Morphine Sul 45mg ER Caps (24h)
WARNING: This is an opioid drug. Opioid drugs can put you at risk for drug use disorder. These can lead to overdose and death. You will be watched closely while taking this drug.Severe breathing problems may happen with this drug. The risk is highest when you first start taking this drug or any time your dose is raised. These breathing problems can be deadly. Call your doctor right away if you have slow, shallow, or trouble breathing. Even one dose of this drug may be deadly if it is taken by someone else or by accident, especially in children. If this drug is taken by someone else or by accident, get medical help right away.Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.Do not take more than what your doctor told you to take. Do not take more often or for longer than you were told. Doing any of these things may raise the chance of severe side effects.Severe side effects have happened when opioid drugs were used with benzodiazepines, alcohol, marijuana, other forms of cannabis, or street drugs. This includes severe drowsiness, breathing problems, and death. Benzodiazepines include drugs like alprazolam, diazepam, and lorazepam. If you have questions, talk with the doctor.Many drugs interact with this drug and can raise the chance of side effects like deadly breathing problems. Talk with your doctor and pharmacist to make sure it is safe to use this drug with all of your drugs.Get medical help right away if you feel very sleepy, very dizzy, or if you pass out. Caregivers or others need to get medical help right away if the patient does not respond, does not answer or react like normal, or will not wake up.If you are pregnant or plan to get pregnant, talk with your doctor right away about the benefits and risks of using this drug during pregnancy. Using this drug for a long time during pregnancy may lead to withdrawal in the newborn baby. Withdrawal in the newborn can be life-threatening if not treated.Swallow whole. Do not chew, break, crush, or dissolve before swallowing. Doing these things can cause very bad side effects and death.If you open this drug and sprinkle the contents on applesauce, do not crush or chew the pellets before swallowing. Doing so can cause severe side effects and death.Make sure you have the right drug; there is more than one strength. A lower strength may not ease pain well enough. A higher strength could lead to accidental overdose and death.Certain strengths of this drug may only be used by people who have been taking drugs like this drug and are used to their effects. The use of these strengths by people who have not been taking drugs like this drug may cause very bad and sometimes deadly breathing problems. Talk with the doctor. @ COMMON USES: It is used to manage pain when daily pain treatment is needed for a long time. It is for use when non-opioid pain drugs do not treat your pain well enough or you cannot take them.
Drug Class
Opioid Analgesic
Pharmacologic Class
Opioid Agonist
Pregnancy Category
Category C
FDA Approved
May 1996
DEA Schedule
Schedule II
Overview
What is this medicine?
Morphine Sulfate Extended-Release Capsules are a strong opioid pain medicine used to manage severe and long-lasting pain that requires around-the-clock treatment. It works by changing how your brain and nervous system respond to pain. Because it is an extended-release medicine, it releases slowly over 24 hours to provide continuous pain relief.
How to Use This Medicine
Taking Your Medication Correctly
To use this medication safely and effectively, follow your doctor's instructions carefully. Read all the information provided to you and follow the instructions closely.
Take this medication by mouth only, with or without food. If it causes stomach upset, take it with food to help minimize discomfort.
Do not inject or snort this medication, as this can lead to severe side effects, including breathing difficulties and overdose, which can be fatal.
Take your medication at the same time every day to establish a routine.
Swallow the medication whole; do not chew, break, crush, or dissolve it before swallowing, as this can cause severe side effects and death.
Important Usage Guidelines
This medication is not intended for fast pain relief or for use on an as-needed basis.
If you have not been taking medications like this one, do not use it for pain relief after surgery.
If you have difficulty swallowing the medication whole, you may sprinkle the contents on applesauce. If you do this, swallow the mixture immediately without chewing, and then rinse your mouth to ensure all the contents have been swallowed.
Administration via Feeding Tube
Some brands of this medication can be given through a specific type of feeding tube, while others cannot. Consult your pharmacist to determine if your brand can be administered this way.
Storage and Disposal
Store the medication at room temperature, protected from light and in a dry place. Avoid storing it in a bathroom.
Keep the medication in a safe location where children cannot see or reach it, and where others cannot access it. Consider using a locked box or secure area.
Keep all medications away from pets.
Missing a Dose
If you miss a dose, skip it and return to your regular dosing schedule. Do not take two doses at the same time or take extra doses.
To use this medication safely and effectively, follow your doctor's instructions carefully. Read all the information provided to you and follow the instructions closely.
Take this medication by mouth only, with or without food. If it causes stomach upset, take it with food to help minimize discomfort.
Do not inject or snort this medication, as this can lead to severe side effects, including breathing difficulties and overdose, which can be fatal.
Take your medication at the same time every day to establish a routine.
Swallow the medication whole; do not chew, break, crush, or dissolve it before swallowing, as this can cause severe side effects and death.
Important Usage Guidelines
This medication is not intended for fast pain relief or for use on an as-needed basis.
If you have not been taking medications like this one, do not use it for pain relief after surgery.
If you have difficulty swallowing the medication whole, you may sprinkle the contents on applesauce. If you do this, swallow the mixture immediately without chewing, and then rinse your mouth to ensure all the contents have been swallowed.
Administration via Feeding Tube
Some brands of this medication can be given through a specific type of feeding tube, while others cannot. Consult your pharmacist to determine if your brand can be administered this way.
Storage and Disposal
Store the medication at room temperature, protected from light and in a dry place. Avoid storing it in a bathroom.
Keep the medication in a safe location where children cannot see or reach it, and where others cannot access it. Consider using a locked box or secure area.
Keep all medications away from pets.
Missing a Dose
If you miss a dose, skip it and return to your regular dosing schedule. Do not take two doses at the same time or take extra doses.
Lifestyle & Tips
- Take exactly as prescribed; do not crush, chew, or dissolve the capsules as this can lead to a rapid release of a potentially fatal dose.
- Do not drink alcohol or use other sedating medications (like benzodiazepines, sleeping pills, or other pain medications) while taking this medicine, as it can cause severe breathing problems, coma, or death.
- Avoid driving or operating heavy machinery until you know how this medication affects you, as it can cause drowsiness and dizziness.
- Store this medication securely away from children and pets, as accidental ingestion can be fatal.
- Discuss all other medications, supplements, and herbal products you are taking with your doctor to avoid dangerous interactions.
- Be prepared for and manage constipation, which is a common side effect. Your doctor may recommend laxatives or stool softeners.
Available Forms & Alternatives
Available Strengths:
- Morphine Sulf Rect 20mg Suppository
- Morphine Sul 10mg Rect Suppository
- Morphine Sulf Rect 30mg Suppository
- Morphine Sulf Rect 5mg Suppository
- Morphine Sul 15mg ER Tabs (12h)
- Morphine Sul 30mg ER Tabs (12h)
- Morphine Sul 60mg ER Tabs (12h)
- Morphine Sulf 100mg ER Tabs (12h)
- Morphine Sulf 200mg ER Tabs (12h)
- Morphine Sul 50mg/ml Inj , 20ml
- Morphine Sul 50mg/ml Inj, 50ml
- Morphine Sul 1mg/ml Inj 10ml
- Morphine Sul 30mg Imm Rel Tab
- Morphine Sul 15mg Imm Rel Tab
- Morphine Sul 10mg/5ml(2mg/ml) Sol
- Morphine Sul 20mg/5ml(4mg/ml) Sol
- Morphine Sulf 100mg/5ml(20mg/ml)sol
- Morphine Sul 10mg/ml Inj, 1ml
- Morphine Sul 10mg ER Caps (24h)
- Morphine Sul 30mg ER Caps (24h)
- Morphine Sul 60mg ER Caps (24h)
- Morphine Sul 45mg ER Caps (24h)
- Morphine Sul 75mg ER Caps (24h)
- Morphine Sul 90mg ER Caps (24h)
- Morphine Sulf 120mg ER Caps (24h)
- Morphine Sul 80mg ER Caps (24h)
- Morphine Sul 30mg ER Caps (24h)
- Morphine Sul 20mg ER Caps(24h)
- Morphine Sul 50mg ER Caps(24h)
- Morphine Sulf 100mg ER Caps (24h)
- Morphine Sul 4mg/ml Inj, 1ml
- Morphine Sulf 100mg/5ml(20mg/ml)sol
- Morphine Sulfate 2mg/ml Inj 1ml
- Morphine Sulf Inj 4mg/ml 1ml Syr
- Morphine Sul 2mg/ml Inj 1ml
- Morphine Sul 8mg/ml Inj, 1ml
- Morphine Sul 30mg ER Tabs
- Morphine Sulfate 4mg/ml Inj, 1ml
- Morphine Sulfate 10mg/ml Inj, 1ml
- Morphine Sul 0.5mg/ml Inj, 5ml
- Morphine Sul 8mg/ml Inj, 1ml Vial
Dosing & Administration
Adult Dosing
Standard Dose:
Individualized, typically initiated with lower doses for opioid-naive patients (e.g., 15 mg every 24 hours) and titrated based on response and tolerability. 45 mg ER is for opioid-tolerant patients requiring around-the-clock pain management.
Dose Range:
15 - 1600 mg
Condition-Specific Dosing:
opioid_naive:
Initial dose 15 mg every 24 hours. Not for acute pain.
opioid_tolerant:
Convert from previous opioid regimen using equianalgesic dosing tables. Administer once every 24 hours.
Pediatric Dosing
Neonatal:
Not established
Infant:
Not established
Child:
Not established
Adolescent:
Not established
Dose Adjustments
Renal Impairment:
Mild:
Use with caution; consider dose reduction and extended dosing interval.
Moderate:
Significant dose reduction (e.g., 50%) and/or extended dosing interval (e.g., every 36-48 hours) recommended due to accumulation of active metabolite (morphine-6-glucuronide).
Severe:
Contraindicated or significant dose reduction (e.g., 75%) and extended dosing interval (e.g., every 48 hours or longer) required. Close monitoring for respiratory depression and sedation is essential.
Dialysis:
Morphine and its metabolites are dialyzable, but accumulation can still occur. Administer after dialysis and monitor closely. Consider alternative analgesics.
Hepatic Impairment:
Mild:
Use with caution; monitor for increased side effects.
Moderate:
Consider dose reduction (e.g., 25-50%) and/or extended dosing interval. Monitor closely for respiratory depression and sedation.
Severe:
Significant dose reduction (e.g., 50-75%) and extended dosing interval required. Close monitoring for respiratory depression and sedation is essential. Avoid if possible.
Pharmacology
Mechanism of Action
Morphine is an opioid agonist that acts primarily at the mu-opioid receptors in the central nervous system (CNS) and other tissues. Its analgesic effects are mediated by binding to these receptors, leading to inhibition of pain transmission, modulation of pain perception, and activation of descending inhibitory pathways. It also produces euphoria, respiratory depression, miosis, and reduced gastrointestinal motility.
Pharmacokinetics
Absorption:
Bioavailability:
20-40% (oral, due to first-pass metabolism)
Tmax:
3-6 hours (extended-release)
FoodEffect:
Food may increase the extent of absorption (AUC) and peak plasma concentrations (Cmax) of morphine ER. Administer consistently with or without food.
Distribution:
Vd:
3-4 L/kg
ProteinBinding:
30-35%
CnssPenetration:
Yes
Elimination:
HalfLife:
8-12 hours (extended-release formulation, apparent half-life)
Clearance:
Not available (highly variable)
ExcretionRoute:
Renal (primarily as glucuronide conjugates)
Unchanged:
<10% (in urine)
Pharmacodynamics
OnsetOfAction:
Not applicable for ER formulation (designed for sustained release)
PeakEffect:
Not applicable for ER formulation (designed for sustained release)
DurationOfAction:
24 hours
Safety & Warnings
BLACK BOX WARNING
RISK OF ADDICTION, ABUSE, AND MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; NEONATAL OPIOID WITHDRAWAL SYNDROME; and RISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS.
Addiction, Abuse, and Misuse: Morphine Sulfate Extended-Release Capsules expose patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient’s risk prior to prescribing Morphine Sulfate Extended-Release Capsules, and monitor all patients regularly for the development of these behaviors and conditions.
Life-Threatening Respiratory Depression: Serious, life-threatening, or fatal respiratory depression may occur with use of Morphine Sulfate Extended-Release Capsules. Monitor for respiratory depression, especially during initiation of Morphine Sulfate Extended-Release Capsules or following a dose increase.
Accidental Ingestion: Accidental ingestion of even one dose of Morphine Sulfate Extended-Release Capsules, especially by children, can result in a fatal overdose of morphine.
Neonatal Opioid Withdrawal Syndrome: Prolonged use of Morphine Sulfate Extended-Release Capsules during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available.
Risks from Concomitant Use with Benzodiazepines or Other CNS Depressants: Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation.
Addiction, Abuse, and Misuse: Morphine Sulfate Extended-Release Capsules expose patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient’s risk prior to prescribing Morphine Sulfate Extended-Release Capsules, and monitor all patients regularly for the development of these behaviors and conditions.
Life-Threatening Respiratory Depression: Serious, life-threatening, or fatal respiratory depression may occur with use of Morphine Sulfate Extended-Release Capsules. Monitor for respiratory depression, especially during initiation of Morphine Sulfate Extended-Release Capsules or following a dose increase.
Accidental Ingestion: Accidental ingestion of even one dose of Morphine Sulfate Extended-Release Capsules, especially by children, can result in a fatal overdose of morphine.
Neonatal Opioid Withdrawal Syndrome: Prolonged use of Morphine Sulfate Extended-Release Capsules during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available.
Risks from Concomitant Use with Benzodiazepines or Other CNS Depressants: Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation.
Side Effects
Urgent Side Effects: Seek Medical Help Right Away
Although rare, some people may experience severe and potentially life-threatening side effects while taking this medication. If you notice any of the following symptoms, contact your doctor immediately or seek emergency medical attention:
Signs of an allergic reaction, such as:
+ Rash or hives
+ Itching or red, swollen, blistered, or peeling skin (with or without fever)
+ Wheezing or tightness in the chest or throat
+ Difficulty breathing, swallowing, or talking
+ Unusual hoarseness or swelling of the mouth, face, lips, tongue, or throat
Signs of low blood sugar, including:
+ Dizziness or lightheadedness
+ Headache or feeling sleepy
+ Weakness, shaking, or a fast heartbeat
+ Confusion, hunger, or sweating
Severe dizziness or fainting
Chest pain or pressure, or a rapid heartbeat
Confusion or disorientation
Breathing difficulties, such as:
+ Slow or shallow breathing
+ Noisy breathing
+ Sleep apnea (breathing problems during sleep)
Seizures
Severe constipation or stomach pain, which may indicate a serious bowel problem
Depression or other mood changes
Swelling in the arms or legs
Fever, chills, or sore throat
Painful urination
Abnormal sensations, such as burning, numbness, or tingling
Serotonin syndrome, a potentially life-threatening condition that may occur when taking this medication with certain other drugs. Symptoms include:
+ Agitation or changes in balance
+ Confusion or hallucinations
+ Fever or abnormal heartbeat
+ Flushing or muscle twitching or stiffness
+ Seizures or shivering and shaking
+ Excessive sweating, diarrhea, or vomiting
+ Severe headache
Adrenal gland problems, which may occur with long-term opioid use. Symptoms include:
+ Extreme fatigue or weakness
+ Fainting or severe dizziness
+ Upset stomach, vomiting, or decreased appetite
Hormonal changes, which may occur with long-term opioid use. Symptoms include:
+ Decreased sex drive
+ Fertility problems or irregular menstrual periods
+ Ejaculation problems
Other Possible Side Effects
Most people experience few or no side effects while taking this medication. However, some common side effects may occur, including:
Dizziness, drowsiness, or fatigue
Dry mouth
Constipation, diarrhea, stomach pain, or decreased appetite
Headache
Anxiety
Excessive sweating
If you experience any of these side effects or any other unusual symptoms, contact your doctor for advice. You can also report side effects to the FDA at 1-800-332-1088 or online at https://www.fda.gov/medwatch.
Although rare, some people may experience severe and potentially life-threatening side effects while taking this medication. If you notice any of the following symptoms, contact your doctor immediately or seek emergency medical attention:
Signs of an allergic reaction, such as:
+ Rash or hives
+ Itching or red, swollen, blistered, or peeling skin (with or without fever)
+ Wheezing or tightness in the chest or throat
+ Difficulty breathing, swallowing, or talking
+ Unusual hoarseness or swelling of the mouth, face, lips, tongue, or throat
Signs of low blood sugar, including:
+ Dizziness or lightheadedness
+ Headache or feeling sleepy
+ Weakness, shaking, or a fast heartbeat
+ Confusion, hunger, or sweating
Severe dizziness or fainting
Chest pain or pressure, or a rapid heartbeat
Confusion or disorientation
Breathing difficulties, such as:
+ Slow or shallow breathing
+ Noisy breathing
+ Sleep apnea (breathing problems during sleep)
Seizures
Severe constipation or stomach pain, which may indicate a serious bowel problem
Depression or other mood changes
Swelling in the arms or legs
Fever, chills, or sore throat
Painful urination
Abnormal sensations, such as burning, numbness, or tingling
Serotonin syndrome, a potentially life-threatening condition that may occur when taking this medication with certain other drugs. Symptoms include:
+ Agitation or changes in balance
+ Confusion or hallucinations
+ Fever or abnormal heartbeat
+ Flushing or muscle twitching or stiffness
+ Seizures or shivering and shaking
+ Excessive sweating, diarrhea, or vomiting
+ Severe headache
Adrenal gland problems, which may occur with long-term opioid use. Symptoms include:
+ Extreme fatigue or weakness
+ Fainting or severe dizziness
+ Upset stomach, vomiting, or decreased appetite
Hormonal changes, which may occur with long-term opioid use. Symptoms include:
+ Decreased sex drive
+ Fertility problems or irregular menstrual periods
+ Ejaculation problems
Other Possible Side Effects
Most people experience few or no side effects while taking this medication. However, some common side effects may occur, including:
Dizziness, drowsiness, or fatigue
Dry mouth
Constipation, diarrhea, stomach pain, or decreased appetite
Headache
Anxiety
Excessive sweating
If you experience any of these side effects or any other unusual symptoms, contact your doctor for advice. You can also report side effects to the FDA at 1-800-332-1088 or online at https://www.fda.gov/medwatch.
Seek Immediate Medical Attention If You Experience:
- Slow, shallow, or difficult breathing (signs of respiratory depression)
- Extreme drowsiness or difficulty waking up
- Dizziness or lightheadedness when standing up
- Confusion or disorientation
- Severe constipation or abdominal pain
- Signs of allergic reaction (rash, itching, swelling of face/tongue/throat, severe dizziness, trouble breathing)
- Symptoms of serotonin syndrome (agitation, hallucinations, rapid heart rate, fever, sweating, shivering, muscle stiffness or twitching, loss of coordination, nausea, vomiting, diarrhea)
Before Using This Medicine
Before Taking This Medication: Important Information to Share with Your Doctor
It is essential to inform your doctor about the following:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Be sure to describe the allergic reaction you experienced.
Certain health conditions, including:
+ Respiratory problems like asthma, breathing difficulties, or sleep apnea
+ Elevated carbon dioxide levels in the blood
+ Stomach or bowel blockage or narrowing
If you have taken specific medications for depression or Parkinson's disease within the last 14 days, such as isocarboxazid, phenelzine, tranylcypromine, selegiline, or rasagiline, as this may lead to severely high blood pressure
If you are currently taking any of the following medications: buprenorphine, butorphanol, linezolid, methylene blue, nalbuphine, or pentazocine
* If you are breastfeeding, as you should not breastfeed while taking this medication
This list is not exhaustive, and it is crucial to discuss all your medications (prescription, over-the-counter, natural products, and vitamins) and health conditions with your doctor and pharmacist. They will help determine if it is safe to take this medication with your other medications and health conditions. Never start, stop, or change the dose of any medication without consulting your doctor.
It is essential to inform your doctor about the following:
Any allergies you have, including allergies to this medication, its components, or other substances, such as foods or drugs. Be sure to describe the allergic reaction you experienced.
Certain health conditions, including:
+ Respiratory problems like asthma, breathing difficulties, or sleep apnea
+ Elevated carbon dioxide levels in the blood
+ Stomach or bowel blockage or narrowing
If you have taken specific medications for depression or Parkinson's disease within the last 14 days, such as isocarboxazid, phenelzine, tranylcypromine, selegiline, or rasagiline, as this may lead to severely high blood pressure
If you are currently taking any of the following medications: buprenorphine, butorphanol, linezolid, methylene blue, nalbuphine, or pentazocine
* If you are breastfeeding, as you should not breastfeed while taking this medication
This list is not exhaustive, and it is crucial to discuss all your medications (prescription, over-the-counter, natural products, and vitamins) and health conditions with your doctor and pharmacist. They will help determine if it is safe to take this medication with your other medications and health conditions. Never start, stop, or change the dose of any medication without consulting your doctor.
Precautions & Cautions
Important Warnings and Cautions
It is essential to inform all your healthcare providers, including doctors, nurses, pharmacists, and dentists, that you are taking this medication.
Caution with Daily Activities
Until you know how this medication affects you, avoid driving and other activities that require you to be alert. To minimize the risk of dizziness or fainting, rise slowly from a sitting or lying position, and be cautious when climbing stairs.
Interactions with Other Medications
Do not take this medication with other strong pain medications or use a pain patch without first consulting your doctor.
Monitoring Your Pain
If your pain worsens, you become more sensitive to pain, or you experience new pain after taking this medication, contact your doctor immediately. Do not exceed the prescribed dose.
Tolerance and Dependence
Long-term or high-dose use of this medication may lead to tolerance, where the medication becomes less effective, and higher doses are needed to achieve the same effect. If you experience a decrease in the medication's effectiveness, consult your doctor. Do not take more than the prescribed dose. Additionally, regular use of opioid medications like this one can cause dependence. If you need to lower your dose or stop taking this medication, consult your doctor to avoid withdrawal or other severe problems. Follow your doctor's instructions carefully, and report any increased pain, mood changes, suicidal thoughts, or other adverse effects.
Allergies and Interactions
If you are allergic to sulfites, discuss this with your doctor, as some products contain sulfites. Do not consume alcohol or use products containing alcohol while taking this medication, as this can lead to unsafe and potentially fatal effects.
Seizure Risk
This medication may increase the risk of seizures, particularly in individuals with a history of seizures. Consult your doctor to determine if you are at a higher risk of seizures while taking this medication.
Special Considerations for Older Adults
If you are 65 or older, use this medication with caution, as you may be more susceptible to side effects.
It is essential to inform all your healthcare providers, including doctors, nurses, pharmacists, and dentists, that you are taking this medication.
Caution with Daily Activities
Until you know how this medication affects you, avoid driving and other activities that require you to be alert. To minimize the risk of dizziness or fainting, rise slowly from a sitting or lying position, and be cautious when climbing stairs.
Interactions with Other Medications
Do not take this medication with other strong pain medications or use a pain patch without first consulting your doctor.
Monitoring Your Pain
If your pain worsens, you become more sensitive to pain, or you experience new pain after taking this medication, contact your doctor immediately. Do not exceed the prescribed dose.
Tolerance and Dependence
Long-term or high-dose use of this medication may lead to tolerance, where the medication becomes less effective, and higher doses are needed to achieve the same effect. If you experience a decrease in the medication's effectiveness, consult your doctor. Do not take more than the prescribed dose. Additionally, regular use of opioid medications like this one can cause dependence. If you need to lower your dose or stop taking this medication, consult your doctor to avoid withdrawal or other severe problems. Follow your doctor's instructions carefully, and report any increased pain, mood changes, suicidal thoughts, or other adverse effects.
Allergies and Interactions
If you are allergic to sulfites, discuss this with your doctor, as some products contain sulfites. Do not consume alcohol or use products containing alcohol while taking this medication, as this can lead to unsafe and potentially fatal effects.
Seizure Risk
This medication may increase the risk of seizures, particularly in individuals with a history of seizures. Consult your doctor to determine if you are at a higher risk of seizures while taking this medication.
Special Considerations for Older Adults
If you are 65 or older, use this medication with caution, as you may be more susceptible to side effects.
Overdose Information
Overdose Symptoms:
- Pinpoint pupils
- Slowed or stopped breathing
- Extreme drowsiness or unresponsiveness
- Limp muscles
- Cold, clammy skin
- Bluish discoloration of lips and fingernails
- Coma
What to Do:
Seek immediate emergency medical attention. Call 911 or your local emergency number. Administer naloxone if available and trained to do so. Call 1-800-222-1222 (Poison Control Center) for additional guidance.
Drug Interactions
Major Interactions
- Benzodiazepines and other CNS depressants (e.g., other opioids, sedatives, hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, phenothiazines, alcohol): Increased risk of profound sedation, respiratory depression, coma, and death.
- Monoamine Oxidase Inhibitors (MAOIs): Concomitant use or within 14 days of MAOI discontinuation can result in severe, unpredictable, and potentially fatal reactions (e.g., serotonin syndrome, respiratory depression, coma).
- Serotonergic drugs (e.g., SSRIs, SNRIs, TCAs, triptans, mirtazapine, tramadol, fentanyl, lithium, St. John's Wort): Increased risk of serotonin syndrome.
- Mixed agonist/antagonist opioids (e.g., butorphanol, nalbuphine, pentazocine): May reduce the analgesic effect of morphine and/or precipitate withdrawal symptoms.
- Partial agonist opioids (e.g., buprenorphine): May reduce the analgesic effect of morphine and/or precipitate withdrawal symptoms.
Moderate Interactions
- Anticholinergics (e.g., atropine, scopolamine, TCAs, antihistamines): Increased risk of urinary retention and/or severe constipation, which may lead to paralytic ileus.
- Diuretics: Opioids may reduce the efficacy of diuretics by inducing the release of antidiuretic hormone.
- CYP2D6 inhibitors (e.g., quinidine, fluoxetine, paroxetine): May increase morphine exposure and effects, though morphine is not primarily metabolized by CYP2D6, its active metabolite M6G is not affected.
- CYP3A4 inhibitors/inducers: Less relevant for morphine as it is primarily metabolized by glucuronidation, not CYP3A4.
Minor Interactions
- Antihypertensives: May cause additive hypotensive effects.
Monitoring
Baseline Monitoring
Pain assessment (intensity, quality, location)
Rationale: To establish baseline pain level and guide initial dosing.
Timing: Prior to initiation of therapy
Respiratory rate and depth
Rationale: To assess baseline respiratory function and identify risk for respiratory depression.
Timing: Prior to initiation of therapy
Level of consciousness/sedation
Rationale: To assess baseline neurological status and identify risk for excessive sedation.
Timing: Prior to initiation of therapy
Bowel function
Rationale: To assess baseline and anticipate opioid-induced constipation.
Timing: Prior to initiation of therapy
Renal and hepatic function tests (CrCl, LFTs)
Rationale: To identify impairment that may necessitate dose adjustment.
Timing: Prior to initiation of therapy
Risk assessment for opioid abuse, addiction, or diversion
Rationale: To identify patients at higher risk and implement appropriate monitoring strategies.
Timing: Prior to initiation of therapy
Routine Monitoring
Pain assessment
Frequency: Regularly, at least daily during titration, then periodically (e.g., weekly/monthly) during maintenance.
Target: Acceptable pain control with tolerable side effects.
Action Threshold: Uncontrolled pain or intolerable side effects warrant dose adjustment or alternative strategies.
Respiratory rate and depth
Frequency: Frequently during initiation/titration (e.g., every 1-4 hours), then periodically during maintenance (e.g., daily or as clinically indicated).
Target: >10-12 breaths/min, regular rhythm.
Action Threshold: <10 breaths/min, shallow breathing, or signs of respiratory distress warrant immediate intervention (e.g., naloxone, respiratory support).
Level of consciousness/sedation
Frequency: Frequently during initiation/titration, then periodically during maintenance.
Target: Alert and oriented, or easily aroused.
Action Threshold: Excessive sedation (e.g., somnolence, difficult to arouse) warrants dose reduction or discontinuation.
Bowel function
Frequency: Daily
Target: Regular bowel movements (e.g., every 1-3 days).
Action Threshold: Constipation (e.g., no bowel movement for >3 days) warrants laxative intervention.
Signs of opioid abuse, addiction, or diversion
Frequency: At every visit
Target: Absence of aberrant drug-related behaviors.
Action Threshold: Presence of aberrant behaviors warrants re-evaluation of treatment plan, referral to addiction specialist, or discontinuation.
Symptom Monitoring
- Respiratory depression (slow, shallow breathing)
- Excessive sedation/drowsiness
- Dizziness/lightheadedness
- Nausea/vomiting
- Constipation
- Pruritus
- Urinary retention
- Confusion/disorientation
- Signs of opioid withdrawal (if dose reduced too quickly or discontinued)
Special Patient Groups
Pregnancy
Prolonged use during pregnancy can result in neonatal opioid withdrawal syndrome (NOWS), which may be life-threatening if not recognized and treated. Use only if the potential benefit justifies the potential risk to the fetus.
Trimester-Specific Risks:
First Trimester:
Limited data, but potential for congenital malformations with first-trimester opioid exposure is suggested by some studies, though not definitively established for morphine.
Second Trimester:
Risk of NOWS increases with prolonged use.
Third Trimester:
High risk of NOWS with prolonged use. Respiratory depression in the neonate if administered close to delivery.
Lactation
Morphine is excreted into breast milk. Monitor infants for signs of sedation, respiratory depression, and poor feeding. Consider alternative analgesics or temporary discontinuation of breastfeeding.
Infant Risk:
L3 (Moderate risk) - Potential for sedation, respiratory depression, and withdrawal symptoms in breastfed infants. Risk is higher with higher maternal doses, prolonged use, or in preterm/neonatal infants.
Pediatric Use
Safety and effectiveness have not been established in pediatric patients. Morphine ER is not recommended for use in children. Accidental ingestion by children can be fatal.
Geriatric Use
Elderly patients may be more sensitive to the analgesic and adverse effects of opioids, particularly respiratory depression. Start with lower doses and titrate slowly. Monitor closely for sedation, respiratory depression, and constipation. Renal impairment is more common in the elderly, requiring dose adjustments.
Clinical Information
Clinical Pearls
- Morphine ER is for around-the-clock pain management and is NOT for as-needed (PRN) pain relief or acute pain.
- Do not crush, chew, or dissolve the capsules; this can lead to rapid release of a potentially fatal dose.
- Always assess for opioid tolerance before initiating Morphine ER. Opioid-naive patients should start with the lowest available dose (e.g., 15 mg every 24 hours).
- Titrate dose slowly and carefully, typically no more frequently than every 3-4 days, based on patient response and tolerability.
- Be vigilant for signs of respiratory depression, especially during initiation or dose escalation. Have naloxone readily available.
- Manage opioid-induced constipation proactively with a bowel regimen.
- Educate patients and caregivers thoroughly on safe storage, administration, and disposal to prevent accidental ingestion and diversion.
- Consider the risk of drug-drug interactions, especially with other CNS depressants, and avoid concomitant use whenever possible.
Alternative Therapies
- Other extended-release opioids (e.g., oxycodone ER, hydromorphone ER, fentanyl transdermal, tapentadol ER)
- Other strong opioid analgesics (e.g., oxycodone, hydromorphone, fentanyl, methadone)
- Non-opioid analgesics for severe pain (e.g., NSAIDs, acetaminophen, gabapentinoids, antidepressants) as adjuncts or for specific pain types.
- Interventional pain management techniques (e.g., nerve blocks, spinal cord stimulation)
- Physical therapy, occupational therapy, psychological therapies (e.g., CBT)
Cost & Coverage
Average Cost:
Not available (highly variable) per capsule
Generic Available:
Yes
Insurance Coverage:
Tier 2 or 3 (generic), Tier 3 or 4 (brand)
General Drug Facts
If your symptoms or health issues persist or worsen, it is essential to contact your doctor promptly. To ensure safe use, do not share your medication with others or take someone else's medication.
This medication is accompanied by a Medication Guide, a patient fact sheet that provides crucial information. It is vital to read this guide carefully and review it again whenever your prescription is refilled. If you have any questions or concerns about this medication, consult your doctor, pharmacist, or other healthcare provider.
In the event of an overdose, a medication called naloxone can be administered to help counteract the effects. Discuss obtaining and using naloxone with your doctor or pharmacist. If an overdose is suspected, seek immediate medical attention, even if naloxone has been administered. Be prepared to provide detailed information about the overdose, including the substance taken, the amount, and the time it occurred.
This medication is accompanied by a Medication Guide, a patient fact sheet that provides crucial information. It is vital to read this guide carefully and review it again whenever your prescription is refilled. If you have any questions or concerns about this medication, consult your doctor, pharmacist, or other healthcare provider.
In the event of an overdose, a medication called naloxone can be administered to help counteract the effects. Discuss obtaining and using naloxone with your doctor or pharmacist. If an overdose is suspected, seek immediate medical attention, even if naloxone has been administered. Be prepared to provide detailed information about the overdose, including the substance taken, the amount, and the time it occurred.