4/1/2019 MS Contin, Astramorph (morphine) dosing, indications, interactions, adverse effects, and more

This site is intended for healthcare professionals

morphine (Rx)
Brand and Other Names: MS Contin, Astramorph, Depodur, Duramorph, Infumorph, Kadian,
MorphaBond, Mitigo
Classes: Opioid Analgesics

Dosing & Uses

Adult Pediatric

Dosage Forms & Strengths

tablet, extended-release (MS Contin): Schedule II

15mg, 30mg, 60mg, 100mg, 200mg

tablet, extended release (abuse-deterrent): Schedule II

15mg, 30mg, 60mg (Arymo ER)

15mg, 30mg, 60mg, 100mg (MorphaBond)

capsule, morphine sulfate extended-release: Schedule II

10mg, 20mg, 30mg, 45mg, 50mg, 60mg

75mg, 80mg, 90mg, 100mg, 120mg

capsule, extended-release (Kadian): Schedule II

10mg, 20mg, 30mg, 40mg, 50mg, 60mg

70mg, 80mg, 100mg, 130mg, 150mg, 200mg

injectable suspension, extended-release, liposomal (DepoDur): Schedule II

10mg/mL

injectable solution (Duramorph): Schedule II

0.5mg/mL
1mg/mL

injectable solution, high potency (Infumorph, Mitigo): Schedule II

10mg/mL (200mg/20mL ampule)

25mg/mL (500mg/20mL ampule)

morphine sulfate, injectable solution: Schedule II

0.5mg/mL, 1mg/mL, 2mg/mL, 4mg/mL, 5mg/mL

8mg/mL, 10mg/mL, 15mg/mL, 25mg/mL, 50mg/mL

tablet, morphine sulfate immediate release : Schedule II

15mg, 30mg
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morphine sulfate, suppository: Schedule II

5mg, 10mg, 20mg, 30mg

morphine sulfate, oral solution: Schedule II

10mg/5mL; 20mg/5mL

morphine sulfate, intramuscular device

10mg/0.7mL

Acute Pain
Immediate-release tablet

Opioid-naïve patients: 15-30 mg PO q4hr PRN

Oral solution

Opioid-naïve patients: 10-20 mg PO q4hr PRN

Suppository

10-20 mg PR q4hr

Parenteral solution

SC/IM (opioid-naïve patients): 5-10 mg q4hr PRN; dose range, 5-20 mg

IV (opioid-naïve patients): 2.5-5 mg q3-4hr PRN, infused over 4-5 minutes; dose range, 4-10
mg

Preservative-free parenteral solution

Epidural injection
Single dose: 5-10 mg once daily in lumbar region
Continuous infusion: 2-4 mg IV infused over 24 hr
Intrathecal
Single dose (opioid naive patients): 0.1-0.3 mg single dose, plus available infusion of
naloxone; dosage range per manufacturer, is 0.2-1 mg/day; because repeated IT
injections are not recommended, alternative route should be used if pain recurs within
24 hours
Continuous infusion (opioid naive patients): 0 .2-1 mg on lumbar region over 24 hr
Continuous infusion (opioid tolerant): 1-10 mg over 24 hr microinfusion on lumbar
region; not to exceed 20 mg over 24 hr

Extended-release liposomal injection

DepoDur treatment of pain after major surgical procedures

After cesarean section: 10 mg as single lumbar epidural injection after umbilical cord is
clamped
Major orthopedic surgery of lower extremity: 10-15 mg as single lumbar epidural injection
before procedure
Lower abdominal or pelvic surgery: 10-15 mg as single lumbar epidural injection before
procedure; may benefit from 20 mg dose

Dosing considerations

Injection formulation not for IV administration unless opioid antagonist immediately available

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Usual dosage of IV morphine in adults, regardless of indication, is 2-10 mg/70 kg body weight
Consider lowest end of dosing range and monitor for side effects in elderly patients and those
with renal or hepatic impairment
Opioid-tolerant patients may require higher initial doses; patients are considered opioid-
tolerant if they take at least 60 mg/day PO of morphine, 30 mg/day PO of oxycodone, 12
mg/day PO of hydromorphone, or equianalgesic dose of another opioid for >1 week
PO solution: 100 mg/5 mL concentration is appropriate only for opioid-tolerant patients
Parenteral solution: IM injection is painful and has variable onset of analgesia because of
delayed onset of action and erratic absorption; repeated SC administration may cause local
tissue damage, as well as induration, irritation, and pain at injection site
Preservative-free parenteral solution: American Pain Society describes "ceiling" for analgesic
effect with dosages >0.3 mg/day and increase in adverse effects (eg, respiratory depression);
extreme caution is warranted with epidural or intrathecal administration in aged or debilitated
patients, and lower dosages are usually adequate
Extended-release liposomal injectable suspension: To be administered only in a single dose
via lumbar epidural route; not recommended for administration into thoracic or higher epidural
spaces; not to be administered IT, IV, or IM

Chronic Severe Pain

Extended-release (ER)/long-acting (LA) formulations are indicated for management of severe pain
requiring daily, around-the-clock, long-term opioid treatment for which alternative options are
inadequate

Immediate-release (IR): May also be used for management of chronic pain but require more
frequent dosing; may also be used in combination with ER/LA products for breakthrough pain

Extended-release tablet (MS Contin)

Opioid-naïve patients (as first opioid dose): Initiate with 15 mg PO q8-12hr; use of higher
starting doses in patients who are not opioid tolerant may cause fatal respiratory depression
Opioid-tolerant patients: Dose depends on daily dose of previous opioid analgesic
(individualization required for conversion)
MS Contin dose equivalent to one-half of patient's calculated 24-hr PO morphine requirement
q12hr; alternatively, dose equivalent to one-third of patient's calculated 24-hr PO morphine
requirement q8hr
Tablet must be swallowed whole and not broken, chewed, dissolved, or crushed; sudden
release of morphine content increases risk of respiratory depression and death

Extended-release capsule (Kadian)

Opioid-naive patients: Not indicated for use as initial opioid analgesic; initiate with IR
formulation, then convert to Kadian
Nonopioid-tolerant patients: 30 mg PO qDay
Opioid-tolerant patients: Dose depends on daily dose of previous opioid analgesic
(individualization required for conversion)
Kadian dose equivalent to one half of patient’s 24-hr PO morphine requirement q12hr;
alternatively, dose equivalent to patient’s 24-hr PO morphine requirement once daily
Capsule must be swallowed whole, or contents must be sprinkled on applesauce and
immediately swallowed; must not be chewed, crushed, or dissolved; sudden release of
morphine content increases risk of respiratory depression and death

Extended-release tablet, abuse deterrent (MorphaBond)

Opioid-naïve patients (as first opioid dose): 15 mg PO q12hr

Opioid-tolerant patients: Dose depends on daily dose of previous opioid analgesic
(individualization required for conversion)

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MorphaBond dose equivalent to one-half of patient's calculated 24-hr PO morphine

requirement administered q12hr
Tablet must be swallowed whole and not broken, chewed, dissolved, or crushed; sudden
release of morphine content increases risk of respiratory depression and death

Extended-release tablet, abuse-deterrent (Arymo ER)

Initial dosing
Opioid naïve patients and opioid non-tolerant patients: 15 mg PO q8-12hr
Conversion to Arymo ER
Morphine recipients: Administer one-half of 24-hr morphine requirement as Arymo ER
PO q12hr, or one-third of 24-hr morphine requirement as Arymo ER PO q8hr
Patients receiving other opioids: Discontinue all around-the-clock opioid drugs, then
initiate Arymo ER 15mg PO q8-12 hours
Arymo ER dose when converted from other opioids or parenteral morphine: Calculate
24-hr PO morphine equivalent requirement and administer one-half of that daily
equivalent as Arymo ER q12hr; alternatively, may give one-third of patient's calculated
24-hour PO morphine requirement q8hr
Methadone to morphine sulfate ER conversion: Methadone has long-half-life and may
accumulate in plasma; conversion dose may vary widely; judicious dosing and close
monitoring is warranted

High-potency injectable solution (Infumorph, Mitigo)

Treatment of intractable chronic pain

Starting dose for epidural or IT administration must be individualized on basis of in-hospital
evaluation of response to serial single-dose bolus injections using lower concentration of
preservative-free morphine solution, with close observation of analgesic efficacy and adverse
effects before surgery involving continuous microinfusion device
IT (opioid-naïve patients): 0.2-1 mg over 24 hr
IT (opioid-tolerant patients): 1-10 mg over 24 hr; caution warranted with dosages >20 mg/24
hr
Epidural (opioid-naïve patients): 3.5-7.5 mg over 24 hr
Epidural (opioid-tolerant patients) 4.5-10 mg over 24 hr

Opioid-tolerant definition

Patients who are opioid tolerant are those receiving, for 1 week or longer, at least 60 mg/day
PO morphine, 25 mcg/hr transdermal fentanyl, 30 mg/day PO oxycodone, 8 mg/day PO
hydromorphone, 25 mg/day PO oxymorphone, or an equianalgesic dose of another opioid

Limitations of use

Because of the risks of addiction, abuse, and misuse with opioids, even at recommended
doses, and because of the greater risks of overdose and death with extended-release opioid
formulations, reserve for patients whom alternative treatment options (eg, nonopioid
analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise
inadequate to provide sufficient management of pain
Not indicated for acute pain or as a PRN analgesic

Dosage Forms & Strengths

injectable solution: Schedule II

0.5mg/mL, 1mg/mL, 2mg/mL, 4mg/mL, 5mg/mL

8mg/mL, 10mg/mL, 15mg/mL, 25mg/mL, 50mg/mL

tablet, immediate release: Schedule II

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15mg, 30mg

Analgesia/Cyanotic Tetralogy of Fallot

Neonates (<30 days): 0.3-1.2 mg/kg/day IM/SC divided q4hr; 0.005-0.03 mg/kg/hr slow IV

Infants and children (PO solution): 0.2-0.5 mg/kg PO q4-6hr PRN

Infants and children (IM/SC): 0.05-0.2 mg/kg q2-4hr PRN; not to exceed 15 mg/dose

Pain

Continuous infusion: 0.025-2.6 mg/kg/hr IV; average, 0.06 mg/kg/hr

Neonates (<30 days): 0.01-0.02 mg/kg/hr by IV infusion

Postoperative pain: 0.01-0.04 mg/kg/hr by IV infusion

Sickle-cell disease, cancer: 0.04-0.07 mg/kg/hr by IV infusion

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