MORPHINE SULFATE

(mor'feen)

Astramorph PF, Avinza, DepoDur, Duramorph, Epimorph

, Infumorph, Kadian, MS Contin, MSIR, Oramorph SR, RMS, Roxanol, Statex

Classifications: analgesic; narcotic (opiate) agonist;
Therapeutic:narcotic (opiate) analgesic
Pregnancy Category: C (D in long-term use or high dose, or close to term)
Controlled Substance: Schedule II

Availability

10 mg, 15 mg, 30 mg tablets/capsules; 10 mg, 15 mg, 20 mg, 30 mg, 50 mg, 60 mg, 90 mg, 100 mg, 120 mg, 200 mg controlled release tablets/capsules; 10 mg/2.5 mL, 10 mg/5 mL, 20 mg/mL, 20 mg/5 mL, 30 mg/1.5 mL, 100 mg/5 mL oral solution; 0.5 mg/mL, 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 injection; 10 mg/mL extended release lysosomal injection; 5 mg, 10 mg, 20 mg, 30 mg suppositories

Action

Natural opium alkaloid with agonist activity by binding with the same receptors as endogenous opioid peptides. Narcotic agonist effects are identified with 3 locations of receptors: analgesia at supraspinal level, euphoria, respiratory depression and physical dependence; analgesia at spinal level, sedation and miosis; and dysphoric, hallucinogenic, and cardiac stimulant effects.

Therapeutic Effect

Controls severe pain; also used as an adjunct to anesthesia.

Uses

Symptomatic relief of severe acute and chronic pain after nonnarcotic analgesics have failed and as preanesthetic medication; also used to relieve dyspnea of acute left ventricular failure and pulmonary edema and pain of MI.

Contraindications

Hypersensitivity to opiates; increased intracranial pressure; convulsive disorders; acute alcoholism; acute bronchial asthma, chronic pulmonary diseases, severe respiratory depression; chemical-irritant induced pulmonary edema; prostatic hypertrophy; diarrhea caused by poisoning until the toxic material has been eliminated; undiagnosed acute abdominal conditions; following biliary tract surgery and surgical anastomosis; pancreatitis; acute ulcerative colitis; severe liver or renal insufficiency; Addison's disease; hypothyroidism; during labor for delivery of a premature infant, in premature infants; pregnancy (category C; D in long-term use or when high dose is used, or close to term).

Cautious Use

Toxic psychosis; cardiac arrhythmias, cardiovascular disease; emphysema; kyphoscoliosis; cor pulmonale; severe obesity; reduced blood volume; very old, very young, or debilitated patients; labor.

Route & Dosage

Pain Relief
Adult: PO 10–30 mg q4h prn or 15–30 mg sustained release q8–12h; (Kadian) dose q12–24h, increase dose prn for pain relief; (Avinza) dose q24h IV 2.5–15 mg/70 kg q2–4h or 0.8–10 mg/h by continuous infusion, may increase prn to control pain or 5–10 mg given epidurally q24h Epidural (DepoDur only) 10–15 mg as single dose 30 min before surgery (max: 20 mg) IM/SC 5–20 mg q4h PR 10–20 mg q4h prn
Child: IV 0.05–0.1 mg/kg q4h or 0.025–2.6 mg/kg/h by continuous infusion (max: 10 mg/dose) IM/SC 0.1–0.2 mg/kg q4h (max: 15 mg/dose) PO 0.2–0.5 mg/kg q4–6h; 0.3–0.6 mg/kg sustained release q12h
Neonate: IV/IM/SC 0.05 mg/kg q4–8h (max: 0.1 mg/kg/dose) or 0.01–0.02 mg/kg/h

Renal Impairment
Cl_cr 10–50 mL/min: use 75% of dose, if lower use 50% of dose

Administration

Oral

Use a fixed, individualized schedule when narcotic analgesic therapy is started to provide effective management; blood levels can be maintained and peaks of pain can be prevented (usually a 4-h interval is adequate).
Use lower dosage for older adult or debilitated patients than for adults.
Do not break in half, crush, or allow sustained release tablet to be chewed.
Do not give patient sustained release tablet within 24 h of surgery.
Dilute oral solution in approximately 30 mL or more of fluid or semisolid food. A calibrated dropper comes with the bottle. Read labels carefully when using liquid preparation; available solutions: 20 mg/mL; 100 mg/mL.

Intravenous

Note: Verify correct IV concentration and rate of infusion/injection for administration to neonates, infants, or children with physician.

PREPARE: Direct: Dilute 2–10 mg in at least 5 mL of sterile water for injection. Continuous: Typically diluted to a range of 0.1–1 mg per mL. More concentrated solutions may be required with fluid restriction.

ADMINISTER: Direct: Give a single dose over 4–5 min. Avoid rapid administration. Continuous: Infuse via a controlled infusion device at a rate determined by patient response as ordered.

INCOMPATIBILITIES Solution/additive: Alteplase, Aminophylline, amobarbital, chlorothiazide, floxacillin, fluorouracil, haloperidol, heparin, meperidine, nitrofurantoin, pentobarbital, phenobarbital, perphenazine, phenytoin, sodium bicarbonate, thiopental. Y-site: Amphotericin B cholesteryl complex, azithromycin, cefepime, doxorubicin liposome, gallium, minocycline, phenytoin, sargramostim, tetracycline.

Store at 15°–30° C (59°–86° F). Avoid freezing. Refrigerate suppositories. Protect all formulations from light.

Adverse Effects (≥1%)

Body as a Whole: Hypersensitivity [Pruritus, rash, urticaria, edema, hemorrhagic urticaria (rare), anaphylactoid reaction (rare)], sweating, skeletal muscle flaccidity; cold, clammy skin, hypothermia. CNS: Euphoria, insomnia, disorientation, visual disturbances, dysphoria, paradoxic CNS stimulation (restlessness, tremor, delirium, insomnia), convulsions (infants and children); decreased cough reflex, drowsiness, dizziness, deep sleep, coma, continuous intrathecal infusion may cause granulomas leading to paralysis. Special Senses: Miosis. CV: Bradycardia, palpitations, syncope; flushing of face, neck, and upper thorax; orthostatic hypotension, cardiac arrest. GI: Constipation, anorexia, dry mouth, biliary colic, nausea, vomiting, elevated transaminase levels. Urogenital: Urinary retention or urgency, dysuria, oliguria, reduced libido or potency (prolonged use). Other: Prolonged labor and respiratory depression of newborn. Hematologic: Precipitation of porphyria. Respiratory: Severe respiratory depression (as low as 2–4/min) or arrest; pulmonary edema.

Diagnostic Test Interference

False-positive urine glucose determinations may occur using Benedict's solution. Plasma amylase and lipase determinations may be falsely positive for 24 h after use of morphine; transaminase levels may be elevated.

Interactions

Drug: cns depressants, sedatives, barbiturates, benzodiazepines, and tricyclic antidepressants potentiate CNS depressant effects. Use mao inhibitors cautiously; they may precipitate hypertensive crisis. phenothiazines may antagonize analgesia. Use with alcohol may lead to potentially fatal overdoses. Herbal: Kava, valerian, St. John's wort may increase sedation.

Pharmacokinetics

Absorption: Variably from GI tract. Peak: 60 min PO; 20–60 min PR; 50–90 min SC; 30–60 min IM; 20 min IV. Duration: Up to 7 h. Distribution: Crosses blood–brain barrier and placenta; distributed in breast milk. Metabolism: In liver. Elimination: 90% in urine in 24 h; 7–10% in bile.

Nursing Implications

Assessment & Drug Effects

Obtain baseline respiratory rate, depth, and rhythm and size of pupils before administering the drug. Respirations of 12/min or below and miosis are signs of toxicity. Withhold drug and report to physician.
Observe patient closely to be certain pain relief is achieved. Record relief of pain and duration of analgesia.
Be alert to elevated pulse or respiratory rate, restlessness, anorexia, or drawn facial expression that may indicate need for analgesia.
Differentiate among restlessness as a sign of pain and the need for medication, restlessness associated with hypoxia, and restlessness caused by morphine-induced CNS stimulation (a paradoxic reaction that is particularly common in women and older adult patients).
Monitor for respiratory depression; it can be severe for as long as 24 h after epidural or intrathecal administration.
Monitor carefully those at risk for severe respiratory depression after epidural or intrathecal injection: Older adult or debilitated patients or those with decreased respiratory reserve (e.g., emphysema, severe obesity, kyphoscoliosis).
Continue monitoring for respiratory depression for at least 24 h after each epidural or intrathecal dose.
Assess vital signs at regular intervals. Morphine-induced respiratory depression may occur even with small doses, and it increases progressively with higher doses (generally max: 90 min after SC, 30 min after IM, and 7 min after IV).
Encourage changes in position, deep breathing, and coughing (unless contraindicated) at regularly scheduled intervals. Narcotic analgesics also depress cough and sigh reflexes and thus may induce atelectasis, especially in postoperative patients.
Be alert for nausea and orthostatic hypotension (with light-headedness and dizziness) in ambulatory patients or when a supine patient assumes the head-up position or in patients not experiencing severe pain.
Monitor I&O ratio and pattern. Report oliguria or urinary retention. Morphine may dull perception of bladder stimuli; therefore, encourage the patient to void at least q4h. Palpate lower abdomen to detect bladder distention.

Patient & Family Education

Avoid alcohol and other CNS depressants while receiving morphine.
Do not use of any OTC drug unless approved by physician.
Do not smoke or ambulate without assistance after receiving drug. Bedside rails are advised.
Use caution or avoid tasks requiring alertness (e.g., driving a car) until response to drug is known since morphine may cause drowsiness, dizziness, or blurred vision.

Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug

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