Drugs List

Therapeutic Indications

Uses

Pain - moderate to severe

Morphine sulfate injection is indicated for the relief of moderate to severe pain. Morphine sulfate injection is used especially in pain associated with cancer, myocardial infarction and surgery. Morphine also reduces the anxiety and insomnia which may be caused by severe pain.

Administration

For intravenous injection or intravenous infusion via a patient controlled analgesia (PCA) system.

Contraindications

Acute abdomen
Acute alcohol intoxication
Children under 12 years
Risk of paralytic ileus
Within 2 weeks of discontinuing MAOIs
Acute asthma
Acute hepatic disorder
Biliary tract spasm
Cardiac failure secondary to pulmonary disorder
Coma
Delayed gastric emptying
Excessive bronchial secretions
Head trauma
Labour
Obstructive pulmonary disease
Paralytic ileus
Phaeochromocytoma
Raised intracranial pressure
Renal impairment - glomerular filtration rate below 20ml/minute
Renal tract spasm
Respiratory depression
Seizures
Severe hepatic impairment
Ulcerative colitis

Precautions and Warnings

Debilitation
Elderly
Obesity
Post operatively
Shock
Adrenal insufficiency
Alcoholism
Asthma
Benign prostatic hyperplasia
Biliary tract disorder
Breastfeeding
Cardiac arrhythmias
Diabetes mellitus
Drug misuse
Gastrointestinal obstruction
History of alcohol abuse
History of drug misuse
Hypotension
Hypothyroidism
Inflammatory bowel disease
Mild hepatic impairment
Mild renal impairment
Myasthenia gravis
Opioid dependence
Pancreatitis
Pregnancy
Psychiatric disorder
Severe cardiac failure
Severe hypopituitarism
Sickle cell disease
Urethral stricture

Reduce dose in hypothyroidism
Reduce dose in patients with hepatic impairment
Reduce dose in patients with renal impairment
Sodium content of formulation may be significant
Advise patient ability to drive or operate machinery may be impaired
Advise patient not to drive until they know how the medicine affects them
Advise patient this medicine is subject to driving restrictions
If adrenal insufficiency occurs, consider corticosteroid cover
Monitor patient's sedation level
Monitor patients with a history of alcoholism and drug abuse
Neonate exposed in utero: Monitor for neonatal withdrawal syndrome
Reassess need for continued treatment at regular intervals
Tolerance and dependence may occur
Consider dose reduction or change in opioid if evidence of hyperalgesia
Potential for withdrawal symptoms
Prolonged use at high doses may result in hyperalgesia
Avoid abrupt withdrawal
Reduce dose in elderly
Advise that effects are potentiated by CNS depressants (including alcohol)

Morphine sulfate injection should be used with caution post-operatively following total joint arthroplasty (colonic pseudo-obstruction).

Before commencing treatment with morphine sulfate, a strategy should be constructed with the patient for ending treatment in order to reduce the risk of addiction and drug withdrawal syndrome.

A full patient history should be established to document concomitant medications and past and present medical and psychiatric conditions. The risk of developing tolerance to morphine sulfate should be explained to the patient prior to treatment. All patients should be closely observed for signs of misuse, abuse or addiction. Patients at risk of opioid misuse may require additional support and monitoring.

Monitor for pain, sedation and signs of respiration impairment during the first few hours of treatment.

Long-term use of opioid analgesics may be associated with decreased sex hormone levels and increased prolactin.

Due to possible association between acute chest syndrome (ACS) and morphine use in sickle cell disease, patients treated with morphine during a vaso-occlusive crisis, close monitoring for ACS is warranted.

Pregnancy and Lactation

Pregnancy

Use morphine sulfate with caution during pregnancy.

Regular use during pregnancy may cause drug dependence in the foetus, causing withdrawal symptoms in the neonate. Administration during labour may depress respiration in the neonate and an antidote for the child should be readily available. Animal studies have shown teratogenic effects. Human data is limited and as such a potential risk cannot be ruled out. Use of morphine sulfate via a Patient Controlled Analgesia (PCA) system is not recommended by some manufacturers.

Schaefer (2015) indicates that morphine use during pregnancy should be limited to special situations where no safer alternatives are available. Tapering off the opioid should always be done gradually to prevent withdrawal symptoms in both the mother and the fetus.

Lactation

Use morphine sulfate with caution in breastfeeding.

The manufacturer does not recommend the use of morphine sulfate injection during breastfeeding as morphine may be secreted in breast milk and cause respiratory depression in the infant. A decision must be made whether to discontinue breastfeeding or to discontinue/abstain from morphine therapy taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman.

Lactmed (2021) indicates that once the mother starts breastfeeding, it is best to provide pain control with a nonnarcotic analgesic and limit maternal intake of morphine to a 2 to 3 days at a low dosage with close infant monitoring, especially in the outpatient setting. If the baby shows signs of increased sleepiness (more than usual), difficulty breastfeeding, breathing difficulties, or limpness, medical help should be sought immediately.

Side Effects

Abdominal pain
Agitation
Allergic reaction
Allodynia
Amenorrhoea
Anaphylaxis
Angioedema
Anorexia
Asthenia
Biliary spasm
Bradycardia
Bronchospasm
Circulatory failure
Coma
Confusion
Constipation
Contact dermatitis
Convulsions
Cough suppression
Death
Delirium
Dependence
Depression
Difficulty in micturition
Disorientation
Dizziness
Drowsiness
Dry mouth
Dyspepsia
Dysphoria
Elevation of liver enzymes
Erectile dysfunction
Euphoria
Exacerbation of pancreatitis
Excitation
Facial flushing
Fasciculation
Flushing
Hallucinations
Headache
Hyperalgesia
Hyperhidrosis
Hypertension
Hypogonadism
Hypotension
Hypothermia
Infertility
Local pain (injection site)
Malaise
Miosis
Mood changes
Muscle rigidity
Myoclonus
Nausea
Nystagmus
Oedema
Orthostatic hypotension
Palpitations
Paraesthesia
Paralytic ileus
Pruritus
Pulmonary oedema
Raised intracranial pressure
Rash
Reduced libido
Reduction of male potency
Renal failure
Respiratory depression
Restlessness
Rhabdomyolysis
Seizures
Sexual dysfunction
Sleep disturbances
Sweating
Syncope
Tachycardia
Taste disturbances
Ureteric spasm
Urinary retention
Urticaria
Vertigo
Visual disturbances
Vomiting
Withdrawal symptoms

Presentation

Infusions of morphine sulfate for use in patient controlled analgesia (PCA) systems.

Drugs List

Therapeutic Indications

Uses

Pain - moderate to severe

Morphine sulfate injection is indicated for the relief of moderate to severe pain. Morphine sulfate injection is used especially in pain associated with cancer, myocardial infarction and surgery. Morphine also reduces the anxiety and insomnia which may be caused by severe pain.

Dosage

Specific analgesic requirements vary between patients and therefore individualised treatment strategies are required.

The duration of treatment should be kept to a minimum, although dependence and tolerance are not usually a problem when morphine is used legitimately in patients with opioid-sensitive pain.

Adults

Patients with Renal Impairment

Administration

For intravenous injection or intravenous infusion via a patient controlled analgesia (PCA) system.

Contraindications

Acute abdomen
Acute alcohol intoxication
Children under 12 years
Risk of paralytic ileus
Within 2 weeks of discontinuing MAOIs
Acute asthma
Acute hepatic disorder
Biliary tract spasm
Cardiac failure secondary to pulmonary disorder
Coma
Delayed gastric emptying
Excessive bronchial secretions
Head trauma
Labour
Obstructive pulmonary disease
Paralytic ileus
Phaeochromocytoma
Raised intracranial pressure
Renal impairment - glomerular filtration rate below 20ml/minute
Renal tract spasm
Respiratory depression
Seizures
Severe hepatic impairment
Ulcerative colitis

Precautions and Warnings

Debilitation
Elderly
Obesity
Post operatively
Shock
Adrenal insufficiency
Alcoholism
Asthma
Benign prostatic hyperplasia
Biliary tract disorder
Breastfeeding
Cardiac arrhythmias
Diabetes mellitus
Drug misuse
Gastrointestinal obstruction
History of alcohol abuse
History of drug misuse
Hypotension
Hypothyroidism
Inflammatory bowel disease
Mild hepatic impairment
Mild renal impairment
Myasthenia gravis
Opioid dependence
Pancreatitis
Pregnancy
Psychiatric disorder
Severe cardiac failure
Severe hypopituitarism
Sickle cell disease
Urethral stricture

Reduce dose in hypothyroidism
Reduce dose in patients with hepatic impairment
Reduce dose in patients with renal impairment
Sodium content of formulation may be significant
Advise patient ability to drive or operate machinery may be impaired
Advise patient not to drive until they know how the medicine affects them
Advise patient this medicine is subject to driving restrictions
If adrenal insufficiency occurs, consider corticosteroid cover
Monitor patient's sedation level
Monitor patients with a history of alcoholism and drug abuse
Neonate exposed in utero: Monitor for neonatal withdrawal syndrome
Reassess need for continued treatment at regular intervals
Tolerance and dependence may occur
Consider dose reduction or change in opioid if evidence of hyperalgesia
Potential for withdrawal symptoms
Prolonged use at high doses may result in hyperalgesia
Avoid abrupt withdrawal
Reduce dose in elderly
Advise that effects are potentiated by CNS depressants (including alcohol)

Morphine sulfate injection should be used with caution post-operatively following total joint arthroplasty (colonic pseudo-obstruction).

Before commencing treatment with morphine sulfate, a strategy should be constructed with the patient for ending treatment in order to reduce the risk of addiction and drug withdrawal syndrome.

A full patient history should be established to document concomitant medications and past and present medical and psychiatric conditions. The risk of developing tolerance to morphine sulfate should be explained to the patient prior to treatment. All patients should be closely observed for signs of misuse, abuse or addiction. Patients at risk of opioid misuse may require additional support and monitoring.

Monitor for pain, sedation and signs of respiration impairment during the first few hours of treatment.

Long-term use of opioid analgesics may be associated with decreased sex hormone levels and increased prolactin.

Due to possible association between acute chest syndrome (ACS) and morphine use in sickle cell disease, patients treated with morphine during a vaso-occlusive crisis, close monitoring for ACS is warranted.

Pregnancy and Lactation

Pregnancy

Use morphine sulfate with caution during pregnancy.

Regular use during pregnancy may cause drug dependence in the foetus, causing withdrawal symptoms in the neonate. Administration during labour may depress respiration in the neonate and an antidote for the child should be readily available. Animal studies have shown teratogenic effects. Human data is limited and as such a potential risk cannot be ruled out. Use of morphine sulfate via a Patient Controlled Analgesia (PCA) system is not recommended by some manufacturers.

Schaefer (2015) indicates that morphine use during pregnancy should be limited to special situations where no safer alternatives are available. Tapering off the opioid should always be done gradually to prevent withdrawal symptoms in both the mother and the fetus.

Lactation

Use morphine sulfate with caution in breastfeeding.

The manufacturer does not recommend the use of morphine sulfate injection during breastfeeding as morphine may be secreted in breast milk and cause respiratory depression in the infant. A decision must be made whether to discontinue breastfeeding or to discontinue/abstain from morphine therapy taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman.

Lactmed (2021) indicates that once the mother starts breastfeeding, it is best to provide pain control with a nonnarcotic analgesic and limit maternal intake of morphine to a 2 to 3 days at a low dosage with close infant monitoring, especially in the outpatient setting. If the baby shows signs of increased sleepiness (more than usual), difficulty breastfeeding, breathing difficulties, or limpness, medical help should be sought immediately.

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 pain
Agitation
Allergic reaction
Allodynia
Amenorrhoea
Anaphylaxis
Angioedema
Anorexia
Asthenia
Biliary spasm
Bradycardia
Bronchospasm
Circulatory failure
Coma
Confusion
Constipation
Contact dermatitis
Convulsions
Cough suppression
Death
Delirium
Dependence
Depression
Difficulty in micturition
Disorientation
Dizziness
Drowsiness
Dry mouth
Dyspepsia
Dysphoria
Elevation of liver enzymes
Erectile dysfunction
Euphoria
Exacerbation of pancreatitis
Excitation
Facial flushing
Fasciculation
Flushing
Hallucinations
Headache
Hyperalgesia
Hyperhidrosis
Hypertension
Hypogonadism
Hypotension
Hypothermia
Infertility
Local pain (injection site)
Malaise
Miosis
Mood changes
Muscle rigidity
Myoclonus
Nausea
Nystagmus
Oedema
Orthostatic hypotension
Palpitations
Paraesthesia
Paralytic ileus
Pruritus
Pulmonary oedema
Raised intracranial pressure
Rash
Reduced libido
Reduction of male potency
Renal failure
Respiratory depression
Restlessness
Rhabdomyolysis
Seizures
Sexual dysfunction
Sleep disturbances
Sweating
Syncope
Tachycardia
Taste disturbances
Ureteric spasm
Urinary retention
Urticaria
Vertigo
Visual disturbances
Vomiting
Withdrawal symptoms

Withdrawal Symptoms and Signs

Some or all of the opioid drug withdrawal syndrome side effects are: restlessness, lacrimation, rhinorrhoea, yawning, perspiration, chills, myalgia, mydriasis and palpitations. Other symptoms may also develop including irritability, agitation, anxiety, hyperkinesia, tremor, weakness, insomnia, anorexia, abdominal cramps, nausea, vomiting, diarrhoea, increased blood pressure, increased respiratory rate or heart rate.

When a patient no longer requires treatment, it is advisable to taper the dose gradually to minimise symptoms of withdrawal. Tapering from a high dose may take weeks to months.

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: October 2021

Reference Sources

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 3rd edition (2015) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

The Renal Drug Handbook. Fifth Edition (2019) ed. Ashley, C. and Dunleavy, A. Radcliffe Publishing Ltd, London.

Summary of Product Characteristics: Morphine Sulfate Injection 1mg/ml. Aurum Pharmaceuticals Ltd. Revised April 2019.
Summary of Product Characteristics: Morphine Sulfate Injection 1mg/ml. Torbay & South Devon NHS Foundation Trust. Revised April 2020.
Summary of Product Characteristics: Morphine Sulfate Injection BP 2mg/ml. Martindale Pharma. Revised April 2019.
Summary of Product Characteristics: Morphine Sulfate Solution for Injection 10mg/10ml. Hameln Pharma Ltd. Revised September 2020.

NICE Evidence Services Available at: www.nice.org.uk Last accessed: 06 October 2021

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: 11 October 2021

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://www.ncbi.nlm.nih.gov/books/NBK501922/
Morphine. Last revised: 24 July 2021
Last accessed: 06 October 2021