Morphine


Article Author:
Patrick Murphy


Article Editor:
Michael Barrett


Editors In Chief:
Patricia Maani-Fogelman
Julianne Oates


Managing Editors:
Frank Smeeks
Scott Dulebohn
Erin Hughes
Pritesh Sheth
Mark Pellegrini
James Hughes
Richard Ciresi
Phillip Hynes


Updated:
10/27/2018 12:31:44 PM

Indications

FDA-approved usage of morphine sulfate includes moderate to severe pain that may be acute or chronic. Most commonly used in pain management, morphine provides major relief to patients afflicted with pain.[1] Clinical situations that benefit greatly by medicating with morphine include management of palliative/end-of-life care, active cancer treatment, and vaso-occlusive pain during sickle cell crisis. Morphine is widely used off-label for almost any condition that causes pain. In the emergency department, morphine is given for musculoskeletal pain, abdominal pain, chest pain, arthritis and even for headaches when patients fail to respond to first and second line agents.[2] Morphine is rarely used for procedural sedation. However, for small procedures, physicians will sometimes combine a low dose of morphine with a low dose of benzodiazepine-like lorazepam. Patients that are actively having acute coronary syndrome are often given morphine in the emergency setting before going to the cath lab. Morphine to relieve pain during a myocardial infarction (MI) has been used since the early 1900s. Although, in 2005, an observational study brought up some concerns there are very few effective alternatives. It has been acknowledged that some concerns do exist. Morphine is a potent opioid; it decreases pain, which in turn leads to a decrease in the activation of the autonomic nervous system. These are desired effects when a patient is having an MI. Additionally, morphine has hemodynamic side effects that can be beneficial during an MI.[3] Morphine can decrease the heart rate, blood pressure, and venous return. Morphine has also been known to stimulate local histamine-mediated processes.[4] In theory, the combination of these can reduce myocardial oxygen demand.

Mechanism of Action

Morphine is considered the classic opioid analgesic with which other painkillers are compared. Like other medications in this class, morphine has an affinity for delta, kappa, and mu opioid receptors.[5] This drug produces the majority of its analgesic effects by binding to the mu opioid receptor within the central nervous system (CNS) and the peripheral nervous system (PNS).[6] The net effect of morphine is activation of descending inhibitory pathways of the CNS as well as inhibition of the nociceptive afferent neurons of the PNS, which leads to an overall reduction of the nociceptive transmission.

Administration

Morphine can be administered through different vehicles. It is most often administered via the following routes: orally (PO), intravenously (IV), epidural, and intrathecal. Oral formulations are available in both immediate and extended release for treatment of acute and chronic pain. Pain that is more severe and not well controlled may be managed with single or continuous doses of IV, epidural, and intrathecal formulations.[2] Infusion dosing can vary significantly between patients and is largely dependent on how naive or tolerant they are to opiates. It is interesting to point out that IV morphine formulation is also commonly given intramuscularly (IM). Morphine is also available as a suppository.[7] Morphine is widely used and abused. As a result of this, people have found ways to insufflate (snort) the medication.[8] Morphine is also available as an oral solution and can be administered sublingually. Sublingual morphine is very popular in palliative care.

Adverse Effects

Among the more common unwanted effects of morphine use is constipation. This occurs via stimulation of mu-opioid receptors on the myenteric plexus, which in turn inhibits gastric emptying and reduces peristalsis. Other common side effects include central nervous system depression, nausea, vomiting, and urinary retention. Respiratory depression is among the more serious adverse reactions with opiate use that is especially important to monitor in the post-operative patient population.[9] Other side effects that have been reported are lightheadedness, sedation, and dizziness. Patients often report nausea and vomiting, which is why in many emergency departments morphine is administered along with an antiemetic such as ondansetron.[10] Other effects include euphoria, dysphoria, agitation, dry mouth, anorexia, and biliary tract spasm, which is why some physicians will avoid morphine when patients present with right upper quadrant pain and they suspect possible biliary tract pathology. Morphine can also affect the cardiovascular system and has been reported to cause flushing, bradycardia, hypotension, and syncope. It is also important to note that patients can experience pruritis, urticaria, edema, and other skin rashes.

Contraindications

Morphine is an incredibly useful medication when used appropriately. However, in certain situations, this medication may be strongly contraindicated. Extreme caution must be used with severe cases of respiratory depression and asthma exacerbation since morphine can further decrease the respiratory drive. Additionally, morphine should be avoided in cases of previous hypersensitivity reaction and immediately discontinued in the presence of an active reaction.[11] Caution must also be used with the concurrent use of monoamine oxidase inhibitors (MAOIs) as these medications have an additive effect with morphine. This can then trigger severe hypotension, serotonin syndrome, or increase respiratory depression in patients. GI obstruction is another important contraindication.[1] It is also considered by many as a contraindication to provide opioids to individuals that have a history of substances abuse, especially if a patient has had a history of abusing opioids. Although this is a very controversial topic, most physicians would agree that pain needs to be managed.[12] However, most will agree and acknowledge that there are alternatives to opioid analgesics.

Monitoring

The efficacy and therapeutic index of morphine may be assessed with a combination of subjective and objective findings. Controlling pain, which is usually the first symptom assessed in patients, is the ultimate goal of morphin use. Other important parameters to monitor include mental status, blood pressure, respiratory drive, and abuse/overuse.[2] Although it may seem intuitive, it is also important to monitor what other medications a patient is taking. This includes but is not limited to prescription medications. All patients taking morphine should be advised to avoid any other substances that could lead to respiratory depression.[13] These medications include but are not limited to alcohol, additional opioids, benzodiazepines, and barbiturates. Patients can become apneic at lower doses if morphine is combined with any of these substances.

Toxicity

Morphine can potentially be a lethal medication when not used properly.[14] It causes a host of symptoms related to depression of the CNS. Severe respiratory depression is the most feared complication of morphine in cases of overdose. Immediate injection of naloxone is required to reverse the effects of morphine.

Enhancing Healthcare Team Outcomes

Ordering and administering morphine requires an interprofessional team of healthcare professionals that includes mostly the nurse, pharmacist, and clinician.[15] However, patients may be transferred throughout the hospital while under the effects of these medications. Morphine use, monitoring, and administration can utilize many resources including laboratory technologists, pharmacist, and a number nurses and nursing assistants. Without proper training and careful monitoring, often starting in the emergency department, patients can develop serious side effects and have adverse reactions to morphine. The clinician is responsible for coordinating the care which includes the following:

  • Ordering the drug
  • Monitoring the patient for signs and symptoms of respiratory depression[16]
  • Administering the drug
  • Consulting with the pharmacist about the use of morphine with other medications that can cause respiratory depression.
  • Consulting with a specialist if an overdose or allergic reaction occurs.
  • Consulting with the radiology if a patient has received morphine prior to imaging
  • Consulting with the cardiologist if morphine is used in a STEMI[17]

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Morphine - Questions

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Which of the following is not among the pharmacologic effects of morphine?



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Morphine is a potent painkiller but should be avoided in patients with which condition?



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Morphine may be best characterized by which of the following statements?



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To which side effect of morphine does tolerance NOT develop?



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A patient receiving intravenous morphine is particularly closely monitored for which one of the following?



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In which condition does morphine sulfate NOT have a relative contraindication?



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Histamine release is frequently seen with which opioid?



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By what factor is intravenous morphine more potent than oral morphine?



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Which clinical feature is not seen after administration of morphine?



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Which is an advantage of morphine over fentanyl?



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What is the bioavailability of oral morphine?



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Which one of the following drugs can cause the release of histamine?



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Which of the following is a precaution for morphine use?



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What medication has a more efficacious metabolite than parental drug?



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What is the most common side effect of morphine?



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Which of the following is least likely to be seen with morphine?



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Which of the following drugs decreases myocardial oxygen demand?



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Which of the following is not true about morphine?



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What schedule class is morphine classified?



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In a medical-surgical unit, the drug morphine is often given for what reason? Select all that apply.



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Morphine - References

References

Hosseininejad SM,Mohammadian Amiri M,Bozorgi F,Montazar SH,Firouzian A,Moosazadeh M,Goli Khatir I,Shahbakhti N,Darvishi-Khezri H, Does co-treatment with ultra-low-dose naloxone and morphine provide better analgesia in renal colic patients? The American journal of emergency medicine. 2018 Aug 16     [PubMed]
Barut GA,Tunç M,Şahin Ş,Ulus F,Sazak H, Effects of epidural morphine and levobupivacaine combination before incision and after incision and in the postoperative period on thoracotomy pain and stress response Turkish journal of medical sciences. 2018 Aug 16     [PubMed]
El Shora HA,El Beleehy AA,Abdelwahab AA,Ali GA,Omran TE,Hassan EA,Arafat AA, Bilateral Paravertebral Block versus Thoracic Epidural Analgesia for Pain Control Post-Cardiac Surgery: A Randomized Controlled Trial. The Thoracic and cardiovascular surgeon. 2018 Aug 16     [PubMed]
Schauer SG,Naylor JF,Maddry JK,Hinojosa-Laborde C,April MD, Trends in Prehospital Analgesia Administration by US Forces From 2007 Through 2016. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2018 Aug 17     [PubMed]
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Gomtsian L,Bannister K,Eyde N,Robles D,Dickenson AH,Porreca F,Navratilova E, Morphine effects within the rodent anterior cingulate cortex and rostral ventromedial medulla reveal separable modulation of affective and sensory qualities of acute or chronic pain. Pain. 2018 Aug 2     [PubMed]
Han L,Su Y,Xiong H,Niu X,Dang S,Du K,Li Q,Liu J,Zhang P,Li S, Oxycodone versus sufentanil in adult patient-controlled intravenous analgesia after abdominal surgery: A prospective, randomized, double-blinded, multiple-center clinical trial. Medicine. 2018 Aug     [PubMed]
Kim M,Custodio RJ,Botanas CJ,de la Peña JB,Sayson LV,Abiero A,Ryoo ZY,Cheong JH,Kim HJ, The circadian gene, Per2, influences methamphetamine sensitization and reward through the dopaminergic system in the striatum of mice. Addiction biology. 2018 Aug 9     [PubMed]
Davis MP,Pasternak G,Behm B, Treating Chronic Pain: An Overview of Clinical Studies Centered on the Buprenorphine Option. Drugs. 2018 Jul 26     [PubMed]
Briggs SB,Hafenbreidel M,Young EJ,Rumbaugh G,Miller CA, The role of nonmuscle myosin II in polydrug memories and memory reconsolidation. Learning     [PubMed]
Kim K,Zheng F,Zhan CG, Oligomerization and catalytic parameters of human UDP-glucuronosyltransferase 1A10: Expression and characterization of the recombinant protein. Drug metabolism and disposition: the biological fate of chemicals. 2018 Aug 15     [PubMed]
Gushgari AJ,Driver EM,Steele JC,Halden RU, Tracking narcotics consumption at a Southwestern U.S. university campus by wastewater-based epidemiology. Journal of hazardous materials. 2018 Jul 24     [PubMed]
Manchikanti L,Sanapati J,Benyamin RM,Atluri S,Kaye AD,Hirsch JA, Reframing the Prevention Strategies of the Opioid Crisis: Focusing on Prescription Opioids, Fentanyl, and Heroin Epidemic. Pain physician. 2018 Jul     [PubMed]
Planelles B,Margarit C,Ajo R,Sastre Y,Muriel J,Inda MD,Esteban MD,Peiró AM, Health benefits of an adverse events reporting system for chronic pain patients using long-term opioids. Acta anaesthesiologica Scandinavica. 2018 Aug 14     [PubMed]

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