derivative
Therapeutic
class: Analgesic
Pregnancy
category: C
Controlled
substance schedule: II
Indications
and Dosages
To relieve acute or
chronic moderate to severe pain; as adjunct to treat pulmonary edema caused by
left-sided heart failure; to supplement general, local, or regional anesthesia
CAPSULES,
ORAL SOLUTION, SYRUP, TABLETS
Adults. Initial: 10 to 30
mg every 4 hr, p.r.n.
Children. Individualized
dosage based on patient’s 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).
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)
Adults. Initial: 2 to 4
mg/24 hr, increased by 1 to 2 mg/24 hr, as directed.
EPIDURAL
INJECTION (PRESERVATIVE-FREE)
Adults. Initial: 5 mg into
lumbar region. If pain isn’t relieved after 1 hr, 1- to 2-mg doses given at
appropriate intervals to relieve pain. Maximum: 10 mg/24 hr.
INTRATHECAL
INJECTION (PRESERVATIVE-FREE)
Adults. 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 patient’s age, size, and need.
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 patient’s response.
To relieve MI pain
I.V.
INJECTION
Adults. 1 to 4 mg
by slow I.V. injection. Repeated up to every 5 min, if needed. Maximum: 2
to 15 mg.
To provide
preoperative analgesia
I.M. OR
SUBCUTANEOUS INJECTION
Adults. 5 to 20 mg
given 45 to 60 min before surgery.
Children. 0.05 to
0.1 mg/kg given 45 to 60 min before surgery. Maximum: 10 mg.
To provide analgesia
during labor
I.M. OR
SUBCUTANEOUS INJECTION
Adults. 10 mg,
with subsequent doses based on patient’s response.
Route Onset Peak Duration
P.O. Unknown 1–2 hr 4–5 hr
P.O. (E.R.) Unknown Unknown 8–12 hr
I.V. Unknown 20 min 4–5 hr
I.M. 10–30 min 30–60 min 4–5 hr
SubQ 10–30 min 50–90 min 4–5 hr
Epidural 15–60 min Unknown Up to 24 hr
Intrathecal 15–60 min Unknown Up
to 24 hr
P.R. 20–60 min Unknown Unknown
Mechanism
of Action
Binds with and activates
opioid receptors (mainly mu receptors) in brain and spinal cord to produce
analgesia and euphoria.
Contraindications
For all
drug forms: Asthma, hypersensitivity to morphine or its components, labor
(premature delivery), prematurity (in infants), respiratory depression, upper
airway obstruction
For oral
solution: Acute abdominal disorders, acute alcoholism, alcohol withdrawal syndrome,
arrhythmias, brain tumor, head injuries, heart failure caused by chronic lung
disease, increased intracranial or cerebrospinal pressure, recent biliary tract
surgery, respiratory insufficiency, seizure disorders, severe CNS depression,
surgical anastomosis, use within 14 days of an MAO inhibitor
For I.V.,
I.M., or subcutaneous injection: Acute alcoholism, alcohol
withdrawal syndrome, arrhythmias, brain tumor, heart failure
caused by chronic lung disease, seizure disorders
For
epidural or intrathecal injection: Anticoagulant therapy, bleeding
tendency, injection site infection, parenteral corticosteroid treatment (or
other treatment or condition that prohibits drug delivery by intrathecal or
epidural route) within 2 weeks
Interactions
DRUGS
amitriptyline,
clomipramine, nortriptyline: Increased CNS and respiratory depression
anticholinergics:
Possibly severe constipation leading to ileus, urine retention
antidiarrheals
(such as loperamide and paregoric): CNS depression, possibly severe
constipation
antihistamines,
chloral hydrate, glutethimide, MAO inhibitors, methocarbamol: Increased
CNS and respiratory depressant effects
antihypertensives,
hypotension-producing drugs: Increased hypotension, risk of
orthostatic hypotension
bupivacaine:
Increased serum morphine level and possibly significant adverse
effects
buprenorphine:
Decreased therapeutic effects of morphine, increased respiratory depression,
possibly withdrawal symptoms
cimetidine:
Increased analgesic and CNS and respiratory depressant effects
CNS
depressants (antiemetics, general anesthetics, hypnotics, phenothiazines,
sedatives, tranquilizers): Possibly coma, hypotension, respiratory
depression, severe sedation
diuretics:
Decreased diuretic efficacy
hydroxyzine:
Increased analgesic, CNS depressant, and hypotensive effects of
morphine
metoclopramide:
Possibly antagonized metoclopramide effect on GI motility
mixed
agonist-antagonist analgesics: Possibly withdrawal symptoms
naloxone: Antagonized
analgesic and CNS and respiratory depressant effects of morphine, possibly
withdrawal symptoms
naltrexone:
Possibly induction or worsening of withdrawal symptoms if morphine
given within 7 to 10 days before naltrexone
neuromuscular
blockers: Increased or prolonged respiratory depression
opioid
analgesics (such as alfentanil and sufentanil): Increased
CNS and respiratory depression, increased hypotension
zidovudine:
Decreased zidovudine clearance
ACTIVITIES
alcohol
use: Increased CNS and respiratory depression, increased hypotension
Adverse
Reactions
CNS: Amnesia,
anxiety, coma, confusion, decreased concentration, delirium, delusions, depression,
dizziness, drowsiness, euphoria, fever, hallucinations, headache, insomnia,
lethargy, light-headedness, malaise, psychosis, restlessness, sedation, seizures,
syncope, tremor, unarousable, unresponsiveness
CV: Bradycardia,
cardiac arrest, hypotension, orthostatic hypotension, palpitations, shock,
tachycardia
EENT: Blurred
vision, diplopia, dry mouth, laryngeal edema or laryngospasm (allergic), miosis,
nystagmus, rhinitis
GI: Abdominal
cramps or pain, anorexia, biliary tract spasm, 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: Decreased
ejaculate potency, decreased libido, difficult ejaculation, impotence, menstrual
irregularities, oliguria, prolonged labor, urinary hesitancy, urine retention
HEME: Anemia,
leukopenia, thrombocytopenia
MS: Arthralgia
RESP: Apnea,
asthma exacerbation, atelectasis, bronchospasm, depressed cough reflex,
hypoventilation, pulmonary edema, respiratory arrest and depression, wheezing
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
Nursing
Considerations
• 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
patient’s 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.
• Keep in mind that when
morphine is given by epidural route, dosage must be individualized according to
patient’s age, body mass, physical status, previous experience with opioids,
risk factors for respiratory depression, and drugs to be coadministered before
or during surgery.
• Give oral form with food
or milk to minimize adverse GI reactions, if needed. Solution can be mixed with
fruit juice to improve taste.
• If needed, open E.R.
capsules and sprinkle contents on applesauce (at room temperature or cooler)
just before giving to patient. Make sure patient doesn’t chew or crush capsules
or dissolve capsule’s pellets
in his mouth.
• Be aware that E.R. forms
of morphine aren’t interchangeable.
• Discard injection
solution that is discolored or darker than pale yellow or that contains
precipitates that don’t dissolve with shaking.
WARNING Don’t
use highly concentrated solutions (such as 10 to 25 mg/ml) for single- dose
I.V., I.M., or subcutaneous administration. These solutions are intended for
use in continuous, controlled microinfusion 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 infusion control 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 dosage to be about one tenth of
epidural dosage.
• 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 during morphine
therapy. Be alert for respiratory depression and 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
haven’t received opioids (15 to 30 mg daily). This regimen minimizes the risk
of withdrawal symptoms.
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 habitforming. 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.
