Select a medication above to begin.
morphine sulfate
generic
Black Box Warnings .
Appropriate Use
should only be prescribed by healthcare professionals knowledgeable about opioid use and how to mitigate assoc. risks; reserve opioid analgesics for pts w/ inadequate tx alternatives; ER form not indicated for prn analgesic use; proper dosing and titration essential to decr. resp. 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 pts
Addiction, Abuse, and Misuse
opioid agonist Schedule II controlled substance w/ 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 pts for misuse, abuse, and addiction
Respiratory Depression
serious, life-threatening, or fatal cases may occur even w/ recommended use, esp. during tx start or after dose incr; to decr. risk, initiate and titrate dose appropriately; instruct pts to swallow ER tabs whole; crushing, dissolving, or chewing ER tabs can cause rapid release and absorption of potentially fatal morphine dose; instruct pts to swallow ER caps whole or sprinkle contents on applesauce and swallow immed. w/o chewing; crushing, dissolving, or chewing pellets w/in ER cap can cause rapid release and absorption of potentially fatal morphine dose
Accidental Ingestion
accidental ingestion of even one dose, esp. by children, can result in fatal morphine overdose
Risks from Concomitant Use w/ Benzodiazepines, CNS Depressants
concomitant opioid use w/ benzodiazepines or other CNS depressants, incl. alcohol, may result in profound sedation, resp. depression, coma, and death; reserve concomitant use for pts w/ inadequate alternative tx options
Neonatal Opioid Withdrawal Syndrome
extended use in pregnant pts can lead to potentially life-threatening neonatal opioid withdrawal syndrome; advise pregnant pts of risks and ensure tx by neonatology experts avail. at delivery if extended opioid use required
Opioid Analgesic REMS
providers are strongly encouraged to complete risk evaluation and mitigation strategy (REMS)-compliant education program, counsel pts and/or caregivers w/ each Rx on serious risks, safe use, and importance of reading medication guide
Avoid Alcohol
instruct pts 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; SOL: 10 mg per 5 mL, 20 mg per 5 mL, 100 mg per 5 mL; SUPP: 5 mg, 10 mg, 20 mg, 30 mg; INJ: various
Special Note
- [prescribing info]
- Info: consider prescribing naloxone if risk of opioid overdose or accidental ingestion
- [formulation clarification]
- Info: morphine sulfate ER products not bioequivalent w/ Kadian; do not substitute on a mg to mg basis
pain, mod-severe acute
- [PO route, IR form]
- Dose: individualize IR dose PO q4h prn; Start: 10-30 mg IR PO q4h prn; Info: 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 pts 65 yo or older; taper dose gradually to D/C if prolonged use
- [intermittent injection]
- Dose: 2.5-10 mg SC/IM/IV q2-6h prn; Info: use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in pts 65 yo or older; taper dose by 25-50% q2-4 days to D/C if prolonged use
- [continuous IV infusion]
- Dose: 0.8-10 mg/h IV; Info: titrate to effect; use lowest effective dose, shortest effective tx duration; max 10 mg/h IV start dose in opioid-naive pts; consider higher start dose in opioid-tolerant pts; consider low start dose, titrate slowly in pts 65 yo or older; taper dose by 25-50% q2-4 days to D/C if prolonged use
- [PCA route]
- Dose: 0.5-2.5 mg IV q6-20min prn; Start: 1-5 mg IV x1; Info: basal rate for opioid-experienced pts 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 pts 65 yo or older; taper dose gradually to D/C if prolonged use
- [epidural route]
- Dose: 1-6 mg epidurally prn; Start: 3-5 mg epidurally x1; Max: 10 mg/24h; Alt: 0.1-0.7 mg/h epidurally prn; Info: use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in pts 65 yo or older; taper dose gradually to D/C if prolonged use
- [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 pts; taper dose gradually to D/C if prolonged use
pain, mod-severe chronic
- [PO route, IR form]
- Dose: individualize IR dose PO q4h prn; Start: 10-30 mg IR PO q4h prn; Info: 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 pts 65 yo or older; taper total daily dose by no more than 10-25% q2-4wk to D/C if long-term use
- [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-naive and opioid-nontolerant pts; individualize dose based on current opioid intake, see pkg insert for conversion; use lowest effective dose, shortest effective tx duration; may incr. dose q3-4 days; may open ER cap, but do not crush/chew/dissolve contents; 90 mg ER cap, 120 mg ER cap for use in opioid-tolerant pts only; taper total daily dose by no more than 10-25% q2-4wk to D/C if long-term use
- [PO route, qd-bid ER cap form]
- Dose: individualize ER dose PO q12-24h; Info: use alternative in opioid-naive pts; start 30 mg ER PO q24h in opioid-nontolerant pts; 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; may open ER cap, but do not crush/chew/dissolve contents; >60 mg/dose ER, >120 mg/day ER, 100 mg ER cap for use in opioid-tolerant pts only; taper total daily dose by no more than 10-25% q2-4wk to D/C if long-term use
- [PO route, bid-tid ER tab form]
- Dose: individualize ER dose PO q8-12h; Info: start 15 mg ER PO q8-12h in opioid-naive pts; start 15 mg ER PO q12h in opioid-nontolerant pts; 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; >60 mg/dose ER, >120 mg/day ER, 100 mg ER tab, 200 mg ER tab for use in opioid-tolerant pts only; do not cut/crush/chew/dissolve ER tab; taper total daily dose by no more than 10-25% q2-4wk to D/C if long-term use
- [intermittent injection]
- Dose: 2.5-10 mg SC/IM/IV q2-6h; Info: use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in pts 65 yo or older; taper dose by 25-50% q2-4 days to D/C if long-term use
- [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 pts; taper dose gradually to D/C if long-term use
angina, unstable (off-label)
- [2-5 mg IV q5-30min]
- Info: some pts require maint. dose 4-8 mg IV q4-6h
MI, acute (off-label)
- [2-5 mg IV q5-30min]
- Info: some pts require maint. dose 4-8 mg IV q4-6h
pulmonary edema, adjunct tx (off-label)
- [1-3 mg IV q5min]
dyspnea (off-label)
- [PO route, IR form]
- Dose: 5-10 mg IR PO q4h prn; Info: for use in palliative care; start 2.5-5 mg IR PO q4h prn in opioid-naive or opioid-nontolerant pts, may incr. dose by 25-50% q24h; individualize dose based on current opioid intake
- [parenteral route]
- Dose: 2-10 mg SC/IV q4h prn; Info: for use in palliative care; individualize dose per current opioid intake
renal dosing
- [see below]
- 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; SOL: 10 mg per 5 mL, 20 mg per 5 mL; INJ: various
Special Note
- [prescribing info]
- Info: consider prescribing naloxone if risk of opioid overdose or accidental ingestion
pain, mod-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 D/C if prolonged use
- [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 D/C if prolonged use
- [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: may start 15 mg IR PO q4h in pts >50 kg; use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if prolonged use
- [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 D/C if prolonged use
- [intermittent injection, 1-6 mo (off-label)]
- Dose: 0.1 mg/kg/dose SC/IV q6h prn; Max: 2.5 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if prolonged use
- [intermittent injection, 7 mo-12 yo (off-label)]
- Dose: 0.1-0.2 mg/kg/dose SC/IV q4h prn; Max: 2.5 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if prolonged use
- [intermittent injection, 13 yo and older (off-label)]
- Dose: 2.5-10 mg SC/IM/IV q2-6h prn; Max: 10 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if prolonged use
- [continuous IV infusion, <1 mo]
- Dose: 0.01 mg/kg/h IV; Start: 0.1 mg/kg/dose IV x1; Info: titrate to effect; use lowest effective dose, shortest effective tx duration; taper dose by 25-50% q2-4 days to D/C if prolonged use
- [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 pts; taper dose by 25-50% q2-4 days to D/C if prolonged use
- [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 pts; taper dose by 25-50% q2-4 days to D/C if prolonged use
- [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 pts; taper dose by 25-50% q2-4 days to D/C if prolonged use
- [PCA route, <50 kg (off-label)]
- Dose: 0.01-0.03 mg/kg/dose IV q6-20min prn; Start: 0.04 mg/kg/dose IV x1; Max: 0.15 mg/kg/h; Info: basal rate for opioid-experienced pts 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 D/C if prolonged use
- [PCA route, >50 kg (off-label)]
- Dose: 0.5-2.5 mg IV q6-20min prn; Start: 1-5 mg IV x1; Info: basal rate for opioid-experienced pts is up to 2 mg/h; dosing varies, refer to institution protocol; use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if prolonged use
- [epidural route, 2-12 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 D/C if prolonged use
pain, mod-severe chronic (off-label)
- [PO route, IR form, <12 mo]
- Dose: 0.08-0.2 mg/kg/dose IR PO q4h; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if long-term use
- [PO route, IR form, 12-23 mo]
- Dose: 0.2-0.4 mg/kg/dose IR PO q4h; Max: 5 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if long-term use
- [PO route, IR form, 2-12 yo]
- Dose: 0.2-0.5 mg/kg/dose IR PO q4h; Max: 5 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if long-term use
- [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; 100 mg ER tab, 200 mg ER tab for use in opioid-tolerant pts only; taper dose gradually to D/C if long-term use
- [intermittent injection, <1 mo]
- Dose: 0.025-0.05 mg/kg/dose SC/IV q6h; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if long-term use
- [intermittent injection, 1-6 mo]
- Dose: 0.1 mg/kg/dose SC/IV q6h; Max: 2.5 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if long-term use
- [intermittent injection, 7 mo-12 yo]
- Dose: 0.1-0.2 mg/kg/dose SC/IV q4h; Max: 2.5 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if long-term use
- [intermittent injection, 13 yo and older]
- Dose: 2.5-10 mg SC/IM/IV q2-6h; Max: 10 mg/dose; Info: use lowest effective dose, shortest effective tx duration; taper dose gradually to D/C if long-term use
neonatal opioid withdrawal syndrome (off-label)
- [0.08-0.2 mg/kg/dose PO q3-4h prn]
- Info: refer to institutional protocol
renal dosing
- [adjust dose amount]
- 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