II. Dosing: Analgesia

  1. Child
    1. IV/IM/SQ Morphine
      1. Dose: 0.1-0.2 mg/kg (0.025 mg/kg may be effective) up to 15 mg IV every 2 to 4 hours
    2. Oral Morphine Immediate Release (MSIR) PO or PR
      1. Dose: 0.2 to 0.5 mg/kg/dose up to 7.5 to 15 mg orally every 4 to 6 hours
    3. Oral Morphine Controlled Release
      1. Dose 0.3 to 0.6 mg/kg/dose orally every 12 hours
  2. Adult
    1. IV Morphine
      1. Start: 0.1 to 0.2 mg/kg up to 15 mg IV
      2. Typical dose 4 mg (2 mg in the elderly) IV titrating every 15 minutes as needed
    2. IM/SC Morphine
      1. Give 10 mg IM/SC every 4 hours as needed
    3. Oral Morphine Immediate Release (MSIR) PO or PR
      1. Start at 7.5 to 15 mg orally every 4 hours
      2. May titrate up to 30 mg orally every 4 hours
      3. Morphine immediate release is available in 15 mg and 30 mg tablets
      4. Morphine immediate release 15 mg orally is equivalent to 5 mg IV
      5. Morphine is less euphoric than Oxycodone and Hydrocodone
    4. Oral Morphine Controlled Release
      1. MS Contin (or Oramorph SR) 30 mg orally every 8 to 12 hours
      2. Kadian 20 mg orally every 12 to 24 hours
      3. Avinza XR 30 mg orally daily

III. Dosing: Procedural Sedation and Analgesia

  1. IV/IM/SC: 0.05 to 0.2 mg/kg every 2-4 hours up to 15 mg (typically given in 2-4 mg increments)
  2. Intramuscular onset of activity may be delayed as long as 30 minutes

IV. Pharmacokinetics

  1. Onset 1 to 2 minutes
  2. Peaks 3 to 5 minutes
  3. Duration 1 to 2 hours
  4. Poor oral absorption
  5. Metabolized via conjugation with glucuronic acid

V. Metabolism

  1. Avoid in severe liver disease or Cirrhosis (increased Bioavailability and decreased clearance)
  2. Avoid in Renal Failure (accumulation of renally cleared metabolites)

VI. Advantages

  1. Compared with other Hydromorphone or Oxycodone, Morphine has less stimulation of euphoria (less abuse risk)

VII. Safety

  1. Pregnancy Category C
  2. Safe in Lactation

VIII. Adverse Effects

  1. See Opioid Adverse Effect
  2. Adverse effects (Pruritus, Nausea, Hypotension) occur in 10% of patients given IV Morphine
  3. Histamine release (more than with other Opioid Analgesics)
    1. Pruritus and/or rash are common
    2. Typically not Allergic Reaction
  4. Nausea or Vomiting
    1. Consider pretreatment with Antiemetic (e.g. Ondansetron)
  5. Hypotension
    1. Consider pretreatment bolus of crystalloid (500 cc or 10-20 cc/kg NS)
  6. Oversedation
    1. Reversal: Naloxone

X. References

  1. Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
  2. Velasco and Kiel (2023) Crit Dec Emerg Med 37(1): 4-9

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Cost: Medications

morphine sulfate (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
MORPHINE SULFATE ER 10 MG CAP Generic $2.38 each
MORPHINE SULFATE ER 20 MG CAP Generic $3.29 each
MORPHINE SULFATE ER 30 MG CAP Generic $2.90 each
MORPHINE SULFATE IR 15 MG TAB Generic $0.24 each
MORPHINE SULFATE IR 30 MG TAB Generic $0.32 each
morphine (on 10/19/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
MORPHINE SULF 10 MG/5 ML SOLN Generic $0.09 per ml
MORPHINE SULF 100 MG/5 ML CONC Generic $0.43 per ml
MORPHINE SULF ER 100 MG TABLET Generic $0.81 each
MORPHINE SULF ER 15 MG TABLET Generic $0.20 each
MORPHINE SULF ER 30 MG TABLET Generic $0.31 each
MORPHINE SULF ER 60 MG TABLET Generic $0.54 each