morphine sulfate

(mor' feen)
Immediate-release tablets:
MSIR
Timed-release:
Kadian, M-Eslon (CAN), MS Contin, Oramorph SR
Oral solution:
MSIR, Rescudose, Roxanol, Roxanol T
Rectal suppositories:
RMS
Injection:
Astramorph PF, Duramorph, Epimorph (CAN)
Preservative-free concentrate for microinfusion devices for intraspinal use:
Infumorph

Pregnancy Category C
Controlled Substance C-II

Drug class
Opioid agonist analgesic

Therapeutic actions
Principal opium alkaloid; acts as agonist at specific opioid receptors in the CNS to
produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to
be the same as those mediating the effects of endogenous opioids (enkephalins,
endorphins).

Indications
• Relief of moderate to severe acute and chronic pain
• Preoperative medication to sedate and allay apprehension, facilitate induction of
anesthesia, and reduce anesthetic dosage
• Analgesic adjunct during anesthesia
• Component of most preparations that are referred to as Brompton's cocktail or
mixture, an oral alcoholic solution that is used for chronic severe pain, especially
in terminal cancer patients
• Intraspinal use with microinfusion devices for the relief of intractable pain
• Unlabeled use: Dyspnea associated with acute left ventricular failure and
pulmonary edema

Contraindications and cautions

• Contraindicated with hypersensitivity to opioids; diarrhea caused by poisoning
until toxins are eliminated; during labor or delivery of a premature infant (may
cross immature blood–brain barrier more readily); after biliary tract surgery or
following surgical anastomosis; pregnancy; labor (respiratory depression in
neonate; may prolong labor).
 • Use cautiously with head injury and increased intracranial pressure; acute asthma,
COPD, cor pulmonale, preexisting respiratory depression, hypoxia, hypercapnia
(may decrease respiratory drive and increase airway resistance); lactation (wait 4–
6 hr after administration to nurse the baby); acute abdominal conditions, CV
disease, supraventricular tachycardias, myxedema, seizure disorders, acute
alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever,
kyphoscoliosis, Addison's disease, prostatic hypertrophy, urethral stricture, recent
GI or GU surgery, toxic psychosis, renal or hepatic dysfunction.

Available forms
Injection—0.5, 1, 2, 4, 5, 8, 10, 15, 25, 50 mg/mL; tablets—15, 30 mg; CR tablets—15,
60, 100, 200 mg; ER tablets—30, 60, 100 mg; soluble tablets—10, 15, 30 mg; oral
solution—10, 20, 100 mg/5 mL; concentrated oral solution—20 mg/mL, 100 mg/5 mL;
suppositories—5, 10, 20, 30 mg; capsules—15, 30 mg; SR capsules—20, 30, 50, 60,
100 mg

Dosages
ADULTS
Oral
One-third to one-sixth as effective as parenteral administration because of first-pass
metabolism; 10–30 mg q 4 hr PO. Controlled-release: 30 mg q 8–12 hr PO or as directed
by physician; Kadian: 20–100 mg PO daily–24-hr release system; MS Contin: 200 mg
PO q 12 hr.
SC and IM
10 mg (5–20 mg)/70 kg q 4 hr or as directed by physician.
IV
2.5–15 mg/70 kg of body weight in 4–5 mL water for injection administered over 4–5
min, or as directed by physician. Continuous IV infusion: 0.1–1 mg/mL in 5% dextrose in
water by controlled infusion device.
Rectal
10–30 mg q 4 hr or as directed by physician.
Epidural
Initial injection of 5 mg in the lumbar region may provide pain relief for up to 24 hr. If
adequate pain relief is not achieved within 1 hr, incremental doses of 1–2 mg may be
given at intervals sufficient to assess effectiveness, up to 10 mg/24 hr. For continuous
infusion, initial dose of 2–4 mg/24 hr is recommended. Further doses of 1–2 mg may be
given if pain relief is not achieved initially.
Intrathecal
Dosage is usually one-tenth that of epidural dosage; a single injection of 0.2–1 mg may
provide satisfactory pain relief for up to 24 hr. Do not inject > 2 mL of the 5 mg/10 mL
ampule or > 1 mL of the 10 mg/10 mL ampule. Use only in the lumbar area. Repeated
intrathecal injections are not recommended; use other routes if pain recurs. For epidural
or intrathecal dosing, use preservative-free morphine preparations only.
PEDIATRIC PATIENTS
Do not use in premature infants.
SC or IM
0.05–0.2 mg/kg (up to 15 mg per dose) q 4 hr or as directed by physician.
GERIATRIC PATIENTS OR IMPAIRED ADULTS
Use caution. Respiratory depression may occur in the elderly, the very ill, those with
respiratory problems. Reduced dosage may be necessary.
Epidural
Use extreme caution; injection of < 5 mg in the lumbar region may provide adequate pain
relief for up to 24 hr.
Intrathecal
Use lower dosages than recommended for adults above.

Pharmacokinetics
Route Onset Peak Duration
Oral Varies 60 min 5–7 hr
TPR Rapid 20–60 min 5–7 hr
SC Rapid 50–90 min 5–7 hr
IM Rapid 30–60 min 5–6 hr
IV Immediate 20 min 5–6 hr

Metabolism: Hepatic; T1/2: 1.5–2 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine and bile

IV facts
Preparation: No further preparation needed for direct injection; prepare infusion by
adding 0.1–1 mg/mL to 5% dextrose in water.
Infusion: Inject slowly directly IV or into tubing of running IV, each 15 mg over 4–5
min; monitor by controlled infusion device to maintain pain control.
Incompatibilities: Do not mix with aminophylline, amobarbital, chlorothiazide, heparin,
meperidine, phenobarbital, phenytoin, sodium bicarbonate, sodium iodide, thiopental.
Y-site incompatibilities: Do not give with minocycline, tetracycline.

Adverse effects
• CNS: Light-headedness, dizziness, sedation, euphoria, dysphoria, delirium,
insomnia, agitation, anxiety, fear, hallucinations, disorientation, drowsiness,
lethargy, impaired mental and physical performance, coma, mood changes,
weakness, headache, tremor, seizures, miosis, visual disturbances, suppression of
cough reflex
• CV: Facial flushing, peripheral circulatory collapse, tachycardia, bradycardia,
arrhythmia, palpitations, chest wall rigidity, hypertension, hypotension, orthostatic
hypotension, syncope
• Dermatologic: Pruritus, urticaria, laryngospasm, bronchospasm, edema
• GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm;
increased colonic motility in patients with chronic ulcerative colitis
• GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy,
oliguria, antidiuretic effect, reduced libido or potency
• Local: Tissue irritation and induration (SC injection)
• Major hazards: Respiratory depression, apnea, circulatory depression,
respiratory arrest, shock, cardiac arrest
 • Other: Sweating, physical tolerance and dependence, psychological dependence

Interactions
Drug-drug
• Increased likelihood of respiratory depression, hypotension, profound sedation or
coma in patients receiving barbiturate general anesthetics
Drug-lab test
• Elevated biliary tract pressure (an effect of opioids) may cause increases in
plasma amylase, lipase; determinations of these levels may be unreliable for 24 hr

Nursing considerations
Assessment
• History: Hypersensitivity to opioids; diarrhea caused by poisoning; labor or
delivery of a premature infant; biliary tract surgery or surgical anastomosis; head
injury and increased intracranial pressure; acute asthma, COPD, cor pulmonale,
preexisting respiratory depression; acute abdominal conditions, CV disease,
supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism,
delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever,
kyphoscoliosis, Addison's disease, prostatic hypertrophy, urethral stricture, recent
GI or GU surgery, toxic psychosis, renal or hepatic dysfunction; pregnancy;
lactation
• Physical: T; skin color, texture, lesions; orientation, reflexes, bilateral grip
strength, affect; P, auscultation, BP, orthostatic BP, perfusion; R, adventitious
sounds; bowel sounds, normal output; urinary frequency, voiding pattern, normal
output; ECG; EEG; thyroid, liver, kidney function tests

Interventions
• Caution patient not to chew or crush controlled-release preparations.
• Dilute and administer slowly IV to minimize likelihood of adverse effects.
• Tell patient to lie down during IV administration.
• Keep opioid antagonist and facilities for assisted or controlled respiration readily
available during IV administration.
• Use caution when injecting SC or IM into chilled areas or in patients with
hypotension or in shock; impaired perfusion may delay absorption; with repeated
doses, an excessive amount may be absorbed when circulation is restored.
• Reassure patients that they are unlikely to become addicted; most patients who
receive opioids for medical reasons do not develop dependence syndromes.

Teaching points
• Take this drug exactly as prescribed. Avoid alcohol, antihistamines, sedatives,
tranquilizers, over-the-counter drugs.
• Swallow controlled-release preparation (MS Contin, Oramorph SR) whole; do not
cut, crush, or chew them.
• Do not take leftover medication for other disorders, and do not let anyone else
take your prescription.
 • These side effects may occur: Nausea, loss of appetite (take with food, lie
quietly); constipation (use laxative); dizziness, sedation, drowsiness, impaired
visual acuity (avoid driving or performing tasks that require alertness and visual
acuity).
• Report severe nausea, vomiting, constipation, shortness of breath or difficulty
breathing, rash.

Adverse effects in Italic are most common; those in Bold are life-threatening.