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Morphine

    DEA Class; Rx

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

    • Opioid Analgesics

    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

    Indicated for the treatment of acute and chronic severe pain requiring an opioid analgesic and for which alternative treatments are inadequate.

    For the treatment of diarrhea.
    For the management of dyspnea.
    For procedural sedation before short diagnostic procedures or endoscopy.
    For sedation during rapid-sequence intubation.
    For the treatment of painful diabetic neuropathy.
    For the treatment of neonatal abstinence syndrome.
    For the treatment of dysautonomia due to tetanus.
    For the treatment of refractory restless legs syndrome (RLS).
    For the treatment of hypercyanotic episodes associated with tetralogy of fallot (i.e. tetralogy spells).

    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

    Adults

    Immediate-release formulations, extended-release tablets, extended-release capsules (Kadian ONLY), injectable solution (NOT DepoDur): With appropriate dosage titration, there is no maximum dose.
    Extended-release capsules (Avinza ONLY): 1600 mg/day PO due to the high concentrations of fumaric acid in the formulation.
    DepoDur liposome injection: 15 mg/dose epidurally.
    Deodorized opium tincture (10 mg/mL concentration ONLY): 6 mg/dose PO and 24 mg/day PO total.
    Camphorated opium tincture (0.4 mg/mL concentration ONLY): 4 mg/dose PO and 16 mg/day PO total.

    Geriatric

    Immediate-release formulations, extended-release tablets, extended-release capsules (Kadian ONLY), injectable solution (NOT DepoDur): With appropriate dosage titration, there is no maximum dose.
    Extended-release capsules (Avinza ONLY): 1600 mg/day PO due to the high concentrations of fumaric acid in the formulation.
    DepoDur liposome injection: 15 mg/dose epidurally.
    Deodorized opium tincture (10 mg/mL concentration ONLY): 6 mg/dose PO and 24 mg/day PO total.
    Camphorated opium tincture (0.4 mg/mL concentration ONLY): 4 mg/dose PO and 16 mg/day PO total.

    Adolescents

    Immediate-release formulations, extended-release tablets (MS Contin ONLY), injectable solution (NOT DepoDur): With appropriate dosage titration, there is no maximum dose.
    Extended-release capsules, extended-release tablets (Arymo ER or Morphabond), DepoDur liposome injection: Safety and efficacy have not been established.
    Deodorized opium tincture (10 mg/mL concentration ONLY): Safety and efficacy have not been established.
    Camphorated opium tincture (0.4 mg/mL concentration ONLY): 0.2 mg/kg/dose PO (Max: 4 mg/dose) and 0.8 mg/kg/day PO (Max: 16 mg/day).

    Children

    Immediate-release formulations, extended-release tablets (MS Contin ONLY), injectable solution (NOT DepoDur): With appropriate dosage titration, there is no maximum dose.
    Extended-release capsules, extended-release tablets (Arymo ER or Morphabond), DepoDur liposome injection: Safety and efficacy have not been established.
    Deodorized opium tincture (10 mg/mL concentration ONLY): Safety and efficacy have not been established.
    Camphorated opium tincture (0.4 mg/mL concentration ONLY): 0.2 mg/kg/dose PO (Max: 4 mg/dose) and 0.8 mg/kg/day PO (Max: 16 mg/day).

    Infants

    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.
    Deodorized opium tincture (10 mg/mL concentration ONLY): Safety and efficacy have not been established.
    Camphorated opium tincture (0.4 mg/mL concentration ONLY): Safety and efficacy have not been established.

    Neonates

    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.
    Deodorized opium tincture (10 mg/mL concentration ONLY): Safety and efficacy have not been established.
    Camphorated opium tincture (0.4 mg/mL concentration ONLY): Safety and efficacy have not been established.

    Morphine sulfate

    tablet, extended-release (MS Contin): Schedule II

    • 15mg, 30mg, 60mg, 100mg, 200mg

    tablet, extended release (abuse-deterrent): Schedule II

    • 15mg, 30mg, 60mg (Arymo ER)

    • 15mg, 30mg, 60mg, 100mg (MorphaBond)

    capsule, morphine sulfate extended-release: Schedule II

    • 10mg, 20mg, 30mg, 45mg, 50mg, 60mg

    • 75mg, 80mg, 90mg, 100mg, 120mg

    capsule, extended-release (Kadian): Schedule II

    • 10mg, 20mg, 30mg, 40mg, 50mg, 60mg

    • 70mg, 80mg, 100mg, 130mg, 150mg, 200mg

    injectable suspension, extended-release, liposomal (DepoDur): Schedule II

    • 10mg/mL

    injectable solution (Duramorph): Schedule II

    • 0.5mg/mL

    • 1mg/mL

    injectable solution, high potency (Infumorph, Mitigo): Schedule II

    • 10mg/mL (200mg/20mL ampule)

    • 25mg/mL (500mg/20mL ampule)

    morphine sulfate, injectable solution: Schedule II

    • 0.5mg/mL, 1mg/mL, 2mg/mL, 4mg/mL, 5mg/mL

    • 8mg/mL, 10mg/mL, 15mg/mL, 25mg/mL, 50mg/mL

    tablet, morphine sulfate immediate release : Schedule II

    • 15mg, 30mg

    morphine sulfate, suppository: Schedule II

    • 5mg, 10mg, 20mg, 30mg

    morphine sulfate, oral solution: Schedule II

    • 10mg/5mL; 20mg/5mL; 20mg/mL

    morphine sulfate, intramuscular device

    • 10mg/0.7mL