Drug Study:Morphine Sulfate (Roxanol)

Generic Name:Morphine Sulfate(mor´feen)
Brand Name:Astramorph PF, Avinza,Duramorph, Epimorph , Kadian, MSIR, MS Contin, Oramorph SR, Roxanol, RMS, Statex
Classifications: central nervous system agent; analgesic; narcotic (opiate) agonist
Prototype:Morphine
Pregnancy Category:B

Availability:  10 mg 15 mg, 30 mg tablets/capsules;  15 mg, 20 mg, 30 mg, 60 mg, 100 mg, 120mg, 200 mg controlled release tablets/capsules; 10 mg/2.5 mL, 10 mg/5 ml, 20 mg/mL, 20 mg/5 mL, 30 mg/1.5 mL, 100 mg/5 mL oral solution;  0.5 mg/mL, 1 mg/mL, 2 mg/mL, 4 mg/mL, 5 mg/mL, 8 mg/mL, 10 mg/mL, 15 mg/mL, 25 mg/mL, 50 mg/mL injection;  5 mg, 10 mg, 20 mg,

Actions
Natural opium alkaloid with agonist activity by binding with the same receptors as endogenous opioid peptides. Narcotic agonist effects are identified with 3 types of receptors: Analgesia at supraspinal level, euphoria, respiratory depression and physical dependence; analgesia at spinal level, sedation and miosis; and dysphoric, hallucinogenic and cardiac stimulant effects.

Therapeutic effects
Controls severe pain; also used as an adjunct to anesthesia.

Uses
Symptomatic relief of severe acute and chronic pain after nonnarcotic analgesics have failed and as preanesthetic medication; also used to relieve dyspnea of acute left ventricular failure and pulmonary edema and pain of MI.

Contraindications
Hypersensitivity to opiates; increased intracranial pressure; convulsive disorders; acute alcoholism; acute bronchial asthma, chronic pulmonary diseases, severe respiratory depression; chemical-irritant induced pulmonary edema; prostatic hypertrophy; diarrhea caused by poisoning until the toxic material has been eliminated; undiagnosed acute abdominal conditions; following biliary tract surgery and surgical anastomosis; pancreatitis; acute ulcerative colitis; severe liver or renal insufficiency; Addison’s disease; hypothyroidism; during labor for delivery of a premature infant, in premature infants; pregnancy (category B; D in long-term use or when high dose is used); lactation

Cautious use
Toxic psychosis; cardiac arrhythmias, cardiovascular disease; emphysema; kyphoscoliosis; cor pulmonale; severe obesity; reduced blood volume; very old, very young, or debilitated patients; labor.

Route & Dosage  

Pain Relief
adult:PO  10–30 mg q4h prn or 15–30 mg sustained release q8–12h; (Kadian) dose q12–24h, increase dose prn for pain relief
IV  2.5–15 mg q4h or 0.8–10 mg/h by continuous infusion, may increase prn to control pain or 5–10 mg given epidurally q24h
IM/SC  5–20 mg q4h
PR  10–20 mg q4h prn
child:  IV  0.05–0.1 mg/kg q4h or 0.025–2.6 mg/kg/h by continuous infusion
IM/SC  0.1–0.2 mg/kg q4h (max: 15 mg/dose)
PO 0.2–0.5 mg/kg q4–6h; 0.3–0.6 mg/kg sustained release q12h
neonate:IV/IM/SC  0.05 mg/kg q4–8h (max: 0.1 mg/kg) or 0.01–0.02 mg/kg/h

Administration

Oral     

• Use a fixed, individualized schedule when narcotic analgesic therapy is started to provide effective management; blood levels can be maintained and peaks of pain can be prevented (usually a 4-h interval is adequate).
• Use lower dosage for older adult or debilitated patients than for adults.
• Do not break in half, crush, or allow sustained release tablet to be chewed.
• Do not give patient sustained release tablet within 24 h of surgery.
• Dilute oral solution in approximately 30 mL or more of fluid or semisolid food. A calibrated dropper comes with the bottle. Read labels carefully when using liquid preparation; available solutions: 20 mg/mL; 100 mg/mL.

Intravenous  

• Note: Verify correct IV concentration and rate of infusion/injection for administration to neonates, infants, or children with physician.

PREPARE  direct: Dilute 2–10 mg in at least 5 mL of sterile water for injection.

ADMINISTER  direct: Give a single dose over 4–5 min. Avoid rapid administration.

Incompatibilities  Solution / Additive:  Aminophylline, Amobarbital, Chlorothiazide, Floxacillin, Fluorouracil, Haloperidol, Heparin, Meperidine, Pentobarbital, Phenobarbital, Phenytoin, Sodium bi-carbonate, Thiopental.   Y-site:  Amphotericin B Cholesteryl Complex, Cefepime, Doxorubicin Liposome, Minocycline, Sargramostim, Tetracycline.  

• Store at 15°–30° C (59°–86° F). Avoid freezing. Refrigerate suppositories. Protect all formulations from light.

Adverse effects

BodyWhole:Hypersensitivity (Pruritus, rash, urticaria, edema, hemorrhagic urticaria (rare), anaphylactoid reaction (rare)), sweating, skeletal muscle flaccidity; cold, clammy skin, hypothermia.
CNS:Euphoria, insomnia, disorientation, visual disturbances, dysphoria, paradoxic CNS stimulation (restlessness, tremor, delirium, insomnia), convulsions (infants and children); decreased cough reflex, drowsiness, dizziness, deep sleep, coma.
SpecSenses:Miosis.
CV:Bradycardia, palpitations, syncope; flushing of face, neck, and upper thorax; orthostatic hypotension, cardiac arrest.
GI:Constipation, anorexia, dry mouth, biliary colic, nausea, vomiting, elevated transaminase levels.
Urogenital:Urinary retention or urgency, dysuria, oliguria, reduced libido or potency (prolonged use).
other:Prolonged labor and respiratory depression of newborn.
Hematologic:Precipitation of porphyria.
Respiratory:Severe respiratory depression (as low as 2–4/min) or arrest; pulmonary edema.

Nursing implications

Assessment & Drug Effects  

• Obtain baseline respiratory rate, depth, and rhythm and size of pupils before administering the drug. Respirations of 12/min or below and miosis are signs of toxicity. Withhold drug and report to physician.
• Observe patient closely to be certain pain relief is achieved. Record relief of pain and duration of analgesia.
• Be alert to elevated pulse or respiratory rate, restlessness, anorexia, or drawn facial expression that may indicate need for analgesia.
• Differentiate among restlessness as a sign of pain and the need for medication, restlessness associated with hypoxia, and restlessness caused by morphine-induced CNS stimulation (a paradoxic reaction that is particularly common in women and older adult patients).
• Monitor for respiratory depression; it can be severe for as long as 24 h after epidural or intrathecal administration.
• Monitor carefully those at risk for severe respiratory depression after epidural or intrathecal injection: Older adult or debilitated patients or those with decreased respiratory reserve (e.g., emphysema, severe obesity, kyphoscoliosis).
• Continue monitoring for respiratory depression for at least 24 h after each epidural or intrathecal dose.
• Assess vital signs at regular intervals. Morphine-induced respiratory depression may occur even with small doses, and it increases progressively with higher doses (generally max: 90 min after SC, 30 min after IM, and 7 min after IV).
• Encourage changes in position, deep breathing, and coughing (unless contraindicated) at regularly scheduled intervals. Narcotic analgesics also depress cough and sigh reflexes and thus may induce atelectasis, especially in postoperative patients.
• Be alert for nausea and orthostatic hypotension (with light-headedness and dizziness) in ambulatory patients or when a supine patient assumes the head-up position or in patients not experiencing severe pain.
• Monitor I&O ratio and pattern. Report oliguria or urinary retention. Morphine may dull perception of bladder stimuli; therefore, encourage the patient to void at least q4h. Palpate lower abdomen to detect bladder distention.

Patient & Family Education

• Avoid alcohol and other CNS depressants while receiving morphine.
• Do not use of any OTC drug unless approved by physician.
• Do not smoke or ambulate without assistance after receiving drug. Bedside rails are advised.
• Use caution or avoid tasks requiring alertness (e.g., driving a car) until response to drug is known since morphine may cause drowsiness, dizziness, or blurred vision.
• Do not breast feed while taking this drug.