Morphine

DEA Class; Rx

Common Brand Names; MS Contin, Astramorph, Depodur, Duramorph, Infumorph, Kadian, MorphaBond, Mitigo

Opiate agonist; alkaloid obtained from the unripened seed capsules of the opium poppy
Used for the relief of moderate to severe acute and chronic pain, preoperative sedation and as a supplement to anesthesia
Available in multiple formulations

Hypersensitivity

Paralytic ileus

Toxin-mediated diarrhea

Respiratory depression, acute or severe bronchial asthma, upper airway obstruction

Within 2 weeks of monoamine oxidase inhibitor (MAOI) therapy

GI obstruction (extended release)

Hypercarbia (immediate release tablets/solution)

Upper airway obstruction (epidural/intrathecal)

Heart failure due to chronic lung disease, head injuries, brain tumors, deliriums tremens, seizure disorders, during labor when premature birth anticipated (injectable formulation)

Cardiac arrhythmia, increased intracranial or cerebrospinal pressure, acute alcoholism, use after biliary tract surgery, surgical anastomosis (suppository formulcation)

• Pruritus (≤80%)
• Urinary retention (epidural/IT) (15-70%)
• Vomiting (7-70%)
• Constipation (>10%)
• Headache (>10%)
• Somnolence (>10%)
• Abdominal pain (5-10%)
• Asthenia (5-10%)
• Backache (5-10%)
• Depression (5-10%)
• Diarrhea (5-10%)
• Dyspnea (5-10%)
• Fever (5-10%)
• Insomnia (5 -10% )
• Loss of appetite (5-10%)
• Nausea (5-10%)
• Paresthesia (5-10%)
• Peripheral edema (5-10%)
• Rash (5-10%)
• Sweating (5-10%)
• Xerostomia (5-10%)
• Respiratory depression (IT) (4-7%)
• Anxiety (6%)
• Dizziness (6%)
• Abnormal liver function test results (<5%)
• Amblyopia (<5%)
• Hiccups (<5%)
• Orthostatic hypotension (<5%)
• Syncope (<5%)
• Urinary retention (PO) (<5%)
• Respiratory depression (epidural) (0.25-0.4% )
• Anaphylaxis (rare )
• Cardiac arrest
• Circulatory depression
• Finding of intracranial pressure
• Ileus
• Lightheadedness
• Malaise
• Miosis
• Myoclonus
• Shock
• Thinking disturbances
• Vertigo

Use with caution in acute pancreatitis, Addison disease, benign prostatic hyperplasia, cardiac arrhythmias, central nervous system (CNS) depression, drug abuse or dependence, emotional lability, gallbladder disease, gastrointestinal (GI) disorder, morbidly obese patients, patients with urinary stricture, pseudomembranous colitis, GI surgery, head injury, hypothyroidism or untreated myxedema, intracranial hypertension, brain tumor, toxic psychosis, urethral stricture, urinary tract surgery, seizures, acute alcoholism, delirium tremens, shock, cor pulmonale, chronic pulmonary disease, emphysema, hypercapnia, kyphoscoliosis, severe obesity, renal or hepatic impairment, elderly or debilitated patients, neonates

May cause constipation; consider preventive measures (eg, stool softener, increased fiber) to reduce potential for constipation, especially in patients with unstable angina and patients with myocardial infarction

Cases of serotonin syndrome, a potentially life-threatening condition, reported with concomitant use of serotonergic drugs; this may occur within the recommended dosage range; the onset of symptoms generally occur within several hours to a few days of concomitant use, but may occur later than that; discontinue therapy immediately if serotonin syndrome is suspected

Use with caution in patients with hypersensitivity reactions to other phenanthrene derivative opioid agonists

Use with caution in patients with adrenal insufficiency, including addison’s disease; chronic opioid use may cause secondary hypogonadism, which may lead to mood disorders, osteoporosis, sexual dysfunction, and infertility

Warn patients not to drive or operate dangerous machinery unless they are tolerant to effects of drug and know how they will react to medication

Use with caution in patients with biliary tract dysfunction, including acute pancreatitis; use may cause constriction of sphincter of Oddi diminishing biliary and pancreatic secretion

Therapy may cause severe hypotension including orthostatic hypotension and syncope in ambulatory patients; there is increased risk in patients whose ability to maintain blood pressure has already been compromised by a reduced blood volume or concurrent administration of certain CNS depressant drugs (e.g., phenothiazines or general anesthetics); monitor patients for signs of hypotension after initiating or titrating dosage; in patients with circulatory shock, therapy may cause vasodilation that can further reduce cardiac output and blood pressure; avoid therapy in patients with circulatory shock

Contraindicated in patients with known or suspected gastrointestinal obstruction, including paralytic ileus; may cause spasm of sphincter of Oddi; opioids may cause increases in serum amylase; monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms

Prolonged use of opioid analgesics during pregnancy for medical or nonmedical purposes can result in physical dependence in the neonate and neonatal opioid withdrawal syndrome shortly after birth

Morphine is present in breast milk; published lactation studies report variable concentrations of morphine in breast milk with administration of immediate-release morphine to nursing mothers in the early postpartum period with a milk-to-plasma morphine AUC ratio of 2.5:1 measured in one lactation study