morphine sulfate
presentation - what the drug is sealed in, its concentration and how it might look
Morphine Sulfate can come in many presentations, however most NHS Ambulance Services prefer the following two:
Solution for injection ampoules: morphine sulfate 10 mg/ml (morphine sulfate 10 mg per 1 ml).
Oral solution: morphine sulfate 10 mg/5 ml (morphine sulfate 2 mg per 1 ml).
INDICATIONS - reasons you should administer this drug
Pain associated with suspected myocardial infarction (analgesic of first choice).
Severe pain as a component of a balanced analgesia regimen.
Oral morphine can be used as a component of managing moderate pain.
CONTRAINDICATIONS - reasons you should not administer this drug
Children under 1 year of age.
Respiratory depression (adult <10 breaths per minute, child <20 breaths per minute).
Hypotension (actual, not estimated, systolic blood pressure <90 mmHg in adults, <80 mmHg in school children, <70 mmHg in pre-school children).
Head injury with significantly impaired level of consciousness (e.g. below P on the AVPU scale or below 9 on the GCS).
Known hypersensitivity to morphine.
Contra-indications specific to Adults at the End of Life
Once the clinician has confirmed the patient has pain and/or breathlessness, and is at the end of life, then the benefits of morphine clearly outweigh treatment-related adverse effects.
Cautions and contra-indications do not generally apply; the focus should be on symptom control for the patient to ensure a peaceful and dignified death.
It is important that palliative care specialists involved in the patient’s care should be consulted as part of the assessment process.
The use of the subcutaneous route also reduces the likelihood of some of these adverse effects
cautions - reasons that if you administer this drug you must monitor for side effects more than usual
Known severe renal or hepatic impairment – smaller doses may be used carefully and titrated to effect.
Use with extreme caution (minimal doses) during pregnancy.
NB: Not to be used for labour pain where Nitrous Oxide (Entonox®) is the analgesic of choice.
Use morphine WITH GREAT CAUTION in patients with chest injuries, particularly those with any respiratory difficulty, although if respiration is inhibited by pain, analgesia may actually improve respiratory status.
Any patients with other respiratory problems (e.g. asthma, COPD).
Head injuries:
Agitation following head injury may be due to acute brain injury, hypoxia or pain.
The decision to administer analgesia to an agitated head injured patient is a clinical one.
It is vital that if such a patient receives opioids they are closely monitored since opioids can cause disproportionate respiratory depression, which may ultimately lead to an elevated intracranial pressure through a raised arterial pCO₂.
Acute alcohol intoxication:
All opioid drugs potentiate the central nervous system depressant effects of alcohol and they should therefore be used with great caution in patients who have consumed significant quantities of alcohol.
Medications:
Prescribed antidepressants, sedatives or major tranquillisers may potentiate the respiratory and cardiovascular depressant effects of morphine.
Morphine may not be the appropriate treatment for a headache when the cause for the headache is uncertain, for example, a possible migraine. Smaller doses should be considered for patients weighing less than 50kg, and for frail and/or older patients who may be more susceptible to complications.
pharmacological action - what does it to the body and what does the body do to it?
FREC 3 and FREC 4:
Morphine is a strong opioid analgesic.
Morphine produces sedation, euphoria and analgesia; it may both depress respiration and induce hypotension.
Histamine is released following morphine administration and this may contribute to its vasodilatory effects. This may also account for the urticaria and bronchoconstriction that are sometimes seen.
FREUC 5 and L4 AAP
Pharmacokinetics:
Absorption: Given IV, so absorption is immediate and predictable.
Distribution: Widely distributed into tissues and crosses the blood–brain barrier. Highly protein-bound and fat soluble.
Metabolism: Metabolised in the liver into active and inactive metabolites.
Excretion: Excreted mainly by the kidneys. Elimination half-life is around 2–3 hours, depending on the patient
Pharmacodynamics
Morphine is a strong opioid analgesic acting mainly on opioid receptors.
Analgesia: Reduces pain by altering pain perception in the brain and spinal cord.
Sedation: Calms and relaxes the patient.
Respiratory depression: Slows the respiratory drive and reduces CO₂ response.
Cardiovascular effects: Mild vasodilation, possible drop in blood pressure.
Other effects: Nausea, vomiting, itching, pinpoint pupils, slowed gut movement.
side effects - unwanted secondary effects of this drug
Respiratory depression.
Cardiovascular depression.
Nausea and vomiting.
Drowsiness.
Pupillary constriction.
dosage and administration - how much do we give and how do we give it?
Adults:
Intravenous/intraosseous (NOT end of life):
NB: Administer by slow IV injection (rate of approximately 2 milligrams per minute, titrate to effect up to initial dose). Observe the patient for at least 5 minutes after completion of initial dose before repeating the dose if required. Smaller initial doses (e.g. 1 milligram) should be used for frail and/or older patients.
Route: IV/IO
Initial dose: Up to 10mg
Repeat dose: 2mg
Dose Interval: 5 minutes
Concentration: 10mg/10ml
Volume: Up to 10ml
Max dose: 20mg
Subcutaneous/intramuscular (NOT end of life) Route:
NB: For patients with major trauma, shock, or cardiac conditions, administer via IV/IO routes. Only administer via the subcutaneous or intramuscular route if the IV/IO routes are not accessible. For administration by the subcutaneous or intramuscular route, do not dilute the morphine, as more than 1 ml of fluid injected into the site of administration is not recommended. The effects of SC/IM morphine are evident after 15–20 minutes. Smaller initial doses (e.g. 1 milligram) should be used for frail and/or older patients.
Route: IV/IO
Initial dose: 10mg
Repeat dose: 10mg
Dose Interval: 60 minutes
Concentration: 10mg/1ml
Volume: 1ml
Max dose: 20mg
Oral (NOT end of life) Route:
NB: Only administer via the oral route in patients with major trauma, shock or cardiac conditions if the IV/IO routes are not accessible.
Route: IV/IO
Initial dose: 10mg to 20mg
Repeat dose: 20mg
Dose Interval: 60 minutes
Concentration: 10mg/5ml
Volume: 10ml
Max dose: 40mg (because it is going to go through the liver which will take approximately 50% of the drug, we double it).
Pain (End of Life) – Subcutaneous/intramuscular Route:
The subcutaneous route is the preferred route for pain management at the end of life. However, the intramuscular route can also be used. For administration by the subcutaneous or intramuscular route, do not dilute the morphine, as more than 1 ml of fluid injected into the site of administration is not recommended. The effects of SC/IM morphine are evident after 15–20 minutes.
Route: SC/IM
Initial dose: Administer prescribed dose.
Repeat dose: Seek senior clinical advice.
Dose Interval: N/A
Concentration: N/A
Volume: N/A
Max dose: N/A
Pain (End of Life) - Oral:
Route: PO.
Initial dose: Administer prescribed dose.
Repeat dose: Seek senior clinical advice.
Dose Interval: N/A
Concentration: N/A
Volume: N/A
Max dose: N/A
Breathlessness (End of Life) – Subcutaneous/intramuscular Route:
Reversible causes of breathlessness should always be considered first. Consider discussing with a senior clinician for advice and support, preferably a clinician with expertise in end of life care before administering morphine for breathlessness. Follow local pathways to access senior clinician support.
Patient at end of life, in distress, and breathless.
Patient has no anticipatory medicines in place.
You are unable to access rapid community/palliative care.
Route: PO
Initial dose: 2.5 mg to 5mg
Repeat dose: Seek senior clinical advice.
Dose Interval: N/A
Concentration: 10mg/5ml
Volume: 1.25ml to 2.5ml
Max dose: 5mg
If the patient remains breathless, consider prompt referral to community/palliative care to consider administration of appropriate medications such as subcutaneous morphine administration via a syringe driver. Follow local procedures for access to local pathways and how to access senior clinician support. Other medications may need to be administered for breathlessness and anxiety such as lorazepam, midazolam, antiemetic-haloperidol and a stimulant laxative (senna).
Children:
Please see JRCALC Page for Age guidelines.
legislation and regulations - what legal class of drug is it, who can possess it and who can give it?
Morphine sulfate is classified as a Class A drug under the Misuse of Drugs Act 1971 and placed in Schedule 2 of the Misuse of Drugs Regulations 2001. It is also a Prescription-Only Medicine and is listed for paramedic use under Schedule 17 of the Human Medicines Regulations 2012. This means morphine is:
A Controlled Drug (CD) and therefore:
Must be stored in a Controlled Drug cabinet that complies with Safe Custody Regulations (I.e. must be able to resist a sustained attack with tools for up to 5 minutes, must be in a well trafficked area and placed behind/under 3 layers of security such as CCTV, locked rooms, key pad entry etc).
All receipt, administration, and disposal must be recorded in a Controlled Drug Register.
Any remaining morphine in an opened ampoule or syringe must be denatured and wasted in the presence of a witness.
Access must be limited to authorised staff, with CD keys held securely according to organisational policy.
Routine CD stock checks and discrepancy procedures must be followed.
A Prescription-Only Medicine (POM) and therefore:
Normally requires a prescription from an authorised prescriber (doctor or independent prescribing AP).
However, morphine may also be administered under non-prescribing exemptions where legally permitted.
A Schedule 17 Paramedic Medicine and therefore:
Paramedics may legally possess and administer morphine in the course of their professional duties without an individual prescription.
Use must follow organisational CD governance, local protocols, and clinical guidelines such as JRCALC.
Additional information:
Morphine is not licensed for use in children but it’s use has been approved by the Medicines and Healthcare Products Regulatory Agency (MHRA) for ‘off label’ use. This means that it can legally be administered under these guidelines by paramedics.
SPECIAL PRECAUTIONS
Naloxone can be used to reverse morphine related respiratory or cardiovascular depression. It should be carefully titrated after assessment and appropriate management of ABC for that particular patient and situation, refer to Naloxone Hydrochloride.
Morphine frequently induces nausea or vomiting which may be potentiated by the movement of the ambulance. Titrating to the lowest dose to achieve analgesia will reduce the risk of vomiting. The use of an anti-emetic should also be considered whenever administering any opioid analgesic, refer to Ondansetron.