morphine (morphine sulfate [MS], MS Contin, Roxanol, Oramorph SR, Kadian, Avinza, DepoDur, Duromorph)

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[1][2][3][4][5][6][7][8][9][10][11][12]

Introduction

Tradenames: MS Contin, Roxanol. (morphine sulfate) DEA-controlled substance: class 2

Indications

Contraindications

pregnancy category = c

safety in lactation = ?

Dosage

  • 0.1 mg/kg up to 2-4 mg increments IV.
  • 0.1-0.2 mg/kg up to 15 mg IM every 4 hours.
  • IV drip requires less morphine than IV push to achieve desired anesthesia.
  • stop IV infusion if urine output ceases; use IV push PRN[6]

parenteral/oral potency: 3/1[6]

conversion of IV to oral morphine, use parenteral/oral potency ratio of 3/1[6]

breakthrough doses (see Immediate release below)

calculate the total 24 hour oral morphine used (sustained release + immediate release) & prescribe this as sustained release

for chronic pain, start with 30-50% of 24 hour morphine dose as sustained release, plus immediate release PRN for breakthrough pain[8]

maximum dose 90 mg/day for chronic pain (not cancer pain)[11]

Injection: 2 mg/mL, 4 mg/mL, 8 mg/mL, 10 mg/mL (1 mL) 15 mg/mL (1 mL, 20 mL), 25 mg/mL (20 mL)

Injection: (preservative-free) 0.5 mg/mL, 1 mg/mL (10 mL)

DepoDur: extended-release liposome epidural injection

Sustained-release:

MS Contin (morphine SA): 15-30 mg PO every 8-12 hours.

Tabs: 15, 30 & 60 mg. Also works given rectally[7]

Kadian: sustained-release form suitable for administration via G-tube

Avinza: sustained-release capsule[7]; QD dosing

Capsules: 30, 60, 90, 120 mg.

  • Do NOT crush, chew or dissolve;
  • potentially fatal release of morphine
  • may sprinkle beads on applesauce, but
  • do NOT chew beads

Immediate release: (MS IR)

Tabs: 15 & 30 mg.

Elixir:

  • 10-30 mg PO every 4 hours. 20 mg/mL.

Tradename: Roxanol. (sublingual)

Dosage adjustment in renal failure

Pharmacokinetics

  • variable absorption depending upon dose & form
  • peak respiratory depression effects
    • at 7 min following IV administration
    • at 90 min following SC administration
  • metabolized by the liver to morphine-6-glucuronide (active) & morphine-3-glucuronide (inactive)
  • morphine glucuronides eliminated in the urine
  • accumulation of glucuronide metablites with renal failure or in elderly patients taking high doses for prolonged periods
Form/route peak duration
tablets/oral solution 1 h 4-5 h
extended-release tablets 1 h 8-12 h
suppository 10-60 min 3-7 h
subcutaneous injection 50-90 min 4-5 h
intramuscular injection 30-60 min 4-5 h
intravenous injection 20 min 4-5 h

elimination via liver

1/2life = 1.8-4.2 hours

protein binding = 35 %

elimination by hemodialysis = -

Adverse effects

Drug interactions

Laboratory

Mechanism of action

More general terms

More specific terms

Component of

References

  1. ↑ The Pharmacological Basis of Therapeutics, 8th ed. Gilman et al, eds. Permagon Press/McGraw Hill pg 489
  2. ↑ Drug Information & Medication Formulary, Veterans Affairs, Central California Health Care System, 1st ed., Ravnan et al eds, 1998
  3. ↑ Kaiser Permanente Northern California Regional Drug Formulary, 1998
  4. ↑ Clinical Guide to Laboratory Tests, NW Tietz (ed) 3rd ed, WB Saunders, Philadelpha 1995
  5. ↑ Prescriber's Letter 9(5):27 2002
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004, 7th edition 2010
  7. ↑ 7.0 7.1 7.2 Prescriber's Letter 13(10): 2006 Alternative or 'Off-label' Routes of Drug Administration Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=221012&pb=PRL (subscription needed) http://www.prescribersletter.com
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Medical Knowledge Self Assessment Program (MKSAP) 16, 17. American College of Physicians, Philadelphia 2012, 2015
  9. ↑ Swetz KM, Kamal AH. In the clinic. Palliative care. Ann Intern Med. 2012 Feb 7;156(3) PMID: https://www.ncbi.nlm.nih.gov/pubmed/22312158
  10. ↑ 10.0 10.1 10.2 Deprecated Reference
  11. ↑ 11.0 11.1 Anello J, Feinberg B, Heinegg J et al New Guidelines and Recommendations Guideline on oioid administration by Veterans Affaris and U.S. Department of Defense http://reference.medscape.com/features/slideshow/guidelines/2017/april
  12. ↑ 12.0 12.1 NEJM Knowledge+

Database

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