Morphine sulfate injection
- Drugs List
- Therapeutic Indications
- Dosage
- Contraindications
- Precautions and Warnings
- Pregnancy and Lactation
- Side Effects
- Monograph
Presentation
Solution for injection containing morphine sulfate.
Drugs List
Therapeutic Indications
Uses
Pain - moderate to severe
Premedication for anaesthesia
Dosage
Treatment should be supervised by a specialist and the patient should be assessed at regular intervals.
Monitor patients closely for pain relief as well as for side effects, especially respiratory depression.
Adults
Intramuscular or subcutaneous administration
Chronic pain
5mg to 20mg every 4 hours as necessary, dependent upon the patient's response and cause of pain.
Acute pain
10mg every 4 hours (or more frequently during titration); adjust according to response.
For the relief of pain and as a pre-anaesthetic, the usual dose is 10mg every 4 hours depending on the severity of the condition and the patient's response. The usual individual dose range is 5mg to 20mg.
Premedication
Up to 10mg, given 60 to 90 minutes before the procedure.
Intravenous administration
Acute Pain
2mg to 15mg by slow intravenous injection (2 mg/minute), or use this dose as a loading dose followed by 2.5mg to 5mg every hour by infusion. If using Patient Controlled Analgesia, bolus doses of 1mg to 2 mg may be given with a lock out of 5 to 20 minutes. A commonly applied dose limit is 30mg in 4hours but some patients may require higher doses.
Alternatively, frequent small doses (e.g. 1mg to 3mg every 5 minutes) reaching a maximum cumulative dose of 2mg/kg to 3mg/kg. This is the preferred regimen for patients with myocardial infarction.
Chronic Pain
Loading doses of 15mg or more. Maintenance doses for infusion are in the range 0.8 to 80 mg/hour, although higher maintenance doses of 150 to 200 mg/hour may be required.
Alternatively, 5mg to 10mg every 4 hours, adjusted according to response.
Open Heart Surgery
Large doses (0.5mg/kg to 3 mg/kg) may be administered intravenously by slow continuous infusion as the sole anaesthetic agent.
Myocardial infarction
5mg to 10mg by slow intravenous injection at a rate of 1 to 2 mg/minute. If considered necessary, dose may be repeated.
Acute pulmonary oedema
5mg to 10 mg by slow intravenous injection to be given at a rate of 2 mg/minute.
Elderly
Use with caution and with a reduced starting dose titrated to provide optimal pain relief. It is recommended to half the adult dosage.
Children
Not all brands are licensed for use in children.
The following doses are suggested by one manufacturer:
Intramuscular or subcutaneous administration
Children aged 6 to 12 years:5mg to 10mg every 4 hours
Children aged 1 to 5 years:2.5mg to 5mg every 4 hours
Children aged 1 to 12 months: 200 micrograms/kg every 4 hours
Slow intravenous infusion
Children aged 6 months to 12 years: 10 to 30 micrograms/kg/hour. A loading dose of 100 micrograms/kg to 200 micrograms/kg may be given initially with bolus top-up doses of 50 micrograms/kg to 100 micrograms/kg every 4 hours.
Children under 6 months: up to 10 micrograms/kg/hour with respiratory support.
Subcutaneous infusion
For relief of pain in terminal disease
Children aged 6 months to 12 years: 30 to 60 micrograms/kg/hour
The following alternate dosing schedule may be suitable:
Subcutaneous injection
Children aged 12 to 18 years: 2.5mg to 10mg every 4 hours, adjust according to individual patient response.
Children aged 2 to 12 years:initially 200 micrograms/kg every 4 hours, adjust according to individual patient response.
Children aged 6 months to 2 years: 100 micrograms/kg to 200 micrograms/kg every 4 hours, adjust according to individual patient response.
Children aged 1 to 6 months: 100 micrograms/kg to 200 micrograms/kg every 6 hours, adjust according to individual patient response.
Children under 1 month: 100 micrograms/kg every 6 hours, adjust according to individual patient response.
Continuous subcutaneous infusion
Children aged 3 months to 18 years: 20 micrograms/kg/hour, adjust according to individual patient response.
Children aged 1 to 3 months: 10 micrograms/kg/hour, adjust according to individual patient response.
Intravenous injection over at least 5 minutes
Children aged 12 to 18 years:5mg every 4 hours, adjust according to individual patient response.
Children aged 6 months to 12 years: 100 micrograms/kg every 4 hours, adjust according to individual patient response.
Children aged 1 to 6 months: 100 micrograms/kg every 6 hours, adjust according to individual patient response.
Children under 1 month:50micrograms/kg every 6 hours, adjust according to individual patient response.
Intravenous administration
Children aged 12 to 18 years: Initial dose of 5mg over at least 5 minutes by intravenous injection. Maintenance dose of 20 micrograms/kg to 30 micrograms/kg per hour. Adjust according to individual patient response.
Children aged 6 months to 12 years:Initial dose of 100 micrograms/kg over at least 5 minutes by intravenous injection. Maintenance dose of 20 micrograms/kg to 30 micrograms/kg per hour. Adjust according to individual patient response.
Children aged 1 to 6 months:Initial dose of 100micrograms/kg over at least 5 minutes by intravenous injection. Maintenance dose of 10 micrograms/kg to 30 micrograms/kg per hour. Adjust according to individual patient response.
Children under 1 month:Initial dose of 50 micrograms/kg over at least 5 minutes by intravenous injection. Maintenance dose of 5 micrograms/kg to 20 micrograms/kg per hour. Adjust according to individual patient response.
Patients with Renal Impairment
Use with caution in patients with renal impairment, it may be advisable to use a reduced dose. The effects of opioid analgesia are increased and there is increased cerebral sensitivity.
The Renal Handbook suggests the following:
20 ml/minute to 50 ml/minute GFR: 75% of normal dose
10 ml/minute to 20 ml/minute GFR: use small doses, e.g. 2.5 to 5 mg and extended dosing intervals. Titrate according to response.
Below 10 ml/minute GFR: use small doses, e.g. 1.25 to 2.5 mg and extended dosing intervals. Titrate according to response.
Patients with Hepatic Impairment
Use with caution in patients with hepatic impairment, it may be advisable to use a reduced dose. Opioid analgesics may precipitate coma in patients with hepatic impairment.
Contraindications
Acute abdomen
Acute alcohol intoxication
Risk of paralytic ileus
Within 2 weeks of discontinuing MAOIs
Acute asthma
Acute respiratory depression
Biliary colic
Cardiac failure secondary to pulmonary disorder
Cerebral oedema
Coma
Delayed gastric emptying
Excessive bronchial secretions
Head trauma
Labour
Obstructive pulmonary disease
Paralytic ileus
Phaeochromocytoma
Pregnancy
Raised intracranial pressure
Seizures
Ulcerative colitis
Precautions and Warnings
Children under 18 years
Debilitation
Elderly
Neonates
Shock
Significant obesity
Acute diarrhoea
Adrenal insufficiency
Asthma
Benign prostatic hyperplasia
Biliary tract disorder
Breastfeeding
Cardiac arrhythmias
Circulatory failure
Diabetes mellitus
Drug misuse
Gall bladder disorder
Gastrointestinal obstruction
Hepatic impairment
History of drug misuse
Hypotension
Hypothyroidism
Inflammatory bowel disease
Kyphoscoliosis with respiratory compromise
Myasthenia gravis
Myxoedema
Pancreatitis
Pulmonary emphysema
Reduced respiratory reserve
Renal impairment - glomerular filtration rate below 50ml/minute
Severe cardiac failure
Sleep apnoea
Urethral stricture
Do not use in acute diarrhoeal conditions (e.g. in colitis or poisoning)
Reduce dose in hypothyroidism
Reduce dose in patients with glomerular filtration rate below 50ml/min
Reduce dose in patients with hepatic impairment
Advise patient drowsiness may affect ability to drive or operate machinery
Advise patient not to drive until they know how the medicine affects them
Advise patient this medicine is subject to driving restrictions
Not all available brands are licensed for all age groups
Not all available brands are licensed for all indications
Treatment to be initiated and supervised by a specialist
Some brands contain metabisulfite, may cause bronchospasm/allergies
In acute pain, subcutaneous injection unsuitable for oedematous patient
Monitor patients with a history of alcoholism and drug abuse
Potential for drug abuse
Tolerance and dependence may occur
Potential for withdrawal symptoms
Avoid abrupt withdrawal
Discontinue if paralytic ileus is suspected
Discontinue if paralytic ileus occurs
Reduce dose in elderly
Advise patient to avoid alcohol during treatment
Alcohol may enhance side effects
Morphine should be used with caution post-operatively, in particular following abdominal or joint arthroplasty surgery as morphine impairs intestinal motility. If paralytic ileus is suspected, or occurs, morphine should be discontinued immediately.
An unexplained increase in pain and disappearance of opioid analgesic effects may indicate development of tolerance or opioid-induced hyperalgesia. An unexplained increase in abdominal pain with disturbed intestinal motility may indicate development of opioid-induced bowel dysfunction or narcotic bowel syndrome. Consider use of alternative analgesics and a morphine detoxification.
Pregnancy and Lactation
Pregnancy
Morphine sulfate is contraindicated in pregnancy.
Injectable morphine should not be administered to women during pregnancy, though it may be administered following clamping of the umbilical cord as part of the anaesthetic technique for caesarean section where facilities for post-operative monitoring are available.
Teratogenic effects have been observed in animal studies, but there are currently no reports linking use at therapeutic doses with major congenital defects, and there is not thought to be any increased incidence of birth defects in humans. Use for prolonged periods of time or at term should be avoided due to increased risk of neonatal depression and withdrawal following maternal use, particularly if used during labour. Use in third trimester and during labour should therefore be avoided. Effects on the neonate include tremors, irritability, diarrhoea, vomiting and seizures. There is a possibility of long-term or late-developing behavioural abnormalities, but the link is unclear at the time of writing.
The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).
Lactation
Morphine sulfate is contraindicated in pregnancy.
In studies of epidural administration of morphine sulfate, small amounts of morphine were detected in breast milk. The infant should be monitored for drowsiness, adequate weight gain and developmental milestones, particularly younger, exclusively breastfed infants, and medical advice should be sought immediately if the infant suffers from increased sleepiness, has difficulty breastfeeding, breathing difficulties or limpness. Particular care should be taken with children with a tendency for apnoea, due to the risk of respiratory depression, and infants should be monitored for somnolence and respiratory problems in the case of repeated doses. Opiate analgesics should only be used for short periods of time during breastfeeding; consider limiting the mother's parenteral morphine dosage by supplementing analgesia with a non-opoid analgesic.
Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1
Effects on Ability to Drive and Operate Machinery
This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988 (England and Wales). This medicine may be subject to police testing and has specified maximum blood levels for driving. When prescribing this medicine: Advise patient the medicine can affect cognitive function and is likely to affect ability to drive. Advise patient not to drive until they know how the medicine affects them. It is an offence to drive while under the influence of this medicine. However, a patient is not committing an offence (called 'statutory defence') if: 1.The medicine has been prescribed to treat a medical or dental problem and 2.The medicine has been taken according to the instructions given by the prescriber and/or in the information provided with the medicine and 3.The medicine was not affecting the ability to drive safely. For further guidance see https://www.gov.uk
Side Effects
Abdominal cramps
Abdominal pain
Agitation
Allergic reaction
Allodynia
Anaphylactic reaction
Anaphylaxis
Angioedema
Anorexia
Asthenia
Biliary spasm
Blurred vision
Bradycardia
Bronchospasm
Chills
Circulatory failure
Coma
Confusion
Constipation
Contact dermatitis
Convulsions
Cough
Death
Decrease in mental acuity
Delirium
Dependence
Depression
Diarrhoea
Difficulty in micturition
Disorientation
Dizziness
Double vision
Drowsiness
Dry mouth
Dyspepsia
Dysphoria
Elevation of liver enzymes
Erectile dysfunction
Euphoria
Excitation
Facial flushing
Fatigue
Flushing
Gastrointestinal disorder
Hallucinations
Headache
Hiccups
Hypalgesia
Hyperaesthesia
Hypersensitivity reactions
Hypertension
Hyperthermia
Hypogonadism
Hypotension
Hypothermia
Infertility
Insomnia
Irritation (injection site)
Itching
Local pain (injection site)
Malaise
Miosis
Mood changes
Muscle rigidity
Myoclonus
Nausea
Nystagmus
Oedema
Oliguria
Orthostatic hypotension
Palpitations
Paraesthesia
Paralytic ileus
Pruritus
Pulmonary oedema
Raised intracranial pressure
Rash
Reduced libido
Reduction of male potency
Renal failure
Respiratory depression
Respiratory failure
Restlessness
Rhabdomyolysis
Sedation
Seizures
Sleep disturbances
Sweating
Syncope
Tachycardia
Taste disturbances
Tolerance
Tremor
Ureteric spasm
Urinary retention
Urticaria
Vertigo
Vomiting
Withdrawal symptoms
Overdosage
It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.
The following number will direct the caller to the relevant local centre (0844) 892 0111
Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).
Further Information
Last Full Review Date: November 2015
Reference Sources
Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.
Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.
Medications and Mothers' Milk, Sixteenth Edition (2014) Hale, T and Rowe, H, Hale Publishing, Plano, Texas.
Summary of Product Characteristics for Min-i-Jet Morphine Sulfate. International Medication Systems (UK) Ltd.Revised June 2010
Summary of Product Characteristics: Morphine Sulfate Injection BP 10mg/ml Injection BP. Wockhardt UK Ltd. Revised January 2021.
Summary of Product Characteristics: Morphine Sulfate Injection BP 15mg/ml and 30mg/ml. Wockhardt UK Ltd. Revised March 2010.
Summary of Product Characteristics: Morphine Sulfate Injection 10mg in 1ml Solution for Injection. Martindale Pharma. Revised September 2020.
Summary of Product Characteristics: Morphine Sulfate Injection 10mg/1ml, 15mg/1ml and 30mg/1ml. UCB Pharma Ltd. Revised June 2010.
Summary of Product Characteristics: Morphine Sulfate Injection 1mg/ml. Torbay Pharmaceuticals. Revised January 2014.
The Renal Drug Handbook. Fourth Edition (2014) ed. Ashley, C and Dunleavy, A, Radcliffe Publishing Ltd, London.
UK Drugs in Lactation Advisory Service.
Available at: https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1
Last accessed: 18 november 2015
US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Morphine Last revised: 06 November 2015
Last accessed: 18 november 2015
Gov.uk. Government departments. Department for Transport. Publications. Drug driving and medicine: advice for healthcare professionals. Drug driving: Guidance for healthcare professionals on drug driving. Available at: https://www.gov.uk Last accessed: 6 January 2015
NICE Evidence Services Available at: www.nice.org.uk Last accessed: 08 September 2017
Medscape UK | Univadis prescription drug monographs & interactions are based on FDB Multilex Content
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