Morphine precautions

List of precautions
PCA Analgesia Use in Patients with Increased Intracranial Pressure or with Head Injury Use in Chronic Pulmonary Disease Use in Hepatic or Renal Disease Use in Patients with Disorders of the Biliary Tract Use with Other Central Nervous System Depressants Carcinogenesis, Mutagenesis, Impairment of Fertility Pregnancy Category C Labor and Delivery Nursing Mothers Pediatric Use Geriatric Use

PCA Analgesia
Although self-administration of opioids by PCA may allow each patient to individually titrate to an acceptable level of analgesia, PCA administration has resulted in adverse outcomes and episodes of respiratory depression. Health care providers and family members monitoring patients receiving PCA analgesia should be instructed in the need for appropriate monitoring for excessive sedation, respiratory depression, or other adverse effects of opioid medications. Return to top

Use in Patients with Increased Intracranial Pressure or with Head Injury
Preservative-free Morphine Sulfate Injection, USP, should be used with extreme caution in patients with increased intracranial pressure or with head injury. Pupillary changes (miosis) from morphine may obscure the existence, extent, and course of intracranial pathology. Clinicians should maintain a high index of suspicion for adverse drug reactions when evaluating altered mental status in patients receiving this treatment. Return to top

Use in Chronic Pulmonary Disease
Care is urged in using this drug in patients who have a decreased respiratory reserve (e.g., emphysema, severe obesity, kyphoscoliosis, or paralysis of the phrenic nerve). Preservative-free Morphine Sulfate Injection, USP, should not be given in cases of chronic asthma, upper airway obstruction, or in any other chronic pulmonary disorder without due consideration of the known risk of acute respiratory failure following morphine administration in such patients. Return to top

Use in Hepatic or Renal Disease
The elimination half-life of morphine may be prolonged in patients with reduced metabolic rates and with hepatic and/or renal dysfunction. Hence, care should be exercised in administering morphine to patients with these conditions, since high blood morphine levels, due to reduced clearance, may take several days to develop. Return to top

Use in Patients with Disorders of the Biliary Tract
Care should be exercised in patients with disorders of the biliary tract because circulating morphine may induce smooth muscle hypertonicity resulting in biliary colic. Return to top

Use with Other Central Nervous System Depressants
The depressant effects of morphine sulfate are potentiated by the presence of other CNS depressants such as alcohol, sedatives or antihistaminics. The minimum effective dose of such agents should be chosen for patients who are receiving PCA morphine to minimize the risk of respiratory depression. Return to top

Carcinogenesis, Mutagenesis, Impairment of Fertility
Studies of morphine sulfate in animals to evaluate the carcinogenic and mutagenic potential or the effect on fertility have not been conducted. Return to top

Pregnancy Category C
Morphine sulfate is not teratogenic in rats at 35 mg/kg/day (thirty-five times the usual human dose), but does result in increased pup mortality and growth retardation at doses that narcotize the animal (> 10 mg/kg/day, ten times the usual human dose). Preservative-free Morphine Sulfate Injection should only be given to pregnant women when clearly needed and means are at hand to manage the delivery and perinatal care of the opiate-dependent infant. Return to top

Labor and Delivery
Intravenous morphine readily passes into the fetal circulation and may result in respiratory depression in the neonate. Naloxone and resuscitative equipment should be available for reversal of narcotic-induced respiratory depression in the neonate. In addition, intravenous morphine may reduce the strength, duration and frequency of uterine contraction resulting in prolonged labor. Return to top

Nursing Mothers
Morphine is excreted in maternal milk in amounts that may cause sedation of a nursing infant. Use in nursing mothers should be individualized based on the clinical situation. Return to top

Pediatric Use
Adequate studies, to establish the safety and effectiveness of PCA-administered morphine in children, have not been performed, and usage in this population is not recommended. Return to top

Geriatric Use
The pharmacodynamic effects of morphine in the aged are more variable than in the younger population. Patients will vary widely in the effective initial dose, rate of development of tolerance, and the frequency and magnitude of associated adverse effects as the dose is increased. Return to top