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morphine sulfate
generic
Black Box Warnings .
Appropriate Use
should only be prescribed by healthcare professionals knowledgeable about opioid use and how to mitigate associated risks; reserve opioid analgesics for patients with inadequate tx alternatives; ER form not indicated for prn analgesic use; proper dosing and titration essential to decr. respiratory depression risk
Medication Error Risk
ensure accuracy when prescribing, dispensing, and administering morphine oral solution and INJ forms; dosing errors due to confusion between mg and mL or different concentrations can result in accidental overdose and death; morphine concentrated oral solution (100 mg per 5 mL) indicated only in opioid-tolerant adult patients
Addiction, Abuse, and Misuse
opioid agonist Schedule II controlled substance with risk of addiction, abuse, and misuse, which can lead to overdose and death; assess opioid abuse or addiction risk prior to prescribing; regularly reassess all patients for misuse, abuse, and addiction
Respiratory Depression
serious, life-threatening, or fatal cases may occur even with recommended use, especially during tx start or after dose incr; to decr. risk, initiate and titrate dose appropriately; instruct patients to swallow ER tabs whole; crushing, dissolving, or chewing ER tabs can cause rapid release and absorption of potentially fatal morphine dose; instruct patients to swallow ER caps whole or sprinkle contents on applesauce and swallow immediately without chewing; crushing, dissolving, or chewing pellets within ER cap can cause rapid release and absorption of potentially fatal morphine dose
Accidental Ingestion
accidental ingestion of even one dose, especially by children, can result in fatal morphine overdose
Risks from Concomitant Use with Benzodiazepines, CNS Depressants
concomitant opioid use with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death; reserve concomitant use for patients with inadequate alternative tx options
Neonatal Opioid Withdrawal Syndrome
advise pregnant patients with extended opioid use of risk of potentially life-threatening neonatal opioid withdrawal syndrome; ensure tx by neonatology experts available at delivery
Opioid Analgesic REMS
providers are strongly encouraged to complete risk evaluation and mitigation strategy (REMS)-compliant education program, counsel patients and/or caregivers with each Rx on serious risks, safe use, and importance of reading medication guide
Avoid Alcohol
instruct patients using ER caps not to consume alcoholic beverages or use alcohol-containing prescription or non-prescription medications; alcohol consumption during tx may result in incr. plasma levels and potentially fatal morphine overdose
Adult Dosing .
Dosage forms: ER CAP (qd-bid): 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg; ER CAP (qd): 30 mg, 45 mg, 60 mg, 75 mg, 90 mg, 120 mg; TAB: 15 mg, 30 mg; ER TAB (bid-tid): 15 mg, 30 mg, 60 mg, 100 mg, 200 mg; SOLUTION: 10 mg per 5 mL, 20 mg per 5 mL, 100 mg per 5 mL; SUPPOSITORY: 5 mg, 10 mg, 20 mg, 30 mg; INJ: various
Special Note
- [prescribing info]
- Info: consider prescribing opioid overdose reversal agent (e.g., naloxone, nalmefene), especially if risk of opioid overdose or accidental ingestion
pain, moderate-severe acute
- [PO route, IR form]
- Dose: individualize IR dose PO q4h prn; Start: 10-30 mg IR PO q4h prn; Info: use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in patients 65 yo and older; 100 mg per 5 mL solution for use in opioid-tolerant patients only; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [intermittent injection]
- Dose: 0.1-0.2 mg/kg/dose SC/IV q4h prn; Alt: start 2-10 mg/70 kg/dose SC/IV x1, then individualize dose SC/IV prn; Info: use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in patients 65 yo and older; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [continuous IV infusion]
- Dose: 0.02-0.1 mg/kg/h IV; Info: titrate to effect; use lowest effective dose, shortest effective tx duration; max 10 mg/h IV start dose in opioid-naive patients; consider higher start dose in opioid-tolerant patients; consider low start dose, titrate slowly in patients 65 yo and older; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PCA route]
- Dose: 0.2-3 mg IV q6-10min prn; Start: 1-5 mg IV x1; Info: basal rate for opioid-experienced patients is up to 2 mg/h; dosing varies, refer to institution protocol; use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in patients 65 yo and older; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [epidural route]
- Dose: individualize dose epidurally prn; Start: 5 mg epidurally x1, then after 1h may give 1-2 mg/dose prn; Max: 10 mg/24h; Info: use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in patients 65 yo and older; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [intrathecal route]
- Dose: 0.2-1 mg intrathecally x1; Info: epidural route preferred to intrathecal route; use lowest effective dose; if additional dose needed, consider alternate route
- [rectal route]
- Dose: 10-20 mg PR q4h prn; Info: use lowest effective dose, shortest effective tx duration; decr. start dose in elderly or debilitated patients; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
pain, moderate-severe chronic
- [PO route, IR form]
- Dose: individualize IR dose PO q4h prn; Info: start 10-30 mg IR PO q4h prn in opioid-naive or opioid-nontolerant patients; individualize dose based on current opioid intake, see pkg insert for conversion; use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in patients 65 yo and older; 100 mg per 5 mL solution for use in opioid-tolerant patients only; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PO route, qd ER cap form]
- Dose: individualize ER dose PO q24h; Max: 1600 mg/day ER; Info: start 30 mg ER PO q24h in opioid-nontolerant patients; individualize dose based on current opioid intake, see pkg insert for conversion; use lowest effective dose, shortest effective tx duration; may incr. by up to 30 mg/dose q3-4 days; consider low start dose, titrate slowly in patients 65 yo and older; may open ER cap, but do not crush/chew/dissolve contents; 90 mg ER cap, 120 mg ER cap for use in opioid-tolerant patients only; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PO route, qd-bid ER cap form]
- Dose: individualize ER dose PO/GT q12-24h; Info: start 30 mg ER PO/GT q24h in opioid-nontolerant patients; individualize dose based on current opioid intake, see pkg insert for conversion; use lowest effective dose, shortest effective tx duration; may incr. dose q1-2 days; consider low start dose, titrate slowly in patients 65 yo and older; may open ER cap, but do not crush/chew/dissolve contents; >60 mg/dose ER, >120 mg/day ER for use in opioid-tolerant patients only; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PO route, bid-tid ER tab form]
- Dose: individualize ER dose PO q8-12h; Info: start 15 mg ER PO q8-12h in opioid-nontolerant patients; individualize dose based on current opioid intake, see pkg insert for conversion; use lowest effective dose, shortest effective tx duration; may incr. dose q1-2 days; consider low start dose, titrate slowly in patients 65 yo and older; >60 mg/dose ER, >120 mg/day ER for use in opioid-tolerant patients only; do not cut/crush/chew/dissolve ER tab; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [intermittent injection]
- Dose: 0.1-0.2 mg/kg/dose SC/IV q4h prn; Alt: start 2-10 mg/70 kg/dose SC/IV x1, then individualize dose SC/IV prn; Info: use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in patients 65 yo and older; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [rectal route]
- Dose: 10-20 mg PR q4h prn; Info: use lowest effective dose, shortest effective tx duration; decr. start dose in elderly or debilitated patients; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
acute angina, severe (off-label)
- [2-4 mg IV q5-15min prn]
- Info: may give up to 10 mg/dose
dyspnea (off-label)
- [PO route, IR form]
- Dose: individualize dose IR PO q2-4h prn; Info: for use in palliative care; start 2.5-5 mg IR PO q2-4h prn in opioid-naive patients; individualize dose based on current opioid intake; may incr. dose by 5-25% q24h
- [parenteral route]
- Dose: individualize dose SC/IV q30min-4h prn; Info: for use in palliative care; start 1.5-3 mg SC/IV q30min-4h prn in opioid-naive patients; individualize dose based on current opioid intake; may incr. dose by up to 50% if inadequate response after 2 doses
renal dosing
- [epidural/intrathecal route]
- renal impairment: not defined, caution advised
- HD/PD: not defined, caution advised
- [all other routes]
- CrCl 10-50: decr. usual dose by 25%, titrate slowly; CrCl <10: avoid use
- HD/PD: avoid use
hepatic dosing
- [see below]
- cirrhosis: decr. usual start dose, amount not defined; Info: titrate slowly
Peds Dosing .
- Dosage forms: TAB: 15 mg, 30 mg; ER TAB: 15 mg, 30 mg, 60 mg, 100 mg, 200 mg; SOLUTION: 10 mg per 5 mL, 20 mg per 5 mL; INJ: various
Special Note
- [prescribing info]
- Info: consider prescribing opioid overdose reversal agent (e.g., naloxone, nalmefene), especially if risk of opioid overdose or accidental ingestion
pain, moderate-severe acute
- [PO route, IR form, <12 mo (off-label)]
- Dose: 0.08-0.2 mg/kg/dose IR PO q4h prn; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PO route, IR form, 12-23 mo (off-label)]
- Dose: 0.2-0.4 mg/kg/dose IR PO q4h prn; Max: 5 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PO route, IR form, 2-17 yo]
- Dose: individualize IR dose PO q4h prn; Start: 0.15-0.3 mg/kg/dose IR PO q4h prn; Max: 20-30 mg/dose for start dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [intermittent injection, <1 mo (off-label)]
- Dose: 0.025-0.05 mg/kg/dose SC/IV q6h prn; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [intermittent injection, 1-6 mo (off-label)]
- Dose: 0.1 mg/kg/dose SC/IV q6h prn; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [intermittent injection, 7 mo and older (off-label)]
- Dose: 0.1-0.2 mg/kg/dose SC/IV q4h prn; Max: 2.5 mg/dose if <13 yo, 10 mg/dose if 13 yo and older; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [continuous IV infusion, <1 mo]
- Dose: 0.01-0.02 mg/kg/h IV; Start: 0.025-0.1 mg/kg/dose IV x1; Info: titrate to effect; use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [continuous IV infusion, 1-11 mo]
- Dose: 0.01-0.03 mg/kg/h IV; Start: 0.05-0.2 mg/kg/dose IV x1; Info: titrate to effect; use lowest effective dose, shortest effective tx duration; consider higher start dose in opioid-tolerant patients; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [continuous IV infusion, 1-17 yo, <50 kg]
- Dose: 0.01-0.06 mg/kg/h IV; Start: 0.02-0.03 mg/kg/h IV, then titrate to effect; Info: use lowest effective dose, shortest effective tx duration; consider higher start dose in opioid-tolerant patients; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [continuous IV infusion, 1-17 yo, >50 kg]
- Dose: 0.8-3 mg/h IV; Start: 1.5 mg/h IV, then titrate to effect; Info: use lowest effective dose, shortest effective tx duration; consider higher start dose in opioid-tolerant patients; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PCA route, <50 kg (off-label)]
- Dose: 0.01-0.03 mg/kg/dose IV q6-10min prn; Start: 0.01-0.03 mg/kg/dose IV x1; Max: 0.15 mg/kg/h; Info: basal rate for opioid-experienced patients is up to 0.03 mg/kg/h; dosing varies, refer to institution protocol; use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PCA route, >50 kg (off-label)]
- Dose: 0.2-3 mg IV q6-10min prn; Start: 1-5 mg IV x1; Info: basal rate for opioid-experienced patients is up to 2 mg/h; dosing varies, refer to institution protocol; use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [epidural route, 6 mo-12 yo (off-label)]
- Dose: 0.015-0.05 mg/kg/dose epidurally prn; Max: 0.1 mg/kg/dose epidurally up to 5 mg/24h; Alt: 0.001-0.005 mg/kg/h epidurally prn; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
pain, moderate-severe chronic (off-label)
- [PO route, IR form, <12 mo]
- Dose: 0.08-0.2 mg/kg/dose IR PO q4h prn; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PO route, IR form, 12-23 mo]
- Dose: 0.2-0.4 mg/kg/dose IR PO q4h prn; Max: 5 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PO route, IR form, 2-12 yo]
- Dose: 0.2-0.5 mg/kg/dose IR PO q4h prn; Max: 5 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [PO route, ER tab form, >12 mo]
- Dose: 0.2-0.8 mg/kg/dose ER PO q12h; Start: individualize dose based on current opioid intake; Info: use lowest effective dose, shortest effective tx duration; do not cut/crush/chew/dissolve ER tab; >60 mg/dose ER, >120 mg/day ER for use in opioid-tolerant patients only; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [intermittent injection, <1 mo]
- Dose: 0.025-0.05 mg/kg/dose SC/IV q6h prn; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [intermittent injection, 1-6 mo]
- Dose: 0.1 mg/kg/dose SC/IV q6h prn; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
- [intermittent injection, 7 mo and older]
- Dose: 0.1-0.2 mg/kg/dose SC/IV q4h prn; Max: 2.5 mg/dose if <13 yo, 10 mg/dose if 13 yo and older; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
neonatal opioid withdrawal syndrome (off-label)
- [0.03-0.05 mg/kg/dose PO q3-4h prn]
- Max: 0.2 mg/kg/dose; Info: may incr. by 0.01 mg/kg/dose if inadequate response after 2 doses; gradually decr. dose by no more than 10% 1-2x/day to D/C; refer to institutional protocol
renal dosing
- [epidural route]
- renal impairment: not defined, caution advised
- HD/PD: not defined, caution advised
- [all other routes]
- CrCl 10-50: decr. usual dose by 25%; CrCl <10: decr. usual dose by 50%; Info: titrate slowly
- HD: decr. usual dose by 50%; supplement after dialysis not defined; PD: decr. usual dose by 50%; supplement not defined; Info: titrate slowly
hepatic dosing
- [see below]
- cirrhosis: decr. usual start dose, amount not defined; Info: titrate slowly