Morphine hydrochloride: Instructions for use: Description of the drug: Price on EUROLAB

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Manufacturers: Macfarlan Smith Limited

Active ingredients

Morphine

Disease class

Unstable angina
Fever of unknown origin
Acute pain
Constant, unrelieved pain
Trauma of unspecified location
Surgical practice

Clinical and pharmacological group

Not indicated. See instructions

Pharmacological action

Analgesic (narcotic)

Pharmacological group

Opioid narcotic analgesics

Substance-powder Morphine hydrochloride (Morphine hydrochloride)

Instructions for medical use of the drug

Description of pharmacological action

Stimulates mu, delta and kappa subtypes of opioid receptors. Inhibits the interneuronal transmission of pain impulses in the central part of the afferent pathway, reduces the emotional assessment of pain, the reaction to it, causes euphoria (mood improves, there is a feeling of mental comfort, complacency and bright prospects, regardless of the real state of affairs), which contributes to the formation of dependence (mental and physical). Reduces the excitability of the thermoregulation center, stimulates the release of vasopressin. It has virtually no effect on vascular tone. In high doses, it exhibits sedative activity, depresses the respiratory, cough and, as a rule, vomiting centers, stimulates the centers of the oculomotor (miosis) and vagus (bradycardia) nerves. Increases the tone of the smooth muscles of the gastrointestinal sphincters with a simultaneous decrease in peristalsis (locking effect). May stimulate the chemoreceptors of the vomiting center trigger zone and cause nausea and vomiting.

Indications for use

Severe pain syndrome (with myocardial infarction, unstable angina, trauma, in the postoperative period, with cancer), as an additional drug for premedication, epidural and spinal anesthesia.

Release form

powder substance; plastic bag (bag) of 1,2,3,5,10,20 and 25 kg, polypropylene container 1;

Pharmacodynamics

Pharmacokinetics

It is quickly absorbed into the blood by any route of administration (orally, subcutaneously and intramuscularly). Easily passes barriers, incl. BBB, placental (can cause depression of the respiratory center in the fetus and therefore is not used for pain relief during labor). Metabolized, forming mainly glucuronides and sulfates. Excreted by the kidneys. Small amounts are secreted by all exocrine glands. The analgesic effect develops 5–15 minutes after subcutaneous and intramuscular administration, after oral administration - after 20–30 minutes and usually lasts 4–5 hours.

Use during pregnancy

During pregnancy and during breastfeeding, use is permissible only for health reasons (respiratory depression and the development of drug dependence in the fetus and newborn are possible).

Other special occasions at reception

Restrictions on use: general severe exhaustion, attack of bronchial asthma, COPD, arrhythmia, convulsions, drug dependence (including history), alcoholism, suicidal tendencies, emotional lability, surgical interventions on the gastrointestinal tract, urinary system; hypothyroidism, severe inflammatory bowel disease, prostatic hyperplasia, urethral stenosis, liver and/or renal failure, insufficiency of the adrenal cortex, old age (the metabolism and excretion of morphine slows down, its level in the blood increases).

Contraindications for use

Hypersensitivity, depression of the respiratory center, severe depression of the central nervous system, abdominal pain of unknown etiology, brain injury, intracranial hypertension, status epilepticus, acute alcohol intoxication, delirious psychosis, pulmonary heart failure due to chronic lung diseases, arrhythmia, paralytic ileus, post-mortem condition surgical intervention on the biliary tract, simultaneous treatment with MAO inhibitors, pregnancy, lactation, children under 2 years of age; with epidural and spinal analgesia (additionally): blood coagulation disorders (including during anticoagulant therapy), infections (risk of infection entering the central nervous system).

Side effects

From the nervous system and sensory organs: dizziness, headache, asthenia, anxiety, irritability, insomnia, nightmares, confusion, hallucinations, delirium, increased intracranial pressure, paresthesia, involuntary muscle twitching, convulsions, incoordination of movements, blurred vision, nystagmus , diplopia, miosis, ringing in the ears, changes in taste; against the background of large doses - muscle rigidity (especially respiratory); in children - paradoxical arousal; physical and mental dependence (after 1–2 weeks of regular use), withdrawal syndrome. From the cardiovascular system and blood (hematopoiesis, hemostasis): tachycardia/bradycardia, palpitations, decreased/increased blood pressure, fainting. From the respiratory system: depression of the respiratory center, bronchospasm, atelectasis. From the gastrointestinal tract: nausea, vomiting, constipation/diarrhea, dry mouth, anorexia, gastralgia, spasm of the biliary tract, cholestasis; in severe inflammatory bowel diseases - intestinal atony, paralytic ileus, toxic megacolon (constipation, flatulence, nausea, stomach cramps, vomiting). From the genitourinary system: decreased diuresis, spasm of the ureters (difficulty and pain when urinating, frequent urge to urinate), spasm of the bladder sphincter, impaired outflow of urine or aggravation of this condition with prostatic hyperplasia and stenosis of the urethra, decreased libido and/or potency . Allergic reactions: wheezing, facial flushing, facial swelling, tracheal swelling, laryngospasm, chills, itching, rash, urticaria. Other: increased sweating, dysphonia, weight loss, dehydration, pain in the extremities; local reactions - hyperemia, swelling, burning at the injection site.

Directions for use and doses

SC, IM or IV. The dosage regimen is individual, doses depend on the indications, route of administration, and patient's condition. The highest daily dose for adults is 50 mg (except for incurable cancer patients, in whom it can reach 1 g/day). Frequency of administration: every 12 hours.

Overdose

Symptoms of acute and chronic overdose: cold clammy sweat, confusion, dizziness, drowsiness, decreased blood pressure, nervousness, fatigue, miosis, bradycardia, severe weakness, slow difficulty breathing, hypothermia, anxiety, dry oral mucosa, delirious psychosis, intracranial hypertension (up to cerebrovascular accident), hallucinations, muscle rigidity, convulsions, in severe cases - loss of consciousness, respiratory arrest, coma. Treatment: resuscitation measures, intravenous administration of a specific antagonist of opioid analgesics - naloxone.

Interactions with other drugs

Extends and enhances the effect of drugs that depress the activity of the central nervous system, incl. sleeping pills, sedatives, drugs for general anesthesia, anxiolytics, neuroleptics and local anesthetics. Drugs that depress the central nervous system, incl. ethanol, enhance the depressive effect and respiratory depression (muscle relaxants also act). With systematic use of barbiturates, especially phenobarbital, there is a possibility of a decrease in the severity of the analgesic effect. Caution should be used simultaneously with MAO inhibitors due to possible overexcitation or inhibition with the occurrence of hyper- or hypotensive crises (initially, to assess the effect of interaction, the dose should be reduced to 1/4 of the recommended). When taken simultaneously with beta-blockers, it is possible to increase the inhibitory effect on the central nervous system, with dopamine - a decrease in the analgesic effect of morphine, with cimetidine - increased respiratory depression, with other opioid analgesics - increased depression of the central nervous system, respiration, hypotension. Chlorpromazine enhances the sedative and analgesic effects of morphine. Phenothiazine derivatives and barbiturates enhance the hypotensive effect and increase the risk of respiratory depression. Naloxone reduces the effect of opioid analgesics, as well as the respiratory and central nervous system depression they cause. Nalorphine reverses the respiratory depression caused by morphine. Strengthens the hypotensive effect of drugs that lower blood pressure (including ganglion blockers, diuretics). Competitively inhibits the hepatic metabolism of zidovudine and reduces its clearance (increases the risk of mutual intoxication). Drugs with anticholinergic activity, antidiarrheal drugs (including loperamide) increase the risk of constipation, including intestinal obstruction, urinary retention and central nervous system depression. Reduces the effect of metoclopramide. Morphine may increase the anticoagulant activity of coumarin and other anticoagulants.

Precautions for use

Morphine should not be used in situations where paralytic ileus may occur. If there is a risk of paralytic ileus, the use of morphine should be discontinued immediately. In patients undergoing cardiac surgery or other surgery with intense pain, the use of morphine should be discontinued 24 hours before surgery. If therapy is subsequently indicated, the dosage regimen is selected taking into account the severity of the operation. If nausea and vomiting occur, a combination with a phenothiazine can be used. During the treatment period, care must be taken when driving vehicles and engaging in other potentially hazardous activities that require increased concentration of attention and speed of psychomotor reactions, and avoid the use of ethanol. The simultaneous use of other drugs acting on the central nervous system (antihistamines, hypnotics, psychotropic drugs, other painkillers) is allowed only with the permission and under the supervision of a physician. It should be kept in mind that children under 2 years of age are more sensitive to the effects of opioid analgesics and may experience paradoxical reactions.

Storage conditions

In a place protected from light, at a temperature not exceeding 25 °C.

Best before date

36 months

ATX classification:

N Nervous system

N02 Analgesics

N02A Opioids

N02AA Opium alkaloids natural

N02AA01 Morphine

Using morphine to relieve pain in a seriously ill person

Pain is one of the most severe and common symptoms experienced by palliative care patients. We often write about this on our portal. In the Pain Management section you can find a lot of materials on this topic - both for doctors and for relatives of seriously ill people. In this article, we have collected key points from the report “Using morphine to relieve pain in a seriously ill person” by British palliative medicine physician Bruce Cleminson, which he presented at the palliative care conference in Yaroslavl in 2022. We would like to thank Olga Vasilyevna Osetrova, chief physician of the Samara Hospice ANO, for her assistance in preparing the publication.

Treatment of mild, moderate and severe pain in palliative patients Tatyana Vladimirovna Kravchenko, chief freelance palliative care specialist in Moscow, talks about the features of drug therapy in palliative patients with different types of chronic pain
Tatyana Kravchenko

Anesthesia

Morphine. Figures and facts

Up to 70-80% of cancer patients receive opioid analgesics during their illness.
Non-cancer patients with serious, life-threatening illnesses often also require morphine.
Cancer patients may experience pain not only in the terminal stage of the disease: 59% receive morphine during curative therapy (intermittent pain relief) and 33% after the end of curative therapy.
In the terminal stage of the disease, morphine is required in 60-80% of patients.
Not all pain is susceptible to morphine. For example, neuropathic pain is not treatable with opioids.

general information

According to the so-called “pain ladder” of the World Health Organization, morphine belongs to the third, highest step. Unlike second-stage opioids, it does not have a “ceiling effect” - a condition where increasing the dose as pain increases does not produce the desired effect, but only leads to side effects.

Currently in Russia there are non-invasive forms of short-acting morphine (tablets in a dosage of 5-10 mg) and extended-release morphine (10, 30, 60 and 100 mg).

Titration is best done with short-acting morphine. Its action begins within an hour and continues for 4 hours. If the effect does not occur within an hour, the dose should be repeated. When titrating extended-release morphine, it takes 4 hours to see the full effect of this drug.

Extended-release drugs are recommended to be prescribed when the amount of morphine has been titrated. If only extended-release morphine is available for titration, titration will take longer.

For breakthrough pain, short-acting morphine should be prescribed in an amount of 1/6 to 1/10 of the daily dose.

“Breakthrough pain” is a new term, not a new problem. Doctor Guzel Abuzarova on the evolution of the term, characteristics of pain, diagnosis and treatment options Guzel Abuzarova

Anesthesia

Methods of taking morphine

Orally. The most preferred method because it allows the patient to maintain as much independence as possible.

Parenterally. Morphine is best administered subcutaneously. It is safer than intravenous administration. This method makes sense when the patient cannot swallow. In addition, this method allows you to double the effect (and, accordingly, halve the amount of the drug).

When administering morphine using a dosage syringe (syringe driver), the maximum effect should be achieved after 4 hours. If this does not happen, you should add a dose for breakthrough pain.

If there is no pump, you can install a butterfly needle subcutaneously and train the caregiver to administer the drug every 4 hours (6 times a day) .

The daily dose is administered using a dosing syringe continuously throughout the day. This allows you to maintain a constant level of morphine in the blood and, thus, control pain and avoid pain spikes. If there is no syringe, then injections must be done every 4 hours (6 times a day).

To extend the effect of the drug to 6 hours, you should increase the dose. Caution: This may cause side effects. For example, intoxication!

Important If morphine is given only as needed, the patient will experience frequent pain because morphine only lasts 4 hours.

For safety reasons, parenteral morphine should be started at 2.5 mg every 4 hours. However, in Russia the minimum volume of available ampoules is 10 mg. By law, the ampoule can only be used as a whole. A way out: using a siring driver.

“From that day I began to live.” about the choice between morphine and pain. Irina Novikova, a patient of the Samara hospice, talks about the fact that pain cannot be tolerated, about personal experience in dealing with pain syndrome, and myths about opioid analgesics. Irina
NovikovaOlga Osetrova

Anesthesia

Situation 1: the doctor has both short-acting morphine and long-acting (extended) morphine available.

Conduct a pain assessment.
If pain is grade 2, the recommended drug is tramadol.
After a day, reassess the pain. If there is no improvement, prescribe the maximum dose of tramadol.
If after another day there is still no improvement, prescribe morphine in a minimal dose (5 mg orally after 4 hours).
Important Switching from tramadol to morphine requires caution. Tramadol is absorbed in the intestines and converted into an active metabolite in the liver. This transformation occurs differently in different patients: in some very quickly, in others very slowly. In order not to overdose on morphine when moving from the second stage, no more than 30 mg/day should be prescribed initially.

If pain relief does not occur after dosing, add morphine (5 mg) every hour until full effect is achieved.
Reassess pain every day, changing the single/single dosage depending on the daily dosage (see How to calculate the required morphine dosage).
When pain is controlled, give half the daily dosage as extended-release morphine twice daily after 12 hours.
Maintain the option of short-acting morphine for breakthrough pain.

Situation 2 : the doctor only has short-acting morphine available.

Proceed as in the first situation, selecting the minimum effective dosage of morphine.

Reassess pain every day until pain relief is achieved.
When the pain is relieved, you need to calculate the daily dosage of morphine, a single/one-time dosage (see How to calculate the required dosage of morphine).
Maintain the option of supplementing with short-acting morphine for breakthrough pain.

Typically, the pain relief effect is achieved within two days.

Situation 3 : The doctor only has extended-release morphine available.

Webinar: Extended infusion in palliative medicine (master class) Indications for the use of infusion, demonstration of methods for conducting extended infusions in conditions of various medical equipment Arif Ibragimov

Anesthesia

Titrate the required daily amount (this takes about a week):

10 mg twice a day → reassessment of pain after 24 hours.
If there is no effect: 20 mg twice a day → reassessment of pain after 24 hours.
And so on - until the effect of anesthesia is achieved.

Situation 4 : the doctor only has parenteral morphine available (or the patient does not swallow) .

The initial single dosage is 2.5 mg subcutaneously every 4 hours, which is quite difficult to organize. For this reason, the best solution is administration using a dosage syringe (syringe driver).
Reassess pain every day until pain relief is achieved.
When the pain is relieved, you need to calculate the daily dosage of morphine, a single/one-time dosage (see How to calculate the required dosage of morphine).

How to calculate the required dose of morphine

All doses of morphine that the patient received within 24 hours must be summed up.
Divide the resulting amount by 6.
Give/administer the resulting dose every 4 hours.

Example: a patient receives 5 mg of morphine orally every 4 hours on the first day of pain relief. Over the course of 24 hours, he had to be given 12 doses. In total, he received 60 mg per day. This means that the one-time dose on the second day will be 10 mg.

Important If the amount of morphine you have given has reached 50 mg parenterally per day (or 100-120 mg orally) and it does not help, you may be treating pain that is not responsive to opioids. For example, neuropathic pain. You can read about this in the article “Factors of difficult-to-control pain.”

According to St. Christopher's Hospice, about 50% of patients require 60 mg or less of oral morphine per day.

Side effects of morphine use

Side effects of morphine and how to cope with them

Factors in difficult-to-control painPalliative medicine professor Robert Twycross explains pain assessment and relief using examples from clinical practice

Robert Twycross

Anesthesia

Morphine intoxication

A low degree of morphine intoxication manifests itself in the form of colorful dreams and mild clonic convulsions.

What to do?

Monitor symptoms of intoxication - ask the patient about dreams, find out if he often drops things.
Consider the risk of dehydration and encourage the patient to take plenty of fluids.
Check renal function, especially if the patient is receiving nonsteroidal anti-inflammatory drugs.
Important By reducing the dose of morphine due to toxicity, we cause increased pain. Discuss with the patient whether he or she will choose to endure some pain or accept the symptoms of intoxication.

To avoid toxicity, it is necessary to find the minimum effective dosage and, if necessary, reduce the dose of morphine to the minimum that relieves pain.

Shared decision-making Chief physician of the Samara Hospice ANO Olga Osetrova on how to help a seriously ill patient make a difficult choice Olga Osetrova

About palliative care

Is morphine addictive?

As a rule, addiction to morphine does not occur.

Example: A patient received morphine for 60 weeks. After radiation therapy, the dose of morphine was reduced. This was possible because the titration of morphine was done very carefully and the dosage was appropriate to the pain.

Tolerance to morphine practically does not develop. This is clearly visible in the therapy chart of one of the patients.

Timeline for morphine therapy and development of tolerance to the drug

The average dose of morphine consumption after 12 weeks and after 24 weeks is practically the same. A slight increase in the curve only indicates tumor growth, but not tolerance to the drug.

Important And remember: there is no evidence that morphine, when used correctly, reduces life expectancy.

Several articles on the topic that will be of interest to you:

Control of pain “breakthroughs” and rotation of opioids About the causes of pain breakthroughs and means to stop them. We present a fragment of the brochure for doctors “Pain management in palliative care. A practical guide for a doctor", prepared by the Vera charity foundation.

Tactics for treating the side effects of strong opioidsWhat are the side effects of strong analgesics and how to deal with them

Features of the approach to symptoms in palliative care Doctor Olga Vasilyevna Osetrova talks about what needs to be taken into account to help a patient with shortness of breath or itching, pain or constipation.
In addition to standard schemes, there are subtleties that are suggested by experience and attentiveness. The material was prepared using a grant from the President of the Russian Federation for the development of civil society provided by the Presidential Grants Foundation.

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** The Drug Directory is intended for informational purposes only. For more complete information, please refer to the manufacturer's instructions. Do not self-medicate; Before you start using Morphine hydrochloride, you should consult your doctor. EUROLAB is not responsible for the consequences caused by the use of information posted on the portal. Any information on the site does not replace medical advice and cannot serve as a guarantee of the positive effect of the drug.

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** Attention! The information presented in this medication guide is intended for medical professionals and should not be used as a basis for self-medication. The description of the drug Morphine hydrochloride is provided for informational purposes and is not intended for prescribing treatment without the participation of a doctor. Patients need to consult a specialist!

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