Initially, 10 to 20 mg PO every 4 hours as needed. Higher doses 10 mg are recommended for IM or subcutaneous administration; dosage may range from 5 to 20 mg IM or subcutaneously every 4 hours depending on patient requirements and response. NOTE: Continuous infusions should only be used in acute care settings e. Loading doses of 15 to 20 mg may be required for adequate analgesia; higher doses may be needed in opioid-tolerant patients. Higher infusion rates may be required in opioid-tolerant patients.
Titrate dose to pain relief. A bolus of 0. Initial infusion rates of 0. Alternatively, rates of 0. Higher maintenance infusion rates up to 0. May increase up to 0. An initial infusion rate of 0. The mean infusion rate was 0. Higher infusion rates, ranging from 0. The starting dose should be based on the patient's recent exposure to opioids.
Titrate the regimen to patient response. Larger doses may be needed in opioid-tolerant patients. Various regimens have been reported. The following settings have been used in pediatric patients; titrate regimen to patient response.
Demand dose: 0. Initially, inject 5 mg epidurally in the lumbar region and assess the patient in 1 hour; if pain relief is not adequate at that time, administer incremental doses of 1 to 2 mg, with sufficient time between injections to appropriately assess for efficacy. The manufacturer recommends a maximum of 10 mg per 24 hours. For continuous epidural infusion, initiate at 2 to 4 mg per 24 hours, with additional doses of 1 to 2 mg given if pain relief is not initially achieved.
The incidence of early and late respiratory depression is dramatically increased with thoracic administration.
Use preservative-free formulations only. Various regimens have been reported including single preoperative and postoperative doses of 0. Intrathecal dosage is usually one-tenth the epidural dosage. Single preoperative doses of 0. Use preservative free formulations only. Use caution in geriatric patients due to the potential for adverse CNS effects; and consider alternative drugs for treatment. Use caution in geriatric patients due to the potential for adverse CNS effects; consider alternative drugs for treatment.
Although no published studies exist on the effectiveness of nonspecific antimotility agents in treating AIDS-associated diarrhea, opioid agonists may be effective. Doses are given in addition to other opiate pain medications. Initially, 2 to 5 mg IV every 5 to 30 minutes as needed for pain; some patients may require maintenance doses of 4 to 8 mg IV every 4 to 6 hours. Premedication with a benzodiazepine may potentiate the response to morphine; a reduced morphine dose may be needed.
Use the lower end of the range for opioid-naive neonates. Onset is typically 5 minutes. Use a preservative-free formulation. Use an initial dosage of 15 mg PO twice daily in those who are not opioid tolerant, and consider this lower dose in geriatric patients or those weighing less than 60 kg.
For Kadian, Avinza, and equivalent generic dose forms that may be given once daily, the highest starting dose for patients who are not opioid tolerant is 30 mg PO every 24 hours [Kadian is administered at a frequency of either once daily every 24 hours or twice daily every 12 hours ; Avinza is administered at a frequency of once daily every 24 hours ].
Clinical practice guidelines classify morphine as probably effective for the treatment of painful diabetic neuropathy. Initially, 0. Once the patient is on a stable dose, individualize weaning based on the patient's symptoms. Titrate based on efficacy and adverse effects. Longer-acting and controlled-release drugs are preferred, especially at night. Camphorated opium tincture 0. Extended-release capsules, extended-release tablets Arymo ER or Morphabond , DepoDur liposome injection: Safety and efficacy have not been established.
Immediate-release formulations, injectable solution NOT DepoDur : With appropriate dosage titration, there is no maximum dose.
Extended-release formulations, DepoDur liposome injection: Safety and efficacy have not been established. With the exception of morphine sulfate extended-release liposome injection, which is only used as a single epidural dose, morphine dosage should be modified depending on clinical response and degree of hepatic impairment. Begin treatment with a lower than usual initial dosage, and titrate slowly while monitoring for sedation, respiratory depression, and hypotension.
The 6-glucuronide and 3-glucuronide metabolites are renally eliminated. With the exception of morphine sulfate extended-release liposome injection, which is only used as a single epidural dose, morphine dosage should be modified to prevent accumulation of the metabolite and excessive side effects.
NOTE: If Duramorph or Infumorph gets on the skin, remove any contaminated clothing and rinse the affected area with water. When initiating therapy, begin with an immediate-release preparation and titrate to the appropriate analgesic dose and then convert the patient to an extended-release product if appropriate.
Storage: Store morphine securely in a location not accessible by others. Disposal: Flush unused morphine down the toilet when it is no longer needed if a drug take-back option is not readily available. Immediate-release Tablets Administer without regard to meals; may be given with food or milk to minimize gastrointestinal irritation.
Capsule contents may be added to juice and administered immediately or delivered via gastric or nasogastric tube by either adding to or following with liquid. Extended-release Tablets e.
Swallow Arymo tablets 1 at a time immediately after placing in the mouth. Do not pre-soak, lick, or otherwise wet Arymo tablets prior to placing in the mouth; the tablet may become sticky leading to difficulty in swallowing, choking, gagging, or regurgitation. Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of therapy initiation or dose escalation. MS Contin and mg tablets or Morphabond mg tablets are only for use in patients in whom tolerance to an opioid of comparable potency has been established.
Limit use of a single dose of extended-release tablets more than 60 mg or a total daily dose more than mg to opioid-tolerant patients. Capsules may be opened and the contents sprinkled on applesauce at room temperature or cooler immediately prior to ingestion; no other food has been tested. The applesauce needs to be swallowed without chewing.
Do not separate applesauce into separate doses; the entire portion should be taken. Discard any unused portion of the capsules after the contents have been sprinkled on the applesauce. Kadian capsules may be administered through a 16 French gastrostomy tube.
Flush the tube with water, and sprinkle the capsule 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 Avinza tablets through a gastrostomy tube. Do not administer Avinza or Kadian through a nasogastric tube. Avoid concurrent administration of Avinza or Kadian with prescription or non-prescription medications that contain alcohol.
Consumption of alcohol while taking the extended-release capsules may result in the rapid release and absorption of a potentially fatal dose of morphine. Avinza 90 and mg capsules or Kadian and mg capsules are only for use in patients in whom tolerance to an opioid of comparable potency has been established. Limit use of a single dose of extended-release capsules more than 60 mg or a total daily dose more than mg to opioid-tolerant patients.
Oral Solution Carefully check dose prior to dispensing medication as many concentrations of morphine oral solution are available. Always use an appropriately calibrated measuring device e. Dispense in unit-dose packaging. Protect from light and excessive heat. The product may deposit sediment if exposed to low temperatures. Filter if necessary. Place poison labels on all containers of opium tincture as well as label the strength of morphine per mL.
Include a warning regarding improper substitution of camphorated opium tincture 0. Extemporaneous 0. Transfer to an appropriate-sized plastic amber bottle. Measure 40 mL of Sterile Water for Irrigation in a syringe or graduated cylinder. Transfer to the plastic amber bottle containing morphine. Shake to mix. Storage: The solution is stable for 60 days when stored in a light protected container at room temperature 20 to 25 degrees C. Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Intermittent IV Injection Inject directly into a vein or into the tubing of a freely flowing IV solution over 4 to 5 minutes. Rapid IV injection of morphine may result in an increased frequency of adverse effects. Common concentrations range from 0. Administer using a controlled-infusion device. Adjust dose and rate based on patient response. Consult the patient-controlled infusion device operator's manual for directions on administering the drug at the desired rate of infusion.
Inject into a large muscle mass e. Inject subcutaneously taking care not to inject intradermally. Adjust rate based on patient response and tolerance.
Use ONLY preservative-free injectable solutions. Intrathecal administration should only be used by specially trained healthcare professionals. Intrathecal dose is approximately one-tenth of the epidural dose. If the product is supplied in a glass vial, filter the drug through a 5 micron or smaller microfilter.
Monitor patient in a fully equipped and staffed environment for at least 24 hours after each dose. Both early and late respiratory depression has occurred more frequently after intrathecal administration than epidural administration. For highly concentrated injections, an implantable controlled-microinfusion device is used.
Monitor patients in a fully equipped and staffed environment for several days after implantation of the device. If dilution of the injection is necessary, 0. Filling of the infusion device reservoir should only be done by fully trained and qualified healthcare professionals. Strict aseptic technique must be used. Ensure proper placement of the needle when filling the reservoir to avoid accidental overdosage.
Epidural administration should only be used by specially trained healthcare professionals. May be given as intermittent bolus, continuous infusion, or as patient-controlled epidural analgesia. Storage: For single use only. Protect from light; discard any unused portion. Instruct patient or caregiver on proper use of suppository. Moisten the suppository with water prior to insertion.
If suppository is too soft because of storage in a warm place, chill in the refrigerator for 30 minutes or run cold water over it before removing the wrapper. Generic: - Discard product if it contains particulate matter, is cloudy, or discolored - Discard unused portion.
Do not store for later use. Although true opiate agonist hypersensitivity is rare, use is contraindicated in patients with a history of hypersensitivity reactions to morphine. Further, do not use other opioid agonists of the phenanthrene subclass including oxycodone, codeine, and hydromorphone in such patients. It may be possible to treat these patients with an opioid agonist from the phenylpiperidine subclass meperidine or fentanyl or the diphenylheptane subclass methadone.
Do not abruptly discontinue morphine in patients who may be physically dependent on opioids. Abrupt discontinuation of morphine in physically opioid-dependent patients has resulted in serious withdrawal symptoms, uncontrolled pain, suicide, and drug-seeking behavior.
Consider the opioid dose, duration of therapy, type of pain being treated, and physical and psychological attributes of the patient when decreasing the opioid dose or discontinuing therapy.
Ensure ongoing care of the physically opioid-dependent patient, including a multimodal approach to pain management, and devise an appropriate tapering schedule and follow-up plan so that patient and provider goals are clear and realistic. When discontinuing therapy due to suspected substance abuse, evaluate and treat the patient or refer for evaluation and treatment of the substance abuse disorder.
Patients who have been taking opioids for shorter periods of time may tolerate a more rapid taper. Reassess patients frequently to manage pain and withdrawal symptoms, if they emerge. Common withdrawal symptoms include restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis. Irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate may also occur.
If withdrawal symptoms arise, pause the taper or increase the opioid dose to the previous dose, then proceed with a slower taper. Monitor patients for changes in mood, emergence of suicidal thoughts, or use of other substances. Avoid use of partial agonists e. The severity of the withdrawal syndrome produced will depend on the degree of physical dependence and on the administered dose of the opioid antagonist.
Morphine tablets, capsules, oral solution, and solution for injection are contraindicated in patients with known or suspected GI obstruction, including paralytic ileus. Morphine suspension for injection is contraindicated in patients with paralytic ileus. Due to the effects of opioid agonists on the gastrointestinal tract, all forms of morphine should be used cautiously in patients with GI disease including GI obstruction, ulcerative colitis, GI bleeding, or pre-existing constipation.
Instruct patients not to pre-soak, lick, or otherwise wet Arymo extended-release tablets prior to placing in the mouth; tablets may become sticky leading to difficulty in swallowing, choking, gagging, regurgitation, and tablets stuck in the throat. Patients should take 1 tablet at a time with enough water to ensure complete swallowing.
Tablet stickiness and swelling may predispose patients to intestinal obstruction and diverticulitis exacerbation. Patients with underlying GI disorders such as esophageal cancer or colon cancer with a small gastrointestinal lumen are at a greater risk of developing these complications. Consider use of an alternative analgesic in patients who have difficulty swallowing and patients at risk for underlying GI disorders resulting in small gastrointestinal lumen.
Patients with ulcerative colitis UC or other inflammatory bowel disease may be more sensitive to the constipating effects of morphine.
Opioid agonists may obscure the diagnosis or clinical course in patients with an acute abdomen; morphine rectal suppositories are contraindicated for use in patients with known or suspected acute abdomen or surgical anastomosis. Although opioid agonists are not desirable for use in patients with diarrhea secondary to poisoning or infectious diarrhea, antimotility agents have been used successfully in these patients.
If possible, opioid agonists should not be given until the toxic substance has been eliminated. Morphine and other opioid agonists increase the tone and pressure in the biliary tract causing spasms especially in the sphincter of Oddi. Morphine should be used cautiously in patients with biliary tract disease or in patients undergoing biliary tract surgery; morphine suppositories are contraindicated for use after biliary tract surgery.
The biliary effects of morphine may result in increased plasma amylase and lipase concentrations of 2 to 15 times the normal values. Morphine should be used with extreme caution in patients with head trauma, a brain tumor, increased intracranial pressure ICP , convulsive disorders such as seizure disorders , or severe CNS depression; the use of morphine suppositories is specifically contraindicated in each of these conditions.
Additionally, morphine suspension for injection DepoDur is contraindicated in patients with head trauma or increased intracranial pressure ICP. Opioid agonists can compromise the evaluation of neurologic parameters. Rapid administration of high-dose opioid agonists may transiently elevate ICP and reduce cerebral perfusion pressures. These events are associated with opioid-induced lowering of mean arterial pressure, which stimulates a regulatory response to increase cerebral blood flow leading to increased ICP.
Opioid agonist-induced respiratory depression can produce cerebral hypoxia and raise cerebrospinal fluid CSF pressure. Monitor patients for signs of sedation and depressed respirations. Use caution in patients with a pre-existing seizure disorder or cerebral arteriosclerosis. Morphine can precipitate seizures, especially at high doses; monitor patients with a history of seizure disorders for worsened seizure control during therapy. Morphine and other opioid agonists produce cholinergic side effects by stimulating medullary vagal nuclei.
Bradycardia and induction of histamine release causing peripheral vasodilation may result. As such, the use of morphine injectable solution Astramorph is contraindicated in patients whose ability to maintain blood pressure has already been compromised by hypovolemia.
Extreme caution should be exercised when using other dosage forms in patients with hypovolemia or in those taking phenothiazines or general anesthetics, which may alter the capacity to sustain adequate pressures. Morphine suspension injection DepoDur is contraindicated in patients with circulatory shock; use of other morphine formulations should also be avoided.
Morphine suppositories are contraindicated in patients with cardiac arrhythmias or heart failure secondary to chronic lung disease, as bradycardia and vasodilation may aggravate these conditions. Use morphine with caution in patients with atrial flutter, atrial fibrillation, or other supraventricular tachycardias, as vagolytic action may produce significant increases in ventricular response rate.
Morphine should also be used cautiously in patients with cardiac disease, angina, or hypotension. Opioid agonists can induce vasovagal syncope or orthostatic hypotension; use caution in patients with pre-existing orthostatic hypotension. Morphine and other opioid agonists can cause urinary retention and oliguria, due to increasing the tension of the detrusor muscle. Patients more prone to these effects include those with bladder obstruction, prostatic hypertrophy, urethral stricture, pelvic malignancy, or renal disease.
Drug accumulation or prolonged duration of action can occur in patients with renal impairment or hepatic disease. In acute situations, patients require close monitoring to avoid excessive toxicity. Patients with chronic liver or renal disease may require less frequent dosing intervals. Urinary retention may occur with single epidural or intrathecal morphine administration, or during the first several days of hospitalization for the initiation of continuous intrathecal or epidural morphine therapy.
Urinary retention may persist for 10 to 20 hours and occurs more frequently in male patients than females. Opioid agonists may be used in children with moderate to severe pain. However, certain morphine dosage formulations or administration methods may not be appropriate for children; children also require close monitoring during opioid use.
Neonates and infants younger than 6 months of age have highly variable clearance of opioid agonists. Therefore, infants younger than 6 months of age may be given morphine but must be closely monitored for apnea until 24 hours after their last dose. Clinical practice guidelines suggest close monitoring of children up to 1 year of age. The safety and efficacy of epidural or intrathecal use of morphine in children, including the DepoDur product, have not been established.
The safety and efficacy of extended-release morphine formulations have not been established in pediatric patients younger than 18 years. Use morphine with caution in geriatric or debilitated patients. Geriatric or debilitated patients are more susceptible to adverse reactions, especially sedation and respiratory depression, probably as a result of the altered distribution of the drug or decreased elimination.
Initial doses may need to be reduced, and doses should be carefully titrated, taking into account analgesic effects, adverse reactions, and concomitant conditions and drugs that may increase CNS depression and depress respiration.
If an opiate must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures and implement strategies to reduce fall risk. In patients receiving palliative care or hospice, the balance of benefits and harms of medication management may differ from those of the general population of older adults.
OBRA cautions that opioids may cause constipation, nausea, vomiting, sedation, lethargy, weakness, confusion, dysphoria, physical and psychological dependency, hallucinations, and unintended respiratory depression, especially in individuals with compromised pulmonary function. These adverse effects can lead to other consequences such as falls. The initiation of longer-acting opioids is not recommended unless shorter-acting opioids have been unsuccessful, or titration of shorter-acting doses has established a clear daily dose of opioid analgesic that can be provided by using a long-acting form.
Any patient receiving an opioid agonist should be warned about the possibility of sedation and to use caution when driving or operating machinery. Use of morphine oral dosage forms, suppositories, and solution for injection is contraindicated in patients who are receiving or have received MAOI therapy within the past 14 days.
Manufacturers of other morphine dosage forms do not recommend the concurrent use of MAOIs or morphine use within 14 days of stopping such treatment. Additive CNS depression, drowsiness, dizziness, or hypotension may occur. Use morphine with caution in patients with adrenal insufficiency i. Such patients may be at increased risk of adverse events. Opioids inhibit the secretion of adrenocorticotropic hormone ACTH , cortisol, and luteinizing hormone LH ; however, the thyroid stimulating hormone may be either stimulated or inhibited by opioids.
Ask your doctor how to safely stop using this medicine. Never crush or break a morphine pill to inhale the powder or mix it into a liquid to inject the drug into your vein. This practice has resulted in death with the misuse of morphine and similar prescription drugs. Store at room temperature, away from heat, moisture, and light. Keep track of your medicine. You should be aware if anyone is using it improperly or without a prescription. Do not keep leftover opioid medication.
Just one dose can cause death in someone using this medicine accidentally or improperly. Ask your pharmacist where to locate a drug take-back disposal program. If there is no take-back program, flush the unused medicine down the toilet. Morphine is sometimes taken only once per day, and sometimes 2 or 3 times per day.
Since morphine is used for pain, you are not likely to miss a dose. If you do miss a dose, take the medicine as soon as you remember. Then take your next dose as follows:. Do not take two doses at one time. Do not take more than your prescribed dose in a hour period.
Seek emergency medical attention or call the Poison Help line at A morphine overdose can be fatal, especially in a child or other person using the medicine without a prescription. Overdose symptoms may include slow heart rate, severe drowsiness, muscle weakness, cold and clammy skin, pinpoint pupils, very slow breathing, or coma. Avoid driving or hazardous activity until you know how this medicine will affect you.
Dizziness or drowsiness can cause falls, accidents, or severe injuries. Get emergency medical help if you have signs of an allergic reaction : hives; difficult breathing; swelling of your face, lips, tongue, or throat. Opioid medicine can slow or stop your breathing, and death may occur. A person caring for you should seek emergency medical attention if you have slow breathing with long pauses, blue colored lips, or if you are hard to wake up.
Seek medical attention right away if you have symptoms of serotonin syndrome, such as: agitation, hallucinations, fever, sweating, shivering, fast heart rate, muscle stiffness, twitching, loss of coordination, nausea, vomiting, or diarrhea. Serious side effects may be more likely in older adults and those who are malnourished or debilitated. Long-term use of opioid medication may affect fertility ability to have children in men or women.
It is not known whether opioid effects on fertility are permanent. This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. Opioid medication can interact with many other drugs and cause dangerous side effects or death. Be sure your doctor knows if you also use:.
This list is not complete. Other drugs may affect morphine, including prescription and over-the-counter medicines, vitamins, and herbal products. Not all possible interactions are listed here. Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.
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