Names and pronunciation
(mor′feen) Arymo ER, Astromorph PF, Doloral , Duramorph Infumorph, Kadian, M-Eslon , M-Eslon IR , Mitigo, Morphine LP Epidural , MS IR , MS Contin, MSIR , Oramorph SR, Statex
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Individual generic drug information
Extracted information for morphine only.
(mor′feen) Arymo ER, Astromorph PF, Doloral , Duramorph Infumorph, Kadian, M-Eslon , M-Eslon IR , Mitigo, Morphine LP Epidural , MS IR , MS Contin, MSIR , Oramorph SR, Statex
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Func. class.: Opioid analgesic
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Chem. class.: Alkaloid Controlled Substance Schedule II
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Do not confuse: morphine/HYDROmorphone MS Contin/OxyCONTIN
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ACTION: Depresses pain impulse transmission at the spinal cord level by interacting with opioid receptors
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USES: Moderate to severe pain
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Unlabeled uses: Agitation, bone/dental pain, dyspnea in end-stage cancer or pulmonary disease, sedation induction, rapid-sequence intubation
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Extracted information for morphine only.
CONTRAINDICATIONS: Hyper- sensitivity, addiction (opioid/alcohol), hemorrhage, bronchial asthma, increased intracranial pressure, paralytic ileus, hypovolemia, shock, MAOI therapy
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Black Box Warning: Respiratory depres- sion Precautions: Pregnancy, breastfeeding, children <18 yr, geriatric patients, addic- tive personality, acute MI, severe heart dis- ease, renal/hepatic disease, bowel impac- tion, abrupt discontinuation, seizures Black Box Warning: Accidental ex- posure, epidural/intrathecal/IM/subcut administration, opioid-naïve patients, substance abuse, coadministration with other CNS depressants, ethanol inges- tion, neonatal opioid withdrawal syn- drome, potential for overdose or poison- ing, requires a specialized care setting Black Box Warning: Accidental ex- posure: if Duramorph or Infumorph gets on skin, remove contaminated clothing, rinse affected area with water Black Box Warning: Requires a spe- cialized care setting: patient should be observed for ≥24 hr; have emergency equipment nearby Black Box Warning: Respiratory dys- function: depression, character, rate, rhythm; notify prescriber if respirations are <12/min; accidental overdose has occurred with high-potency oral sols • Gradual withdrawal after long-term use Black Box Warning: Pregnancy/breast- feeding: use only if benefits outweigh risk to fetus; longer use can result in neonatal opioid withdrawal syndrome; do not breastfeed Black Box Warning: To keep out of the reach of children, pets Black Box Warning: To notify health care professional if pregnancy is planned or suspected • To avoid driving, hazardous activities until response is known • To turn, cough, and deep breathe if on bed rest • To report constipation, as other prod- ucts will need to be used • To change position slowly; orthostatic hypotension may occur • To report any symptoms of CNS changes, allergic reactions • That physical dependency may result from long-term use • To avoid use of alcohol, CNS depressants • That withdrawal symptoms may occur: nausea, vomiting, cramps, fever, faint- ness, anorexia • To take exactly as directed; do not crush, break, chew, or dissolve caps or tabs
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SIDE EFFECTS CNS: Drowsiness, dizziness, confusion, headache, sedation, euphoria, insomnia, seizures CV: Palpitations, bradycardia, change in B/P, shock, cardiac arrest, chest pain, hypo/hypertension, edema, tachycardia EENT: Blurred vision, miosis, diplopia ENDO: Gynecomastia GI: Nausea, vomiting, anorexia, constipa- tion, cramps, biliary tract pressure GU: Urinary retention, impotence, gonadal suppression HEMA: Thrombocytopenia INTEG: Rash, urticaria, bruising, flush- ing, diaphoresis, pruritus RESP: Respiratory depression, respira- tory arrest, apnea
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INTERACTIONS • Unpredictable reaction, avoid use: MAOIs • Greater risk of cross-sensitivity with organic and semiorganic opioids Increase: serotonin syndrome risk— SSRIs, SNRIs, tricyclics, MAOIs, amoxa- pine, dolasetron, palonosetron, antimi- graine agents, linezolid, lithium, methylene blue, traZODone; monitor for serotonin syndrome Increase: effects with other CNS depres- sants—alcohol, opiates, sedative/hyp- notics, antipsychotics, skeletal muscle relaxants, general anesthetics, benzodi- azepine; avoid using together; increased respiratory depression Decrease: morphine effect—butorpha- nol, nalbuphine, pentazocine; consider using another product; withdrawal symp- toms may occur Decrease: morphine action—rifAMPin Drug/Herb Increase: CNS depression—chamomile, hops, kava, St. John’s wort, valerian Drug/Lab Test Increase: amylase, lipase
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TREATMENT OF OVERDOSE: Naloxone (Narcan) 0.2-0.8 mg IV (cau- tion with opioid-tolerant individuals), O2, IV fluids, vasopressors HIGH ALERT
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Extracted information for morphine only.
DOSAGE AND ROUTES Acute and chronic moderate pain or severe pain PO Route IR Adults: Initially, 10-30 mg q4hr as needed in opioid-naive patients. Titrate to pain re- lief. Only use the concentrated oral mor- phine solution (20 mg/mL) in opioid-toler- ant patients Infants, children, and adolescents 6 mo to 17 yr (unlabeled): Initially, 0.2-0.3 mg/ kg/dose q3-6 hr as needed Intermittent IV, IM, or SUBCUT Adults: Initially, 2-10 mg/70 kg q3-4hr as needed, titrated to pain relief Infants >6 mo and older, children, and adolescents: 0.05-0.2 mg/kg/dose q2-4hr as needed; begin at the lower end of dosage range and titrate to effect (usual max dose: 4 mg for children or 8 mg for adolescents) Neonates (unlabeled) and infants <6 mo: Initially, 0.03-0.1 mg/kg/dose q3-4hr as needed. Titrate upward as needed for adequate pain relief Continuous IV infusion dosage (unlabeled) Continuous infusions should only be used in acute care settings (ICU) Adults: Loading dose by slow IV infusion at a rate of 2 mg/min. Loading doses of 15-20 mg may be required; initial infu- sion rates of 2-5 mg/hr Infants, children, and adolescents: A bo- lus of 0.05-0.2 mg/kg IV (or 5-10 mg for patients weighing more than 60 kg) fol- lowed by a continuous infusion. Initial infusion rates of 0.01-0.03 mg/kg/hr, but initial doses up to 0.06 mg/kg/hr may be used Neonates: 0.01-0.02 mg/kg/hr and ti- trate to effect. May increase up to 0.03 mg/kg/hr Continuous subcut infusion dosage (unlabeled) Adults: Initial infusion rates of 2-5 mg/hr may be used, with usual rates of 2-30 mg/ hr used in critically ill patients Infants, children, and adolescents: Initial rate of 0.03 mg/kg/hr. Titrate dose to pain relief IV dosage (patient-controlled analgesia [PCA]) Adults: Starting dose should be based on the patient’s recent exposure to opioids. Titrate to patient response. Larger doses may be needed in opioid- tolerant patients. For OPIOID-NAIVE patients, start with a demand dose of 1 mg (range: 0.5-2.5 mg) and lockout interval of 6 min (range: 5-10 min), with a maximal dosing rate of 10 mg/ hr. For OPIOID TOLERANT patients, start with a demand dose of 2-5 mg IV and lockout interval of 6 min (range: 5-10 min), with a maximal dosing rate of 30 mg/hr Children >7 yr and adolescents Demand dose: 0.01-0.025 mg/kg IV (max: 1 mg/dose) Lockout interval: 5-10 min Doses per hour: 5 Epidural dosage (morphine sulfate injection, but not DepoDur) Adults: Initially, inject 5 mg epidurally in the lumbar region and assess the patient in 1 hr; if pain relief is not adequate, give incremental doses of 1-2 mg, with suffi- cient time between injections to appropri- ately assess for efficacy. Max: 10 mg per 24 hr. For continuous epidural infusion, initiate at 2-4 mg per 24 hr, with additional doses of 1-2 mg given if pain relief is not achieved Intrathecal dosage (morphine sulfate injection, but not DepoDur) Adults: 0.2-1 mg in the lumbar area as a single dose or to establish dosage for continuous intrathecal infusion Rectal dosage Adults: 10-20 mg q4hr, as needed PO [extended-release tablets (Arymo ER, MS Contin) or capsules (Kadian)] in opioid nontolerant adult patients M Adults: 15 mg q8hr or q12hr (Arymo ER, Morphabond, or MS Contin) or 30 mg q24hr (Avinza) for use as the first opioid analgesic. Do not use Kadian capsules as a first opioid analgesic; ini- tiate with an IR and then convert pa- tients to Kadian. For opioid nontolerant patients, initiate with 15 mg q12hr (MS Contin), 15 mg q8hr or q12hr (Arymo ER or Morphabond), or 30 mg q24hr (Avinza or Kadian). With the exception of Avinza, adjust the dose every 1-2 days based upon the total daily morphine requirements (ER dose plus break- through doses). Adjust the dose of Avinza q3-4days in increments of 30 mg or less PO dosage [ER tablets (Arymo ER, MS Contin) or capsules (Kadian)] in adult patients receiving other opioid agonist therapy Adults: Discontinue all other around- the-clock opioids. To convert from other morphine formulations, calcu- late the morphine 24-hr oral require- ment; the 24-hr oral dose is 3 times the 24-hr parenteral requirement. Initiate dosing, using the 24-hr oral requirement (round down to the closest available tablet/capsule strength), for: Arymo ER, MS Con- tin at one-half of the requirement every 12 hr or one-third q8hr; Avinza at the total requirement once q24hr; and Kadian at one-half q12hr or the total once q24hr. Initiate dosing for: Arymo ER, or MS Contin at 15 mg q8hr or q12hr; and Kadian at 30 mg q24hr
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Available forms: IR tablets 15, 30 mg; ER tablets (Arymo ER) 15, 30, 60 mg; ER tablets (MS Contin) 15, 30, 60, 100, 200 mg; ER tablets 15, 30, 60, 100 mg; ER capsules (Kadian) 10, 20, 30, 40, 50, 60, 70, 80, 100, 130, 150, 200 mg; ER capsules 30, 45, 60, 75, 90, 120 mg; oral solution 1 mg/mL , 2 mg/mL, 4 mg/mL, 5 mg/mL , 20 mg/mL; rectal suppositories 5, 10, 20, 30 mg; solution for injection (IM, IV, SUBCUT) 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 epidural, IV (no preservative) 0.5 mg/mL, 1 mg/mL; solution for IT or epidural, continuous microinfusion device; no preservative 10 mg/mL, 25 mg/mL; solution for IV (PCA device) 1 mg/mL, 2 mg/mL, 3 mg/mL, 5 mg/mL
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Administer: PO route • Give with food or milk to minimize GI effects • Begin with immediate-release products and titrate to correct dose and convert to a sustained-release product • Immediate-release cap: may swallow whole, or cap may be opened and con- tents sprinkled on cool food (pudding or applesauce) or added to juice; give im- mediately or delivered via gastric or NG tube by either adding to or following with liquid • Extended-release and controlled- release tabs: swallow whole; do not crush, break, dissolve, or chew • The use of MS Contin 100-mg or 200- mg tabs should be limited to opioid- tolerant patients requiring oral doses equivalent to ≥200 mg/day; use of the 100-mg or 200-mg tablet is only recom- mended for patients who have already been titrated to a stable analgesic regi- men using lower strengths of MS Contin or other opioids • Sustained-release caps: swallow; do not chew, crush, or dissolve; caps may be opened and contents sprinkled on applesauce (at room temperature or cooler) immediately before ingestion; do not chew, crush, or dissolve the pel- lets/beads inside the cap; the apple- sauce should be swallowed without chewing; if the pellets/beads are chewed, an immediate release of a po- tentially fatal morphine dose may be delivered; rinse mouth • Kadian caps: may be given through a 16-F gastrostomy tube; flush with water, and sprinkle the cap contents into 10 mL of water; using a funnel and a swirling motion, pour the pellets and water into the tube; rinse the beaker with 10 mL of water, and pour the water into the funnel; repeat until no pellets remain in the beaker; do not administer Kadian through a na- sogastric tube • Kadian 100 mg, 130 mg, 150 mg, or 200 mg caps are given only to opioid- tolerant patients Oral liquid • Check dose before use because many concentrations of oral solution are avail- able; may be diluted in fruit juice; protect from light Injectable administration • Visually inspect for particulate matter, discoloration before use; do not use if a precipitate is present after shaking; do not use the Duramorph solution if a precipitate is present or if the color is darker than pale yellow SUBCUT route • Inject, taking care not to inject intra- dermally • Continuous SC infusion: morphine is not approved by the FDA for subcut use; dilute to an appropriate concentration in D5W; give using a portable, controlled, subcut device; adjust rate based on pa- tient response and tolerance; max subcut rate is 2 mL/hour/site Intrathecal/epidural route • Morphine sulfate injection is not in- terchangeable with morphine sulfate extended-release liposome injection (DepoDur); DepoDur is only for epidural administration • Do not use Infumorph (10 mg/mL or 25 mg/mL) for single-dose neuraxial injec- tion because lower doses can be more re- liably administered with Duramorph (0.5 mg/mL or 1 mg/mL) Rectal route • Moisten the suppository with water before insertion; if suppository is too soft, chill in the refrigerator for 30 min or run cold water over it before removing the wrapper IV route • Before use, an opiate antagonist and emergency facilities should be available • Do not use the highly concentrated morphine injections (i.e., 10-25 mg/mL) for IV, IM, or SC administration of single doses; these injection solutions are in- tended for use via continuous, controlled microinfusion devices • Direct IV route: dilute dose with ≥5 mL of sterile water for injection or NS injection; inject 2.5-15 mg directly into a vein or into the tubing of a freely flow- ing IV solution over 4-5 min; do not give rapidly • Continuous IV infusion: dilute in 5% dextrose; use a controlled-infusion de- vice; adjust dosage and rate based on patient response • Patient-controlled analgesia (PCA): a compatible patient-controlled infusion device must be used; dilute solutions to a concentration of 1 or 10 mg/mL for ease in calculations and programming of PCA pumps; adjust dosage and rate based on patient response; consult the patient- controlled infusion device manual for directions on rate of infusion Y-site compatibilities: Acetaminophen, aldesleukin, allopurinol, amifostine, amikacin, aminophylline, amiodarone, amsacrine, atenolol, atracurium, aztre- onam, bumetanide, calcium chloride, cefamandole, ceFAZolin, cefotaxime, cefoTEtan, cefOXitin, cefTAZidime, ceftizoxime, cefTRIAXone, cefuroxime, cephalothin, chloramphenicol, cisatra- curium, cladribine, clindamycin, cyclophosphamide, cytarabine, dexa- methasone, digoxin, diltiaZEM, DOBU- Tamine, DOPamine, doxycycline, enal- aprilat, EPINEPHrine, erythromycin, esmolol, etomidate, famotidine, fen- taNYL, filgrastim, fluconazole, fludara- bine, foscarnet, gentamicin, grani setron, heparin, hydrocortisone, HYDROmorphone, kanamycin, labet- alol, lidocaine, LORazepam, magne- sium sulfate, melphalan, meropenem, methotrexate, methyldopate, meth ylPREDNISolone, metoclopramide, metoprolol, metroNIDAZOLE, mid- M azolam, milrinone, nafcillin, niCARdi pine, nitroglycerin, norepinephrine, ondansetron, oxacillin, oxytocin, PACLitaxel, pancuronium, penicillin G potassium, piperacillin, piperacillin/ tazobactam, potassium chloride, pro- pranolol, raNITIdine, remifentanil, sodium bicarbonate, teniposide, thio- tepa, ticarcillin, ticarcillin/clavulanate, tigecycline, tobramycin, vancomycin, vecuronium, vinorelbine, vit B/C, war- farin, zidovudine, zoledronic acid
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Extracted information for morphine only.
Assess: • Pain: location, intensity, type, charac- ter; check for pain relief 20 min follow- ing IV, 1 hr following PO/IM/Subcut; ti- trate to relieve pain; give dose before pain becomes severe • Bowel status; constipation common, use stimulant laxative if needed; provide increased bulk, fluids in diet • I&O ratio; check for decreasing out- put; may indicate urinary retention; monitor serum sodium • B/P, pulse, respirations (character, depth, rate) • CNS changes: dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction • Abrupt discontinuation: gradually ta- per to prevent withdrawal symptoms; decrease by 50% q1-2days; avoid use of narcotic antagonists • Allergic reactions: rash, urticaria
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Evaluate: • Therapeutic response: decrease in pain intensity
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CLINICAL CONSIDERATIONS
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Patient and caregiver information:
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Extracted information for morphine only.
PHARMACOKINETICS PO: Onset variable, peak 60 min, dura- tion 4-5 hr IM: Onset ½ hr, peak 30-60 min, dura- tion 4-5 hr SUBCUT: Onset 15-20 min, peak 50-90 min, duration 4-5 hr IV: Peak 20 min, duration 4-5 hr RECT: Peak ½-1 hr, duration 3-7 hr Intrathecal: Onset rapid, duration ≤24 hr Metabolized by liver, crosses placenta; excreted in urine, breast milk; half-life IM 3-4 hr; Kadian 11-13 hr
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Filter the extracted dose blocks for this individual drug.