morphine

Implementation

• High Alert: Do not confuse Avinza(morphine sulfate) with Invanz (ertapenem) or Evista (raloxifene). Do not confuse MS Contin (morphine sulfate) with Oxycontin (oxycodone). Do not confuse morphine (non-concentrated oral liquid) with morphine (concentrated oral liquid).

• High Alert: Do not confuse morphine with hydromorphone—errors have resulted in death. Other errors associated with morphine include overdose and infusion pump miscalculations, especially in children. Consider patients' previous analgesic use and current requirements, but clarify doses that greatly exceed normal range. Have second practitioner independently check original order, dose calculations, and infusion pump settings. Use only preservative-free formulations for neonates, and for epidural and intrathecal routes in all patients.

• Explain therapeutic value of medication prior to administration to enhance the analgesic effect.

» Regularly administered doses may be more effective than prn administration. Analgesic is more effective if given before pain becomes severe.

» Coadministration with nonopioid analgesics may have additive analgesic effects and may permit lower doses.

» When transferring from other opioids or other forms of morphine to extended-release tablets, administer a total daily dose of oral morphine equivalent to previous daily dose (see Equianalgesic Dosing Guidelines) and divided every 8 hr (MS Contin), every 12 hr (Embeda, Kadian, MS Contin, Oramorph SR), every 24 hr (Kadian or Avinza).

» Morphine should be discontinued gradually to prevent withdrawal symptoms after long-term use.

• PO: Doses may be administered with food or milk to minimize GI irritation.

» Administer oral solution with properly calibrated measuring device; may be diluted in a glass of fruit juice just prior to administration to improve taste. Verify correct dose (mg) and correct volume (mL) prior to administration. Use an oral syringe when using 20 mg/mL concentration of oral solution.

» Swallow extended-release and controlled-release tablets whole; do not break, crush, dissolve, or chew (could result in rapid release and absorption of a potentially toxic dose).

» Embeda, Kadian, and Avinza capsules may be opened and the pellets sprinkled onto applesauce immediately prior to administration. Patients should rinse mouth and swallow to assure ingestion of entire dose. Pellets should not be chewed, crushed, or dissolved. Kadian capsules may also be opened and sprinkled on approximately 10 mL of water and flushed while swirling through a pre-wetted 16 French gastrostomy tube fitted with a funnel at the port end. Additional water should be used to transfer and flush any remaining pellets. Kadian should not be administered via a nasogastric tube.

• Rect: MS Contin and Oramorph SR have been administered rectally.

• IM, SC: Use IM route for repeated doses, because morphine is irritating to subcut tissues.

• pH:
4.5.

• IV:
Solution is colorless; do not administer discolored solution.

• Direct IV:

Diluent: Dilute with at least 5 mL of sterile water or 0.9% NaCl for injection.
Concentration: 0.5–5 mg/mL.

• Rate:
High Alert: Administer 2.5–15 mg over 5 min. Rapid administration may lead to increased respiratory depression, hypotension, and circulatory collapse.

• Continuous Infusion:

Diluent: May be added to D5W, D10W, 0.9% NaCl, 0.45% NaCl, Ringer's or LR, dextrose/saline solution, or dextrose/Ringer's or LR.
Concentration: 0.1–1 mg/mL or greater for continuous infusion.

• Rate:
Administer via infusion pump to control the rate. Dose should be titrated to ensure adequate pain relief without excessive sedation, respiratory depression, or hypotension. May be administered via patient-controlled analgesia (PCA) pump.

• Y-Site Compatibility:

» aldesleukin

» alfentanil

» allopurinol

» amifostine

» amikacin

» aminophylline

» amiodarone

» amsacrine

» anikinra

» anidulafungin

» argatroban

» ascorbic acid

» atracurium

» atropine

» aztreonam

» benztropine

» bivalirudin

» bleomycin

» bumetanide

» buprenorphine

» butorphanol

» calcium chloride

» calcium gluconate

» carboplatin

» carmustine

» caspofungin

» cefazolin

» cefonocid

» cefotaxime

» cefotetan

» cefoxitin

» ceftaroline

» ceftazidime

» ceftriaxone

» cefuroxime

» chloramphenicol

» chlorpromazine

» cisatracurium

» cladribine

» clindamycin

» cyanocobalamin

» cyclophosphamide

» cyclosporine

» cytarabine

» dactinomycin

» daptomycin

» dexamethasone

» dexmedetomidine

» digoxin

» diltiazem

» diphenhydramine

» dobutamine

» docetaxel

» dopamine

» doripemen

» doxacurium

» doxorubicin

» doxycycline

» enalaprilat

» ephedrine

» epinephrine

» epirubicin

» epoetin alfa

» eptifibatide

» ertapenem

» erythromycin

» esmolol

» etomidate

» etoposide

» etoposide phosphate

» famotidine

» fenoldopam

» fentanyl

» filgrastim

» fluconazole

» fludarabine

» fluorouracil

» foscarnet

» gemcitabine

» gentamicin

» glycopyrrolate

» granisetron

» heparin

» hydrocortisone

» hydromorphone

» idarubicin

» ifosfamide

» imipenem/cilastatin

» irinotecan

» isoproterenol

» kanamycin

» ketorolac

» labetalol

» lidocaine

» linezolid

» lorazepam

» magnesium sulfate

» mannitol

» mechlorethamine

» melphalan

» meperidine

» meropenem

» metaraminol

» methotrexate

» methoxamine

» methyldopate

» methylprednisolone

» metoclopramide

» metoprolol

» metronidazole

» midazolam

» milrinone

» mitoxantrone

» multivitamins

» mycophenolate

» nafcillin

» naloxone

» nicardipine

» nitroglycerin

» nitroprusside

» norepinephrine

» octreotide

» ondansetron

» oxacillin

» oxaliplatin

» oxytocin

» paclitaxel

» palonosetron

» pamidronate

» pancuronium

» pemetrexed

» penicillin G

» phenobarbital

» phentolamine

» phenylephrine

» phytonadione

» piperacillin/tazobactam

» potassium acetate

» potassium chloride

» procainamide

» prochlorperazine

» promethazine

» propranolol

» protamine

» pyridoxime

» quniupristin/dalfopristin

» ranitidine

» remifentanil

» rituximab

» rocuronium

» scopolamine

» sodium acetate

» sodium bicarbonate

» streptokinase

» succinylcholine

» sufentanil

» tacrolimus

» teniposide

» theophylline

» thiamine

» thiotepa

» ticarcillin/clavulanate

» tigecycline

» tirofiban

» tobramycin

» tolazoline

» trtimetaphan

» trimethoprim/sulfamethoxazole

» vancomycin

» vasopressin

» vecuronium

» verapamil

» vincristine

» vinorelbine

» vitamin B complex with C

» voriconazole

» warfarin

» zidovudine

» zoledronic acid

• Y-Site Incompatibility:

» amphotericin B cholesteryl

» amphotericin B colloidal

» amphotericin B lipid complex

» amphotericin B liposome

» azathioprine

» azithromycin

» dantrolene

» diazoxide

» doxorubicin liposome

» folic acid

» ganciclovir

» indomethacin

» micafungin

» pentamidine

» pentobarbital

» phenytoin

» sargramostim

» trastuzumab

• Epidural: Invert vial gently to re-suspend liposomal product immediately prior to administration; do not shake. Administer undiluted. If a lidocaine test dose is administered, flush catheter with 0.9% NaCl and wait 15 min before administration of DepoDur. Do not use an in-line filter. Do not admix or administer other medications in epidural space for 48 hr after administration. Administer within 4 hr after removing from vial. Store in refrigerator; do not freeze.