Dosing & Uses
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
morphine sulfate, suppository: Schedule II
- 5mg, 10mg, 20mg, 30mg
morphine sulfate, oral solution: Schedule II
- 10mg/5mL; 20mg/5mL; 20mg/mL
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
- Oral formulation of 20 mg/mL is for use only in opioid tolerant adult patients
- Injection formulation not for IV administration unless opioid antagonist immediately available
- 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)
- 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
Dosing Considerations
Access to naloxone for opioid overdose
- Assess need for naloxone upon initiating and renewing treatment
-
Consider prescribing naloxone
- Based on patient’s risk factors for overdose (eg, concomitant use of CNS depressants, a history of opioid use disorder, prior opioid overdose); presence of risk factors should not prevent proper pain management
- Household members (including children) or other close contacts at risk for accidental ingestion or overdose
-
Consult patients and caregivers on the following:
- Availability of naloxone for emergency treatment of opioid overdose
- Ways differ on how to obtain naloxone as permitted by individual state dispensing and prescribing requirements or guidelines (eg, by prescription, directly from a pharmacist, as part of a community-based program)
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
- 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
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Contraindicated (2)
- alvimopan
alvimopan, morphine. receptor binding competition. Contraindicated. Alvimopan is contraindicated in opioid tolerant patients (ie, those who have taken therapeutic doses of opioids for >7 consecutive days immediately prior to taking alvimopan). Patients recently exposed to opioids are expected to be more sensitive to the effects of alvimopan and therefore may experience abdominal pain, nausea and vomiting, and diarrhea. No significant interaction is expected with concurrent use of opioid analgesics and alvimopan in patients who received opioid analgesics for 7 or fewer consecutive days prior to alvimopan.
- safinamide
morphine, safinamide. Either increases toxicity of the other by serotonin levels. Contraindicated. Concomitant use could result in life-threatening serotonin syndrome.
Serious - Use Alternative (49)
- artemether/lumefantrine
artemether/lumefantrine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.
- benzhydrocodone/acetaminophen
benzhydrocodone/acetaminophen, morphine. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- bremelanotide
bremelanotide will decrease the level or effect of morphine by Other (see comment). Avoid or Use Alternate Drug. Bremelanotide may slow gastric emptying and potentially reduces the rate and extent of absorption of concomitantly administered oral medications. Avoid use when taking any oral drug that is dependent on threshold concentrations for efficacy. Interactions listed are representative examples and do not include all possible clinical examples.
- buprenorphine
buprenorphine, morphine. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.
- buprenorphine buccal
buprenorphine buccal, morphine. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.
- butorphanol
butorphanol, morphine. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.
- calcium/magnesium/potassium/sodium oxybates
morphine, calcium/magnesium/potassium/sodium oxybates. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- cimetidine
cimetidine increases effects of morphine by decreasing metabolism. Avoid or Use Alternate Drug.
- citalopram
morphine, citalopram. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- clonidine
clonidine, morphine. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration enhances CNS depressant effects.
- clopidogrel
morphine will decrease the level or effect of clopidogrel by Other (see comment). Avoid or Use Alternate Drug. coadministration of opioid agonists delay and reduce absorption of clopidogrel, presumably because of slowed gastric emptying, resulting in reduced exposure to its metabolites; consider use of parenteral antiplatelet agents in acute coronary syndrome patients requiring coadministration of morphine or other opioid agonists
- desvenlafaxine
morphine and desvenlafaxine both increase serotonin levels. Avoid or Use Alternate Drug.
- diazepam intranasal
diazepam intranasal, morphine. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- eluxadoline
morphine, eluxadoline. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid coadministration with other drugs that cause constipation. Increases risk for constipation related serious adverse reactions. .
- erdafitinib
erdafitinib will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If coadministration unavoidable, separate administration by at least 6 hr before or after administration of P-gp substrates with narrow therapeutic index.
- escitalopram
morphine, escitalopram. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- fentanyl
fentanyl, morphine. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration with other CNS depressants, such as skeletal muscle relaxants, may cause respiratory depression, hypotension, profound sedation, coma, and/or death. Consider dose reduction of either or both agents to avoid serious adverse effects. Monitor for hypotension, respiratory depression, and profound sedation.
- fentanyl intranasal
fentanyl intranasal, morphine. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration with other CNS depressants, such as skeletal muscle relaxants, may cause respiratory depression, hypotension, profound sedation, coma, and/or death. Consider dose reduction of either or both agents to avoid serious adverse effects. Monitor for hypotension, respiratory depression, and profound sedation.
- fentanyl transdermal
fentanyl transdermal, morphine. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration with other CNS depressants, such as skeletal muscle relaxants, may cause respiratory depression, hypotension, profound sedation, coma, and/or death. Consider dose reduction of either or both agents to avoid serious adverse effects. Monitor for hypotension, respiratory depression, and profound sedation.
- fentanyl transmucosal
fentanyl transmucosal, morphine. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration with other CNS depressants, such as skeletal muscle relaxants, may cause respiratory depression, hypotension, profound sedation, coma, and/or death. Consider dose reduction of either or both agents to avoid serious adverse effects. Monitor for hypotension, respiratory depression, and profound sedation.
- fluoxetine
fluoxetine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.
morphine, fluoxetine. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug. - hydrocodone
hydrocodone, morphine. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- isocarboxazid
isocarboxazid and morphine both increase serotonin levels. Avoid or Use Alternate Drug.
isocarboxazid increases toxicity of morphine by unknown mechanism. Avoid or Use Alternate Drug. Risk of hypotension, hyperpyrexia, somnolence, or death; separate by 14 d. - lasmiditan
lasmiditan increases levels of morphine by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.
- linezolid
linezolid and morphine both increase serotonin levels. Avoid or Use Alternate Drug. Linezolid may increase serotonin as a result of MAO-A inhibition. If linezolid must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity. Serotonergic therapy may be resumed 24 hours after last linezolid dose or after 2 weeks of monitoring, whichever comes first.
linezolid increases toxicity of morphine by unknown mechanism. Avoid or Use Alternate Drug. Risk of hypotension, hyperpyrexia, somnolence, or death; separate by 14 d. - lumefantrine
lumefantrine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.
- methylene blue
methylene blue and morphine both increase serotonin levels. Avoid or Use Alternate Drug. Methylene blue may increase serotonin as a result of MAO-A inhibition. If methylene blue must be administered, discontinue morphine (if possible) and monitor for CNS toxicity. Morphine may be resumed 24 hours after last methylene blue dose or after 2 weeks of monitoring, whichever comes first.
- metoclopramide intranasal
morphine, metoclopramide intranasal. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Avoid use of metoclopramide intranasal or interacting drug, depending on importance of drug to patient.
- nalbuphine
nalbuphine, morphine. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.
- ozanimod
ozanimod and morphine both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Avoid or Use Alternate Drug. Because the active metabolite of ozanimod inhibits MAO-B in vitro, there is a potential for serious adverse reactions, including hypertensive crisis. Therefore, coadministration of ozanimod with drugs that can increase norepinephrine or serotonin is not recommended. Monitor for hypertension with concomitant use.
- paroxetine
paroxetine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.
morphine, paroxetine. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug. - pentazocine
pentazocine, morphine. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.
- phenelzine
phenelzine and morphine both increase serotonin levels. Avoid or Use Alternate Drug.
phenelzine increases toxicity of morphine by unknown mechanism. Avoid or Use Alternate Drug. Risk of hypotension, hyperpyrexia, somnolence, or death; separate by 14 d. - prasugrel
morphine will decrease the level or effect of prasugrel by inhibition of GI absorption. Applies only to oral form of both agents. Avoid or Use Alternate Drug. Coadministration of opioid agonists delay and reduce the absorption of prasugrel?s active metabolite presumably because of slowed gastric emptying. Consider using a parenteral antiplatelet agent in acute coronary syndrome patients requiring coadministration of morphine or other opioid agonists. Risks associated with other opioids are unknown.
- procarbazine
procarbazine increases toxicity of morphine by unknown mechanism. Avoid or Use Alternate Drug. MAOIs may potentiate CNS depression and hypotension. Do not use within 14 days of MAOI use. .
- quinidine
quinidine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.
- rasagiline
rasagiline increases toxicity of morphine by unknown mechanism. Avoid or Use Alternate Drug. May cause additive CNS depression, drowsiness, dizziness or hypotension, so use with MAOIs should be cautious; lower initial dosages of the analgesic are recommended followed by careful titration. Avoid combination within 14 days of MAOI use.
- selegiline transdermal
selegiline transdermal increases toxicity of morphine by unknown mechanism. Avoid or Use Alternate Drug. Risk of hypotension, hyperpyrexia, somnolence, or death.
- selinexor
selinexor, morphine. unspecified interaction mechanism. Avoid or Use Alternate Drug. Patients treated with selinexor may experience neurological toxicities. Avoid taking selinexor with other medications that may cause dizziness or confusion.
- sertraline
morphine, sertraline. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- sodium oxybate
morphine, sodium oxybate. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- sotorasib
sotorasib will decrease the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If use is unavoidable, refer to the prescribing information of the P-gp substrate for dosage modifications.
- sufentanil SL
sufentanil SL, morphine. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration may result in hypotension, profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- tepotinib
tepotinib will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If concomitant use unavoidable, reduce the P-gp substrate dosage if recommended in its approved product labeling.
- ticagrelor
morphine will decrease the level or effect of ticagrelor by inhibition of GI absorption. Applies only to oral form of both agents. Avoid or Use Alternate Drug. Co-administration of opioid agonists delay and reduce absorption of ticagrelor and its active metabolite presumably by slowing gastric emptying; consider the use of a parenteral anti-platelet agent in acute coronary syndrome patients requiring co-administration of opioid agonists
- tramadol
tramadol, morphine. Other (see comment). Avoid or Use Alternate Drug. Comment: Tramadol may reinitiate opiate dependence in pts. previously addicted to other opiates; it may also provoke withdrawal Sx. in pts. who are currently opiate dependent.
- tranylcypromine
tranylcypromine and morphine both increase serotonin levels. Avoid or Use Alternate Drug.
tranylcypromine increases toxicity of morphine by unknown mechanism. Avoid or Use Alternate Drug. Risk of hypotension, hyperpyrexia, somnolence, or death; separate by 14 d. - valerian
valerian and morphine both increase sedation. Avoid or Use Alternate Drug.
- vortioxetine
morphine, vortioxetine. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
Monitor Closely (256)
- 5-HTP
5-HTP and morphine both increase serotonin levels. Use Caution/Monitor.
- albuterol
morphine increases and albuterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- alfentanil
alfentanil and morphine both increase sedation. Use Caution/Monitor.
- almotriptan
almotriptan and morphine both increase serotonin levels. Use Caution/Monitor.
- alprazolam
alprazolam and morphine both increase sedation. Use Caution/Monitor.
- amiodarone
amiodarone will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- amitriptyline
morphine and amitriptyline both increase sedation. Use Caution/Monitor.
amitriptyline and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - amobarbital
amobarbital and morphine both increase sedation. Use Caution/Monitor.
- amoxapine
morphine and amoxapine both increase sedation. Use Caution/Monitor.
amoxapine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - apalutamide
apalutamide will decrease the level or effect of morphine by increasing elimination. Use Caution/Monitor. Apalutamide induces UGT and may decrease systemic exposure of drugs that are UGT substrates.
- apomorphine
morphine and apomorphine both increase sedation. Use Caution/Monitor.
- arformoterol
morphine increases and arformoterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- aripiprazole
morphine and aripiprazole both increase sedation. Use Caution/Monitor.
- armodafinil
morphine increases and armodafinil decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- asenapine
asenapine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- azelastine
azelastine and morphine both increase sedation. Use Caution/Monitor.
- baclofen
baclofen and morphine both increase sedation. Use Caution/Monitor.
- belladonna and opium
morphine and belladonna and opium both increase sedation. Use Caution/Monitor.
- benperidol
morphine and benperidol both increase sedation. Use Caution/Monitor.
- benzphetamine
morphine increases and benzphetamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- berotralstat
berotralstat will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Monitor or titrate P-gp substrate dose if coadministered.
- brexanolone
brexanolone, morphine. Either increases toxicity of the other by sedation. Use Caution/Monitor.
- brompheniramine
brompheniramine and morphine both increase sedation. Use Caution/Monitor.
- buprenorphine
buprenorphine and morphine both increase sedation. Use Caution/Monitor.
- buprenorphine buccal
buprenorphine buccal and morphine both increase sedation. Use Caution/Monitor.
- buprenorphine, long-acting injection
morphine increases toxicity of buprenorphine, long-acting injection by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of buprenorphine and benzodiazepines or other CNS depressants increases risk of adverse reactions including overdose, respiratory depression, and death. Cessation of benzodiazepines or other CNS depressants is preferred in most cases. In some cases, monitoring at a higher level of care for tapering CNS depressants may be appropriate. In others, gradually tapering a patient off of a prescribed benzodiazepine or other CNS depressant or decreasing to the lowest effective dose may be appropriate.
- bupropion
bupropion will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- buspirone
buspirone and morphine both increase serotonin levels. Modify Therapy/Monitor Closely.
- butabarbital
butabarbital and morphine both increase sedation. Use Caution/Monitor.
- butalbital
butalbital and morphine both increase sedation. Use Caution/Monitor.
- butorphanol
butorphanol and morphine both increase sedation. Use Caution/Monitor.
- caffeine
morphine increases and caffeine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- cannabidiol
cannabidiol will increase the level or effect of morphine by Other (see comment). Modify Therapy/Monitor Closely. Cannabidiol may potentially inhibit UGT2B7 activity. Consider reducing the dose when concomitantly using UGT2B7 substrates.
- captopril
morphine, captopril. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Both drugs lower blood pressure. Monitor blood ressure.
- carbinoxamine
carbinoxamine and morphine both increase sedation. Use Caution/Monitor.
- carisoprodol
carisoprodol and morphine both increase sedation. Use Caution/Monitor.
- celecoxib
celecoxib will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- chloral hydrate
chloral hydrate and morphine both increase sedation. Use Caution/Monitor.
- chlordiazepoxide
chlordiazepoxide and morphine both increase sedation. Use Caution/Monitor.
- chloroquine
chloroquine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- chlorpheniramine
chlorpheniramine and morphine both increase sedation. Use Caution/Monitor.
- chlorpromazine
morphine and chlorpromazine both increase sedation. Use Caution/Monitor.
- chlorzoxazone
chlorzoxazone and morphine both increase sedation. Use Caution/Monitor.
- cimetidine
cimetidine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- cinnarizine
cinnarizine and morphine both increase sedation. Use Caution/Monitor.
- citalopram
citalopram and morphine both increase serotonin levels. Use Caution/Monitor. Combination may increase risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions.
- clemastine
clemastine and morphine both increase sedation. Use Caution/Monitor.
- clobazam
morphine, clobazam. Other (see comment). Use Caution/Monitor. Comment: Concomitant administration can increase the potential for CNS effects (e.g., increased sedation or respiratory depression).
- clomipramine
morphine and clomipramine both increase sedation. Use Caution/Monitor.
clomipramine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - clonazepam
clonazepam and morphine both increase sedation. Use Caution/Monitor.
- clorazepate
clorazepate and morphine both increase sedation. Use Caution/Monitor.
- clozapine
morphine and clozapine both increase sedation. Use Caution/Monitor.
- cocaine
cocaine and morphine both increase serotonin levels. Use Caution/Monitor.
- codeine
codeine and morphine both increase sedation. Use Caution/Monitor.
- cyclizine
cyclizine and morphine both increase sedation. Use Caution/Monitor.
- cyclobenzaprine
cyclobenzaprine and morphine both increase sedation. Use Caution/Monitor.
- cyproheptadine
cyproheptadine and morphine both increase sedation. Use Caution/Monitor.
- dantrolene
dantrolene and morphine both increase sedation. Use Caution/Monitor.
- darifenacin
darifenacin will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- desflurane
desflurane and morphine both increase sedation. Use Caution/Monitor. Opioids may decrease MAC requirements, less inhalation anesthetic may be required.
- desipramine
morphine and desipramine both increase sedation. Use Caution/Monitor.
desipramine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - desvenlafaxine
desvenlafaxine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Desvenlafaxine inhibits CYP2D6; with higher desvenlafaxine doses (ie, 400 mg) decrease the CYP2D6 substrate dose by up to 50%; no dosage adjustment needed with desvenlafaxine doses <100 mg
- deutetrabenazine
morphine and deutetrabenazine both increase sedation. Use Caution/Monitor.
- dexchlorpheniramine
dexchlorpheniramine and morphine both increase sedation. Use Caution/Monitor.
- dexfenfluramine
morphine increases and dexfenfluramine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
dexfenfluramine and morphine both increase serotonin levels. Use Caution/Monitor. - dexmedetomidine
dexmedetomidine and morphine both increase sedation. Use Caution/Monitor.
- dexmethylphenidate
morphine increases and dexmethylphenidate decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- dextroamphetamine
morphine increases and dextroamphetamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
dextroamphetamine and morphine both increase serotonin levels. Use Caution/Monitor. - dextromethorphan
dextromethorphan and morphine both increase serotonin levels. Modify Therapy/Monitor Closely.
- dextromoramide
dextromoramide and morphine both increase sedation. Use Caution/Monitor.
- diamorphine
diamorphine and morphine both increase sedation. Use Caution/Monitor.
- diazepam
diazepam and morphine both increase sedation. Use Caution/Monitor.
- dichlorphenamide
dichlorphenamide and morphine both decrease serum potassium. Use Caution/Monitor.
- diethylpropion
morphine increases and diethylpropion decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- difenoxin hcl
difenoxin hcl and morphine both increase sedation. Use Caution/Monitor.
- dihydroergotamine
dihydroergotamine and morphine both increase serotonin levels. Use Caution/Monitor.
- dihydroergotamine intranasal
dihydroergotamine intranasal and morphine both increase serotonin levels. Use Caution/Monitor.
- dimenhydrinate
dimenhydrinate and morphine both increase sedation. Use Caution/Monitor.
- diphenhydramine
diphenhydramine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
diphenhydramine and morphine both increase sedation. Use Caution/Monitor. - diphenoxylate hcl
diphenoxylate hcl and morphine both increase sedation. Use Caution/Monitor.
- dipipanone
dipipanone and morphine both increase sedation. Use Caution/Monitor.
- dobutamine
morphine increases and dobutamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- dopamine
morphine increases and dopamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- dopexamine
morphine increases and dopexamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- dosulepin
morphine and dosulepin both increase sedation. Use Caution/Monitor.
- doxepin
morphine and doxepin both increase sedation. Use Caution/Monitor.
doxepin and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - doxylamine
doxylamine and morphine both increase sedation. Use Caution/Monitor.
- dronedarone
dronedarone will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- droperidol
morphine and droperidol both increase sedation. Use Caution/Monitor.
- duloxetine
duloxetine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
duloxetine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - elagolix
elagolix will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.
- eletriptan
eletriptan and morphine both increase serotonin levels. Use Caution/Monitor.
- eliglustat
eliglustat increases levels of morphine by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Monitor therapeutic drug concentrations, as indicated, or consider reducing the dosage of the P-gp substrate and titrate to clinical effect.
- eltrombopag
eltrombopag increases levels of morphine by decreasing metabolism. Use Caution/Monitor. UGT inhibition; significance of interaction unclear.
- ephedrine
morphine increases and ephedrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- epinephrine
morphine increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- epinephrine racemic
morphine increases and epinephrine racemic decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- ergotamine
ergotamine and morphine both increase serotonin levels. Use Caution/Monitor.
- escitalopram
escitalopram and morphine both increase serotonin levels. Modify Therapy/Monitor Closely.
- esketamine intranasal
esketamine intranasal, morphine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.
- estazolam
estazolam and morphine both increase sedation. Use Caution/Monitor.
- ethanol
morphine and ethanol both increase sedation. Use Caution/Monitor.
- etomidate
etomidate and morphine both increase sedation. Use Caution/Monitor.
- fenfluramine
morphine increases and fenfluramine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
fenfluramine and morphine both increase serotonin levels. Use Caution/Monitor. - flibanserin
morphine and flibanserin both increase sedation. Modify Therapy/Monitor Closely. Risk for sedation increased if flibanserin is coadministration with other CNS depressants.
- fluoxetine
fluoxetine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely.
- fluphenazine
morphine and fluphenazine both increase sedation. Use Caution/Monitor.
- flurazepam
flurazepam and morphine both increase sedation. Use Caution/Monitor.
- fluvoxamine
fluvoxamine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely.
- formoterol
morphine increases and formoterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- fostamatinib
fostamatinib will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Concomitant use of fostamatinib may increase concentrations of P-gp substrates. Monitor for toxicities of the P-gp substrate drug that may require dosage reduction when given concurrently with fostamatinib.
- frovatriptan
frovatriptan and morphine both increase serotonin levels. Use Caution/Monitor.
- gabapentin
gabapentin, morphine. Either increases effects of the other by Mechanism: pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of CNS depressants can result in serious, life-threatening, and fatal respiratory depression. Use lowest dose possible and monitor for respiratory depression and sedation.
gabapentin, morphine. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of CNS depressants can result in serious, life-threatening, and fatal respiratory depression. Use lowest dose possible and monitor for respiratory depression and sedation. - gabapentin enacarbil
gabapentin enacarbil, morphine. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of CNS depressants can result in serious, life-threatening, and fatal respiratory depression. Use lowest dose possible and monitor for respiratory depression and sedation.
- glecaprevir/pibrentasvir
glecaprevir/pibrentasvir will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.
- haloperidol
haloperidol will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
morphine and haloperidol both increase sedation. Use Caution/Monitor. - hydromorphone
hydromorphone and morphine both increase sedation. Use Caution/Monitor.
- hydroxyzine
hydroxyzine and morphine both increase sedation. Use Caution/Monitor.
- iloperidone
morphine and iloperidone both increase sedation. Use Caution/Monitor.
- imatinib
imatinib will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- imipramine
morphine and imipramine both increase sedation. Use Caution/Monitor.
imipramine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - isoniazid
isoniazid and morphine both increase serotonin levels. Use Caution/Monitor.
- isoproterenol
morphine increases and isoproterenol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- istradefylline
istradefylline will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Istradefylline 40 mg/day increased peak levels and AUC of P-gp substrates in clinical trials. Consider dose reduction of sensitive P-gp substrates.
- ivacaftor
ivacaftor increases levels of morphine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Ivacaftor and its M1 metabolite has the potential to inhibit P-gp; may significantly increase systemic exposure to sensitive P-gp substrates with a narrow therapeutic index.
- ketamine
ketamine and morphine both increase sedation. Use Caution/Monitor.
- ketotifen, ophthalmic
morphine and ketotifen, ophthalmic both increase sedation. Use Caution/Monitor.
- L-tryptophan
L-tryptophan and morphine both increase serotonin levels. Use Caution/Monitor.
- lasmiditan
lasmiditan, morphine. Either increases effects of the other by sedation. Use Caution/Monitor. Coadministration of lasmiditan and other CNS depressant drugs, including alcohol have not been evaluated in clinical studies. Lasmiditan may cause sedation, as well as other cognitive and/or neuropsychiatric adverse reactions.
- lemborexant
lemborexant, morphine. Either increases effects of the other by sedation. Modify Therapy/Monitor Closely. Dosage adjustment may be necessary if lemborexant is coadministered with other CNS depressants because of potentially additive effects.
- levalbuterol
morphine increases and levalbuterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- levomilnacipran
levomilnacipran and morphine both increase serotonin levels. Modify Therapy/Monitor Closely.
- levonorgestrel oral/ethinylestradiol/ferrous bisglycinate
levonorgestrel oral/ethinylestradiol/ferrous bisglycinate will decrease the level or effect of morphine by unknown mechanism. Use Caution/Monitor.
- levorphanol
levorphanol and morphine both increase sedation. Use Caution/Monitor.
- lisdexamfetamine
morphine increases and lisdexamfetamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- lithium
lithium and morphine both increase serotonin levels. Use Caution/Monitor.
- lofepramine
morphine and lofepramine both increase sedation. Use Caution/Monitor.
lofepramine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - lofexidine
morphine and lofexidine both increase sedation. Use Caution/Monitor.
- lonafarnib
lonafarnib will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Lonafarnib is a weak P-gp inhibitor. Monitor for adverse reactions if coadministered with P-gp substrates where minimal concentration changes may lead to serious or life-threatening toxicities. Reduce P-gp substrate dose if needed.
- loprazolam
loprazolam and morphine both increase sedation. Use Caution/Monitor.
- lorazepam
lorazepam and morphine both increase sedation. Use Caution/Monitor.
- lormetazepam
lormetazepam and morphine both increase sedation. Use Caution/Monitor.
- loxapine
morphine and loxapine both increase sedation. Use Caution/Monitor.
- loxapine inhaled
morphine and loxapine inhaled both increase sedation. Use Caution/Monitor.
- lsd
lsd and morphine both increase serotonin levels. Use Caution/Monitor.
- lurasidone
lurasidone, morphine. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: Potential for increased CNS depressant effects when used concurrently; monitor for increased adverse effects and toxicity.
- maprotiline
morphine and maprotiline both increase sedation. Use Caution/Monitor.
maprotiline and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - maraviroc
maraviroc will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- marijuana
marijuana will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
morphine and marijuana both increase sedation. Use Caution/Monitor. - melatonin
morphine and melatonin both increase sedation. Use Caution/Monitor.
- meperidine
meperidine and morphine both increase sedation. Use Caution/Monitor.
meperidine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - meprobamate
morphine and meprobamate both increase sedation. Use Caution/Monitor.
- metaproterenol
morphine increases and metaproterenol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- metaxalone
metaxalone and morphine both increase sedation. Use Caution/Monitor.
- methadone
methadone and morphine both increase sedation. Use Caution/Monitor.
- methamphetamine
morphine increases and methamphetamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- methocarbamol
methocarbamol and morphine both increase sedation. Use Caution/Monitor.
- methylenedioxymethamphetamine
morphine increases and methylenedioxymethamphetamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- midazolam
midazolam and morphine both increase sedation. Use Caution/Monitor.
- midazolam intranasal
midazolam intranasal, morphine. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Concomitant use of barbiturates, alcohol, or other CNS depressants may increase the risk of hypoventilation, airway obstruction, desaturation, or apnea and may contribute to profound and/or prolonged drug effect.
- midodrine
morphine increases and midodrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- milnacipran
milnacipran and morphine both increase serotonin levels. Modify Therapy/Monitor Closely.
- mirtazapine
morphine and mirtazapine both increase sedation. Use Caution/Monitor.
mirtazapine and morphine both increase serotonin levels. Use Caution/Monitor. - modafinil
morphine increases and modafinil decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- motherwort
morphine and motherwort both increase sedation. Use Caution/Monitor.
- moxonidine
morphine and moxonidine both increase sedation. Use Caution/Monitor.
- nabilone
morphine and nabilone both increase sedation. Use Caution/Monitor.
- nalbuphine
morphine and nalbuphine both increase sedation. Use Caution/Monitor.
- naratriptan
naratriptan and morphine both increase serotonin levels. Use Caution/Monitor.
- nefazodone
nefazodone and morphine both increase serotonin levels. Modify Therapy/Monitor Closely.
- nilotinib
nilotinib will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- norepinephrine
morphine increases and norepinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- nortriptyline
morphine and nortriptyline both increase sedation. Use Caution/Monitor.
nortriptyline and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - olanzapine
morphine and olanzapine both increase sedation. Use Caution/Monitor.
- oliceridine
oliceridine, morphine. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- opium tincture
morphine and opium tincture both increase sedation. Use Caution/Monitor.
- orphenadrine
orphenadrine and morphine both increase sedation. Use Caution/Monitor.
- oxazepam
oxazepam and morphine both increase sedation. Use Caution/Monitor.
- oxycodone
morphine and oxycodone both increase sedation. Use Caution/Monitor.
- oxymorphone
morphine and oxymorphone both increase sedation. Use Caution/Monitor.
- paliperidone
morphine and paliperidone both increase sedation. Use Caution/Monitor.
- papaveretum
morphine and papaveretum both increase sedation. Use Caution/Monitor.
- papaverine
morphine and papaverine both increase sedation. Use Caution/Monitor.
- parecoxib
parecoxib will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- paroxetine
paroxetine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely.
- pegvisomant
morphine decreases effects of pegvisomant by unknown mechanism. Use Caution/Monitor.
- pentazocine
morphine and pentazocine both increase sedation. Use Caution/Monitor.
morphine and pentazocine both increase serotonin levels. Use Caution/Monitor. - pentobarbital
pentobarbital and morphine both increase sedation. Use Caution/Monitor.
- perampanel
perampanel and morphine both decrease sedation. Use Caution/Monitor.
- perphenazine
perphenazine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
morphine and perphenazine both increase sedation. Use Caution/Monitor. - phendimetrazine
morphine increases and phendimetrazine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- phenobarbital
phenobarbital and morphine both increase sedation. Use Caution/Monitor.
- phentermine
morphine increases and phentermine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- phenylephrine
morphine increases and phenylephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- phenylephrine PO
morphine increases and phenylephrine PO decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor. .
- pholcodine
morphine and pholcodine both increase sedation. Use Caution/Monitor.
- pimozide
morphine and pimozide both increase sedation. Use Caution/Monitor.
- pirbuterol
morphine increases and pirbuterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- ponatinib
ponatinib increases levels of morphine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.
- pregabalin
pregabalin, morphine. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of CNS depressants can result in serious, life-threatening, and fatal respiratory depression. Use lowest dose possible and monitor for respiratory depression and sedation.
- primidone
primidone and morphine both increase sedation. Use Caution/Monitor.
- prochlorperazine
morphine and prochlorperazine both increase sedation. Use Caution/Monitor.
- promethazine
promethazine and morphine both increase sedation. Use Caution/Monitor.
- propafenone
propafenone will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- propofol
propofol and morphine both increase sedation. Use Caution/Monitor.
- propylhexedrine
morphine increases and propylhexedrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- protriptyline
morphine and protriptyline both increase sedation. Use Caution/Monitor.
protriptyline and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - quazepam
quazepam and morphine both increase sedation. Use Caution/Monitor.
- quetiapine
morphine and quetiapine both increase sedation. Use Caution/Monitor.
- quinacrine
quinacrine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- ramelteon
morphine and ramelteon both increase sedation. Use Caution/Monitor.
- ranolazine
ranolazine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- remimazolam
remimazolam, morphine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely. Coadministration may result in profound sedation, respiratory depression, coma, and/or death. Continuously monitor vital signs during sedation and recovery period if coadministered. Carefully titrate remimazolam dose if administered with opioid analgesics and/or sedative/hypnotics.
- risperidone
morphine and risperidone both increase sedation. Use Caution/Monitor.
- ritonavir
ritonavir will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- rizatriptan
rizatriptan and morphine both increase serotonin levels. Use Caution/Monitor.
- salmeterol
morphine increases and salmeterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- SAMe
morphine and SAMe both increase serotonin levels. Use Caution/Monitor.
- sarecycline
sarecycline will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Monitor for toxicities of P-gp substrates that may require dosage reduction when coadministered with P-gp inhibitors.
- scullcap
morphine and scullcap both increase sedation. Use Caution/Monitor.
- secobarbital
secobarbital and morphine both increase sedation. Use Caution/Monitor.
- selegiline
selegiline and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. Potential for increased CNS depression, drowsiness, dizziness or hypotension, so use with any MAOI should be cautious.
- selegiline transdermal
selegiline transdermal and morphine both increase serotonin levels. Modify Therapy/Monitor Closely.
- sertraline
sertraline will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
sertraline and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - sevoflurane
sevoflurane and morphine both increase sedation. Use Caution/Monitor.
- shepherd's purse
morphine and shepherd's purse both increase sedation. Use Caution/Monitor.
- St John's Wort
morphine and St John's Wort both increase serotonin levels. Modify Therapy/Monitor Closely.
- stiripentol
stiripentol will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Consider reducing the dose of P-glycoprotein (P-gp) substrates, if adverse reactions are experienced when administered concomitantly with stiripentol.
stiripentol, morphine. Either increases effects of the other by sedation. Use Caution/Monitor. Concomitant use stiripentol with other CNS depressants, including alcohol, may increase the risk of sedation and somnolence. - sufentanil
morphine and sufentanil both increase sedation. Use Caution/Monitor.
- sumatriptan
sumatriptan and morphine both increase serotonin levels. Use Caution/Monitor.
- sumatriptan intranasal
sumatriptan intranasal and morphine both increase serotonin levels. Use Caution/Monitor.
- suvorexant
suvorexant and morphine both increase sedation. Modify Therapy/Monitor Closely. Dosage adjustments of suvorexant and concomitant CNS depressants may be necessary
- tapentadol
morphine and tapentadol both increase sedation. Use Caution/Monitor.
- temazepam
temazepam and morphine both increase sedation. Use Caution/Monitor.
- tenofovir DF
tenofovir DF increases levels of morphine by decreasing renal clearance. Use Caution/Monitor. Potential for increased toxicity. .
- terbutaline
morphine increases and terbutaline decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- thioridazine
thioridazine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
morphine and thioridazine both increase sedation. Use Caution/Monitor. - thiothixene
morphine and thiothixene both increase sedation. Use Caution/Monitor.
- tipranavir
tipranavir will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- topiramate
morphine and topiramate both increase sedation. Modify Therapy/Monitor Closely.
- tramadol
morphine and tramadol both increase sedation. Use Caution/Monitor.
morphine and tramadol both increase serotonin levels. Use Caution/Monitor. - trazodone
morphine and trazodone both increase sedation. Use Caution/Monitor.
trazodone and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - triazolam
triazolam and morphine both increase sedation. Use Caution/Monitor.
- triclofos
triclofos and morphine both increase sedation. Use Caution/Monitor.
- trifluoperazine
morphine and trifluoperazine both increase sedation. Use Caution/Monitor.
- trimipramine
morphine and trimipramine both increase sedation. Use Caution/Monitor.
trimipramine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - triprolidine
triprolidine and morphine both increase sedation. Use Caution/Monitor.
- trospium chloride
morphine, trospium chloride. Either increases levels of the other by decreasing renal clearance. Use Caution/Monitor.
- tucatinib
tucatinib will increase the level or effect of morphine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Consider reducing the dosage of P-gp substrates, where minimal concentration changes may lead to serious or life-threatening toxicities.
- venlafaxine
venlafaxine will increase the level or effect of morphine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
venlafaxine and morphine both increase serotonin levels. Modify Therapy/Monitor Closely. - xylometazoline
morphine increases and xylometazoline decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- yohimbine
morphine increases and yohimbine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- ziconotide
morphine and ziconotide both increase sedation. Use Caution/Monitor.
- ziprasidone
morphine and ziprasidone both increase sedation. Use Caution/Monitor.
- zolmitriptan
zolmitriptan and morphine both increase serotonin levels. Use Caution/Monitor.
- zotepine
morphine and zotepine both increase sedation. Use Caution/Monitor.
Minor (10)
- benazepril
morphine, benazepril. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. May increase risk of hypotension.
- brimonidine
brimonidine increases effects of morphine by pharmacodynamic synergism. Minor/Significance Unknown. Increased CNS depression.
- celandine
celandine increases effects of morphine by unspecified interaction mechanism. Minor/Significance Unknown. Based on animal studies.
- dextroamphetamine
dextroamphetamine increases effects of morphine by unspecified interaction mechanism. Minor/Significance Unknown.
- eucalyptus
morphine and eucalyptus both increase sedation. Minor/Significance Unknown.
- lidocaine
lidocaine increases toxicity of morphine by pharmacodynamic synergism. Minor/Significance Unknown. Risk of increased CNS depression.
- rifabutin
rifabutin decreases levels of morphine by increasing metabolism. Minor/Significance Unknown.
- rifampin
rifampin decreases levels of morphine by increasing metabolism. Minor/Significance Unknown.
- sage
morphine and sage both increase sedation. Minor/Significance Unknown.
- ziconotide
ziconotide, morphine. Mechanism: unspecified interaction mechanism. Minor/Significance Unknown. Additive decreased GI motility. Additive analgesia. Ziconotide does NOT potentiate opioid induced respiratory depression.
Adverse Effects
>10%
Pruritus (≤80%)
Urinary retention (epidural/IT) (15-70%)
Vomiting (7-70%)
Constipation (>10%)
Headache (>10%)
Somnolence (>10%)
1-10%
Abdominal pain (5-10%)
Asthenia (5-10%)
Backache (5-10%)
Depression (5-10%)
Diarrhea (5-10%)
Dyspnea (5-10%)
Fever (5-10%)
Insomnia (5 -10% )
Loss of appetite (5-10%)
Nausea (5-10%)
Paresthesia (5-10%)
Peripheral edema (5-10%)
Rash (5-10%)
Sweating (5-10%)
Xerostomia (5-10%)
Respiratory depression (IT) (4-7%)
Anxiety (6%)
Dizziness (6%)
Abnormal liver function test results (<5%)
Amblyopia (<5%)
Hiccups (<5%)
Orthostatic hypotension (<5%)
Syncope (<5%)
Urinary retention (PO) (<5%)
<1%
Respiratory depression (epidural) (0.25-0.4% )
Frequency Not Defined
Anaphylaxis (rare )
Cardiac arrest
Circulatory depression
Finding of intracranial pressure
Ileus
Lightheadedness
Malaise
Miosis
Myoclonus
Shock
Thinking disturbances
Vertigo
Warnings
Black Box Warnings
Infumorph not recommended for single-dose intravenous, intramuscular or subcutaneous administration due to associated risk of overdosage
Improper or erroneous substitution of infumorph 200 or 500 (10-25 mg/mL, respectively for regular duramorph (0.5 or 1 mg/mL) could result in serious overdosage leading to seizures, respiratory depression and, possibly fatal outcome
Intrathecal dosage is usually 1/10 that of epidural dosage
Observe patient in a fully equipped and staffed environment for at least 24 hr after initial epidural or intrathecal dose
Naloxone injection and resuscitative equipment should be immediately available for administration, when administering duramorph or infumorph, to treat life-threatening or intolerable side effects
Inspect drug products for particular matter before opening amber ampule, and again for color after removing contents from ampule; after removal do not use unless solution is colorless or pale yellow; the 100 mg/5 mL oral solution is indicated for use in opioid tolerant patients only
Opioid analgesic risk evaluation and mitigation strategy (REMS)
- To ensure that benefits of opioid analgesics outweigh risks of addiction, abuse, and misuse, the Food and Drug Administration (FDA) has required a REMS for these products; under requirements of the REMS, drug companies with approved opioid analgesic products must make REMS-compliant education programs available to healthcare providers Healthcare providers are strongly encouraged to
Healthcare providers are strongly encouraged to
- Complete a REMS-compliant education program
- Counsel patients and/or their caregivers, with every prescription, on safe use, serious risks, storage, and disposal of these products
- Emphasize to patients and their caregivers the importance of reading the Medication Guide every time it is provided by their pharmacist
- Consider other tools to improve patient, household, and community safety
Addiction, abuse, and misuse
- Risk of opioid addiction, abuse, and misuse, which can lead to overdose and death
- Assess each patient’s risk prior to prescribing and monitor all patients regularly for the development of these behaviors or conditions
Life-threatening respiratory depression
- Serious, life-threatening, or fatal respiratory depression may occur
- Monitor for respiratory depression, especially during initiation or following a dose increase
- Instruct patients to swallow tablet/capsule whole; crushing, chewing, or dissolving can cause rapid release and absorption of a potentially fatal dose
Accidental exposure
- Accidental ingestion of even 1 dose, especially by children, can result in a fatal overdose
- Accidental skin espoxure to Duramorph, Astramorph/PF, or Infumorph should be rinsed with water; remove contaminated clothing
Neonatal opioid withdrawal syndrome
- Prolonged use 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
- Syndrome presents as irritability, hyperactivity and abnormal sleep pattern, high pitched cry, tremor, vomiting, diarrhea and failure to gain weight
- Onset, duration, and severity of neonatal opioid withdrawal syndrome vary based on the specific opioid used, duration of use, timing and amount of last maternal use, and rate of elimination of the drug by the newborn
- 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
Alcohol interaction
- Instruct patients not to consume alcoholic beverages or use alcohol-containing drug products while taking morphine due to risk of additive sedation and respiratory depression
- Coingestion of alcohol with opioid analgesics may increase plasma opioid levels and potentially result in fatal overdose
- Some long-acting products (ie, Kadian) should not be administered with alcoholic beverages or ethanol-containing products as it may alter the characteristics of the extended-release product and cause rapid release and absorption of a potentially fatal dose
Central nervous system (CNS) depressants
- Coadministration with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death
- Reserve concomitant prescribing for use in patients for whom alternative treatment options are inadequate; limit dosages and durations to the minimum required; and follow patients for signs and symptoms of respiratory depression and sedation
- Instruct patients not to consume alcoholic beverages or use alcohol-containing drug products while taking morphine due to risk of additive sedation and respiratory depression
Contraindications
Hypersensitivity
Paralytic ileus
Toxin-mediated diarrhea
Respiratory depression, acute or severe bronchial asthma, upper airway obstruction
Within 2 weeks of monoamine oxidase inhibitor (MAOI) therapy
GI obstruction (extended release)
Hypercarbia (immediate release tablets/solution)
Upper airway obstruction (epidural/intrathecal)
Heart failure due to chronic lung disease, head injuries, brain tumors, deliriums tremens, seizure disorders, during labor when premature birth anticipated (injectable formulation)
Cardiac arrhythmia, increased intracranial or cerebrospinal pressure, acute alcoholism, use after biliary tract surgery, surgical anastomosis (suppository formulcation)
Cautions
Use with caution in acute pancreatitis, Addison disease, benign prostatic hyperplasia, cardiac arrhythmias, central nervous system (CNS) depression, drug abuse or dependence, emotional lability, gallbladder disease, gastrointestinal (GI) disorder, morbidly obese patients, patients with urinary stricture, pseudomembranous colitis, GI surgery, head injury, hypothyroidism or untreated myxedema, intracranial hypertension, brain tumor, toxic psychosis, urethral stricture, urinary tract surgery, seizures, acute alcoholism, delirium tremens, shock, cor pulmonale, chronic pulmonary disease, emphysema, hypercapnia, kyphoscoliosis, severe obesity, renal or hepatic impairment, elderly or debilitated patients, neonates
May cause constipation; consider preventive measures (eg, stool softener, increased fiber) to reduce potential for constipation, especially in patients with unstable angina and patients with myocardial infarction
Cases of serotonin syndrome, a potentially life-threatening condition, reported with concomitant use of serotonergic drugs; this may occur within the recommended dosage range; the onset of symptoms generally occur within several hours to a few days of concomitant use, but may occur later than that; discontinue therapy immediately if serotonin syndrome is suspected
Use with caution in patients with hypersensitivity reactions to other phenanthrene derivative opioid agonists
Use with caution in patients with adrenal insufficiency, including addison's disease; chronic opioid use may cause secondary hypogonadism, which may lead to mood disorders, osteoporosis, sexual dysfunction, and infertility
Warn patients not to drive or operate dangerous machinery unless they are tolerant to effects of drug and know how they will react to medication
Use with caution in patients with biliary tract dysfunction, including acute pancreatitis; use may cause constriction of sphincter of Oddi diminishing biliary and pancreatic secretion
Therapy may cause severe hypotension including orthostatic hypotension and syncope in ambulatory patients; there is increased risk in patients whose ability to maintain blood pressure has already been compromised by a reduced blood volume or concurrent administration of certain CNS depressant drugs (e.g., phenothiazines or general anesthetics); monitor patients for signs of hypotension after initiating or titrating dosage; in patients with circulatory shock, therapy may cause vasodilation that can further reduce cardiac output and blood pressure; avoid therapy in patients with circulatory shock
Contraindicated in patients with known or suspected gastrointestinal obstruction, including paralytic ileus; may cause spasm of sphincter of Oddi; opioids may cause increases in serum amylase; monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms
In patients who may be susceptible to intracranial effects of CO2 retention (e.g., those with evidence of increased intracranial pressure or brain tumors), therapy may reduce respiratory drive, and resultant CO2 retention can further increase intracranial pressure; monitor such patients for signs of sedation and respiratory depression, particularly when initiating therapy; opioids may obscure clinical course in a patient with a head injury; avoid the use in patients with impaired consciousness or coma
Some formulations may contain sodium benzoate/benzoic acid, which have been associated with potentially fatal toxicity (gasping syndrome) in neonates
Use in patients with acute or severe bronchial asthma in an unmonitored setting or in absence of resuscitative equipment is contraindicated; patients with significant chronic obstructive pulmonary disease or cor pulmonale, and with substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression are at increased risk of decreased respiratory drive including apnea, even at recommended dosages
While serious, life-threatening, or fatal respiratory depression can occur at any time during therapy, risk is greatest during initiation of therapy or following dosage increase; monitor patients closely for respiratory depression, especially within first 24 to 72 hr of initiating therapy with and following dosage increases; accidental ingestion of even one dose, especially by children, can result in respiratory depression and death due to overdose of opioid
Opioids can cause sleep-related breathing disorders including central sleep apnea (CSA) and sleep-related hypoxemia; opioid use increases risk of CSA in a dose-dependent fashion; in patients who present with CSA, consider decreasing opioid dosage using best practices for opioid taper
Avoid use of mixed agonist/antagonist (e.g., pentazocine, nalbuphine, and butorphanol) or partial agonist (e.g., buprenorphine) analgesics in patients who are receiving a full opioid agonist analgesic; mixed agonist/antagonist and partial agonist analgesics may reduce analgesic effect and/or precipitate withdrawal symptoms; when discontinuing therapy in physically-dependent patient, gradually taper dosage; do not abruptly discontinue therapy in these patients
Due to risk of respiratory depression with concomitant use of skeletal muscle relaxants and opioids, consider prescribing naloxone for the emergency treatment of opioid overdose
Monoamine oxidase inhibitors (MAOIs) may potentiate effects of opioid, opioid’s active metabolite, including respiratory depression, coma, and confusion; therapy should not be administered within 14 days of initiating or stopping MAOIs
Cases of adrenal insufficiency reported with opioid use, more often following greater than one month of use; symptoms may include nausea, vomiting, anorexia, fatigue, weakness, dizziness, and low blood pressure; if adrenal insufficiency is diagnosed, treat with physiologic replacement doses of corticosteroids; wean patient off of opioid to allow adrenal function to recover and continue corticosteroid treatment until adrenal function recovers; other opioids may be tried as some cases reported use of a different opioid without recurrence of adrenal insufficiency
Products are designed for specific routes; use caution when prescribing, dispensing, or administering to use formulations only by intended routes
Some formulations contain sulfites, which may cause allergic reactions in sulfite sensitive patients
Kadian: Avoid concurrent consumption of alcohol or alcohol-containing foods or medications; co-ingestion results in increased plasma levels and potentially fatal overdose
May cause CNS depression and impair ability to operate heavy machinery
All formulations are capable of producing respiratory depression
Use with caution, particularly with IV administration, in patients with hypovolemia, cardiovascular disease, circulatory shock, or drugs that may exaggerate hypotensive effects, including general anesthetics and phenothiazines; may cause orthostatic hypotension and syncope in ambulatory patients
After chronic maternal exposure to opioids, neonatal withdrawal syndrome may occur in the newborn
Opioid pharmacokinetics may be altered in patients with renal failure; clearance may be decreased and metabolites may accumulate much higher plasma levels in patients with renal failure as compared to patients with normal renal function; start with a lower than normal dosage or with longer dosing intervals and titrate slowly while monitoring for signs of respiratory depression, sedation, and hypotension
Use caution when selecting dosage for an elderly patient, usually starting at low end of dosing range, reflecting greater frequency of decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy; because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and may be useful to monitor renal function
Use in patients with acute or severe bronchial asthma in an unmonitored setting or in absence of resuscitative equipment is contraindicated; patients with significant chronic obstructive pulmonary disease or cor pulmonale, and with substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression are at increased risk of decreased respiratory drive including apnea, even at recommended dosages
Therapy may increase frequency of seizures in patients with seizure disorders and in other clinical settings associated with seizures; monitor patients for worsened seizure control during therapy
May obscure diagnosis or clinical course of patients with acute abdominal conditions
Risk of seizures
- Morphine may increase frequency of seizures in patients with seizure disorders, and may increase risk of seizures occurring in other clinical settings associated with seizures
- Monitor patients with a history of seizure disorders for worsened seizure control during morphine sulfate injection therapy
- Excitation of central nervous system, resulting in convulsions, may accompany high doses of morphine given intravenously
Long-acting opioids
- Schedule II opioid analgesics expose users to the risks of addiction, abuse, and misuse; there is a greater risk for overdose and death with extended-release opioids due to the larger amount of active opioid present (see Black Box Warnings)
- Addiction, abuse, and misuse risks are increased in patients with a personal or family history of substance abuse or mental illness (eg, major depression); the potential for these risks should not, however, prevent the prescribing of proper pain management in any given patient; intensive monitoring is necessary (see Black Box Warnings)
- Serious, life-threatening, or fatal respiratory depression reported (see Black Box Warnings)
- Accidental exposure reported, including fatalities (see Black Box Warnings)
- Neonatal opioid withdrawal syndrome reported with long-term use during pregnancy (see Black Box Warnings)
- Profound sedation, respiratory depression, coma, and death may result from concomitant administration with benzodiazepines or other CNS depressants (e.g., non-benzodiazepine sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opioids, alcohol); because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate Life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients as they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients; if concomitant use with benzodiazepine warranted, consider prescribing naloxone for emergency treatment of opioid overdose
- Not indicated for PRN use
Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS)
- To ensure that benefits of opioid analgesics outweigh risks of addiction, abuse, and misuse, the Food and Drug Administration (FDA) has required a Risk Evaluation and Mitigation Strategy (REMS) for these products
- Discuss the safe use, serious risks, and proper storage and disposal of opioid analgesics with patients and/or their caregivers every time these medicines are prescribed; Use the following link to obtain the Patient Counseling Guide (PCG): www.fda.gov/OpioidAnalgesicREMSPCG
- Emphasize to patients and their caregivers the importance of reading the Medication Guide that they will receive from their pharmacist every time an opioid analgesic is dispensed to them
- Consider using other tools to improve patient, household, and community safety, such as patient-prescriber agreements that reinforce patient-prescriber responsibilities
- To obtain further information on opioid analgesic REMS and for a list of accredited REMS CME/CE, call 1-800-503-0784, or log on to www.opioidanalgesicrems.com; the FDA Blueprint can be found at www.fda.gov/OpioidAnalgesicREMSBlueprint
Patient access to naloxone for emergency treatment of opioid overdose
- Assess potential need for naloxone; consider prescribing for emergency treatment of opioid overdose
- Consult on availability and ways to obtain naloxone as permitted by individual state naloxone dispensing and prescribing requirements or guidelines
- Educate patients regarding the signs and symptoms of respiratory depression and to call 911 or seek immediate emergency medical help in the event of a known or suspected overdose
Pregnancy & Lactation
Pregnancy
Prolonged use of opioid analgesics during pregnancy for medical or nonmedical purposes can result in physical dependence in the neonate and neonatal opioid withdrawal syndrome shortly after birth; the onset, duration, and severity of neonatal opioid withdrawal syndrome vary based on specific opioid used, duration of use, timing and amount of last maternal use, and rate of elimination of drug by newborn; observe newborns for symptoms of neonatal opioid withdrawal syndrome and manage accordingly
Labor and delivery
- Opioids cross placenta and may produce respiratory depression and psycho-physiologic effects in neonates; an opioid antagonist, such as naloxone, must be available for reversal of opioid induced respiratory depression in neonate; drug is not recommended for use in women during and immediately prior to labor, when use of shorter-acting analgesics or other analgesic techniques are more appropriate; opioid analgesics can prolong labor through actions that temporarily reduce strength, duration, and frequency of uterine contractions; however, this effect is not consistent and may be offset by an increased rate of cervical dilatation, which tends to shorten labor; monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
Infertility
- Due to effects of androgen deficiency, chronic use of opioids may cause reduced fertility in females and males of reproductive potential; it is not known whether effects on fertility are reversible
Lactation
Morphine is present in breast milk; published lactation studies report variable concentrations of morphine in breast milk with administration of immediate-release morphine to nursing mothers in the early postpartum period with a milk-to-plasma morphine AUC ratio of 2.5:1 measured in one lactation study; however, there is insufficient information to determine effects of morphine on breastfed infant and effects of morphine on milk production; no information is available on effects of drug on breastfed infant or effects of drug on milk production
The developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and any potential adverse effects on breastfed infant from therapy or from underlying maternal condition
Monitor infants exposed to therapy through breast milk for excess sedation and respiratory depression; withdrawal symptoms can occur in breastfed infants when maternal administration of morphine is stopped, or when breastfeeding is stopped
Pregnancy Categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available.Pharmacology
Mechanism of Action
Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain pathways, thus altering response to pain; produces analgesia, respiratory depression, and sedation; suppresses cough by acting centrally in medulla
Absorption
Onset: PO, 15-30 min; IV, <5 min
Duration: 4 hr (immediate-release)
Peak plasma time: PO, <60 min; PR, 20-60 min; SC, 50-90 min; IM, 30-60 min; IV, 20 min
Peak plasma concentration: PO, 20-40 ng/mL
Distribution
Protein bound: IV, 36%
Vd: IV, 1-4.7 L/kg
Metabolism
Metabolized in liver via conjugation with glucuronic acid
Metabolites: 6-Glucuronide, 3,6-diglucuronide, 3-glucuronide
Elimination
Half-life: 2-4 hr (immediate release); 11-13 hr (Kadian)
Excretion: Urine (2-12%), feces (7-10%)
Administration
IV Incompatibilities
Additive: Aminophylline, amobarbital, chlorothiazide, floxacillin, fluorouracil, heparin, meperidine, midazolam(?), phenobarbital, phenytoin, sodium bicarbonate, thiopental
Syringe: Haloperidol, meperidine, pentobarbital(?), prochlorperazine(?), promethazine(?), thiopental
Y-site: Acyclovir (concentration-dependent?), alatrofloxacin, amphotericin B cholesteryl sulfate, azithromycin, cefepime, doxorubicin liposomal, furosemide(?), minocycline, phenytoin, propofol (concentration-dependent?), sargramostim, thiopental (concentration-dependent?)
IV Compatibilities
Solution: Most common solvents
Additive (partial list): Alteplase, atracurium, baclofen, dobutamine, fluconazole, furosemide, metoclopramide, ondansetron, succinylcholine, verapamil
Syringe (partial list): Atropine, chlorpromazine, cimetidine, clonidine, dimenhydrinate, diphenhydramine, fentanyl, glycopyrrolate, heparin(?), hydroxyzine, ketamine, metoclopramide, midazolam, milrinone, ondansetron, ranitidine
Y-site (partial list): Allopurinol, amikacin, amiodarone, ampicillin, atenolol, atracurium, atropine, aztreonam, calcium chloride, cefazolin, cisplatin, clindamycin, cytarabine, diazepam, diltiazem, diphenhydramine, dobutamine, dopamine, doxorubicin, erythromycin, esmolol, fentanyl, fluconazole, granisetron, haloperidol, heparin, hydroxyzine, labetalol, linezolid, lorazepam, magnesium sulfate, metoclopramide, metronidazole, midazolam, milrinone, nitroglycerin, penicillin G, phenobabital, potassium chloride, propranolol, sodium bicarbonate, sodium nitroprusside, tirofiban, tobramycin, trimethoprim-sulfamethoxazole, vancomycin, vecuronium, vitamins B and C, warfarin, zidovudine
IV Preparation
IV push: Dilute 2.5-15 mg in 4-5 mL of SWI
Infusion: Dilute in D5W to 0.1-1 mg/mL
Solution should be colorless; if it is discolored, do not administer
IV Administration
IV push: Administer over 4-5 minutes
Continuous infusion: Administer via controlled infusion device
Intrathecal & Epidural Administration
High-potency injectable solution (Infumorph): To be administered only IT or epidurally; not to be administered SC, IM, or IV, because of overdose risk; may require dilution before use, depending based on administration device and patient dose
Oral Administration
Extended-release tablet (MS Contin)
- Coingestion of alcohol with long-acting morphine products is known to disrupt slow-release delivery properties and lead to rapid release of drug, which may result in toxicity and potential overdose
- Swallow tablet whole; crushing, dissolving, or chewing the tablet can cause rapid release and absorption of a potentially fatal dose of morphine
Extended-release capsule (Kadian)
- 100-, 130-, 150-, and 200-mg capsules are appropriate only for patients tolerant of comparably potent opioid
- Kadian is not bioequivalent to other ER morphine products, and same total daily doses may result in excess sedation or inadequate pain relief
- Consumption of alcohol or alcohol-containing medications should be avoided during use, in that coingestion of alcohol may result in increased levels of morphine and potentially fatal overdose
- Swallow capsule whole; dissolving, or chewing the tablet can cause rapid release and absorption of a potentially fatal dose of morphine
- Alternatively, the contents of the Kadian capsules (pellets) may be sprinkled over applesauce and then swallowed; this method is appropriate only for patients able to reliably swallow the applesauce without chewing (rinse mouth following to be sure all pellets are swallowed)
- Do not administer through a nasogastric-tube
Administered through a 16-Fr gastronomy-tube
- Contents of the Kadian capsules (pellets) may be administered through a 16 French gastrostomy tube
- Flush the gastrostomy tube with water to ensure that it is wet
- Sprinkle the pellets into 10 mL of water
- Use a swirling motion to pour the pellets and water into the gastrostomy tube through a funnel
- Rinse the beaker with a further 10 mL of water and pour this into the funnel
- Repeat rinsing until no pellets remain in the beaker
Extended-release tablet, abuse deterrent (MorphaBond)
- 100-mg tablets, a single dose >60 mg, or a total daily dose >120 mg, are only for use in patients in whom tolerance to an opioid of comparable potency has been established
- Swallow tablet whole; crushing, dissolving, or chewing the tablet can cause rapid release and absorption of a potentially fatal dose of morphine
Extended-release tablet, abuse deterrent (Arymo ER)
- A single dose >60 mg or a total daily dose >120 mg are only for use in patients who are opioid-tolerant
- Swallow tablet whole with sufficient water; do not crush, chew, or dissolve
- Do not lick or wet tablet prior to swallowing tablet
General principles for opioid administration
Titration and maintenance
- Breakthrough pain may be managed with PRN morphine sulfate IR
- Subsequent dose increases may be made every 1-2 days combining morphine sulfate ER dose and morphine sulfate IR dose
- Titrate dose according to response
Discontinuation
- Taper dose gradually by 25-50% every 2 to 4 days, monitoring for symptoms of withdrawal
- If symptoms occur, increase dose to previous dose and titrate more slowly
Images
| BRAND | FORM. | UNIT PRICE | PILL IMAGE |
|---|---|---|---|
| morphine rectal - | 30 mg suppos |  | |
| morphine rectal - | 20 mg suppos |  | |
| morphine rectal - | 10 mg suppos |  | |
| morphine rectal - | 5 mg suppos |  | |
| morphine oral - | 15 mg tablet |  | |
| morphine oral - | 30 mg tablet |  | |
| morphine oral - | 20 mg/5 mL (4 mg/mL) solution |  | |
| morphine oral - | 10 mg/5 mL solution |  | |
| morphine oral - | 20 mg/5 mL (4 mg/mL) solution |  | |
| morphine oral - | 200 mg tablet |  | |
| morphine oral - | 100 mg tablet |  | |
| morphine oral - | 15 mg tablet |  | |
| morphine oral - | 10 mg capsule |  | |
| morphine oral - | 15 mg tablet |  | |
| morphine oral - | 30 mg tablet |  | |
| morphine oral - | 200 mg tablet |  | |
| morphine oral - | 60 mg tablet |  | |
| morphine oral - | 15 mg tablet |  | |
| morphine oral - | 60 mg tablet |  | |
| morphine oral - | 15 mg tablet |  | |
| morphine oral - | 30 mg tablet |  | |
| morphine oral - | 15 mg tablet |  | |
| morphine oral - | 50 mg capsule |  | |
| morphine oral - | 15 mg tablet |  | |
| morphine oral - | 15 mg tablet |  | |
| morphine oral - | 100 mg tablet |  | |
| morphine oral - | 60 mg tablet |  | |
| morphine oral - | 100 mg tablet |  | |
| morphine oral - | 30 mg tablet |  | |
| morphine oral - | 20 mg capsule |  | |
| morphine oral - | 200 mg tablet |  | |
| morphine oral - | 100 mg tablet |  | |
| morphine oral - | 30 mg capsule |  | |
| morphine oral - | 20 mg capsule |  | |
| morphine oral - | 10 mg capsule |  | |
| morphine oral - | 30 mg tablet |  | |
| morphine oral - | 100 mg tablet |  | |
| morphine oral - | 60 mg tablet |  | |
| morphine oral - | 60 mg tablet |  | |
| morphine oral - | 30 mg tablet |  | |
| morphine oral - | 15 mg tablet |  | |
| morphine oral - | 200 mg tablet |  | |
| morphine oral - | 200 mg tablet |  | |
| morphine oral - | 80 mg capsule |  | |
| morphine oral - | 60 mg capsule |  | |
| morphine oral - | 50 mg capsule |  | |
| morphine oral - | 10 mg/5 mL solution |  | |
| morphine oral - | 100 mg tablet |  | |
| morphine oral - | 50 mg capsule |  | |
| morphine oral - | 20 mg/5 mL (4 mg/mL) solution |  | |
| morphine oral - | 20 mg/5 mL (4 mg/mL) solution |  | |
| morphine oral - | 10 mg/5 mL solution |  | |
| morphine oral - | 10 mg/5 mL solution |  | |
| morphine oral - | 30 mg tablet |  | |
| morphine oral - | 100 mg capsule |  | |
| morphine oral - | 30 mg capsule |  | |
| morphine oral - | 100 mg capsule |  | |
| morphine oral - | 60 mg tablet |  | |
| morphine oral - | 30 mg tablet |  | |
| morphine oral - | 30 mg tablet |  | |
| morphine oral - | 15 mg tablet |  | |
| morphine oral - | 90 mg capsule |  | |
| morphine intravenous - | 4 mg/mL vial |  | |
| morphine intravenous - | 50 mg/mL vial |  | |
| morphine intravenous - | 4 mg/mL vial |  | |
| morphine intravenous - | 8 mg/mL vial |  | |
| morphine intravenous - | 25 mg/mL vial |  | |
| morphine intravenous - | 50 mg/mL vial |  | |
| MS Contin oral - | 200 mg tablet |  | |
| MS Contin oral - | 100 mg tablet |  | |
| MS Contin oral - | 15 mg tablet |  | |
| MS Contin oral - | 30 mg tablet |  | |
| MS Contin oral - | 60 mg tablet |  | |
| morphine intramuscular - | 10 mg/0.7 mL injection |  | |
| morphine injection - | 10 mg/mL solution |  | |
| morphine injection - | 8 mg/mL solution |  | |
| morphine injection - | 5 mg/mL solution |  | |
| morphine injection - | 4 mg/mL solution |  | |
| morphine injection - | 2 mg/mL solution |  |
Copyright © 2010 First DataBank, Inc.
Patient Handout
morphine oral
MORPHINE SUSTAINED-ACTION CAPSULE - ORAL
(MORE-feen)
COMMON BRAND NAME(S): Kadian
WARNING: Morphine has a risk for abuse and addiction, which can lead to overdose and death. Morphine may also cause severe, possibly fatal, breathing problems. To lower your risk, your doctor should have you take the smallest dose of morphine that works, and take it for the shortest possible time. See also How to Use section for more information about addiction.The risk for severe breathing problems is higher when you start this medication and after a dose increase, or if you take the wrong dose/strength. Taking this medication with alcohol or other drugs that can cause drowsiness or breathing problems may cause very serious side effects, including death. Be sure you know how to take morphine and what other drugs you should avoid taking with it. See also Drug Interactions section. Get medical help right away if any of these very serious side effects occur: slow/shallow breathing, unusual lightheadedness, severe drowsiness/dizziness, difficulty waking up.Do not crush, chew, or dissolve this medication or the contents of the capsules. Taking crushed, chewed, or dissolved forms of sustained-action morphine could cause a fatal overdose.Keep this medicine in a safe place to prevent theft, misuse, or abuse. If someone accidentally swallows this drug, get medical help right away.Before using this medication, women of childbearing age should talk with their doctor(s) about the risks and benefits. Tell your doctor if you are pregnant or if you plan to become pregnant. During pregnancy, this medication should be used only when clearly needed. It may slightly increase the risk of birth defects if used during the first two months of pregnancy. Also, using it for a long time or in high doses near the expected delivery date may harm the unborn baby. To lessen the risk, take the smallest effective dose for the shortest possible time. Babies born to mothers who use this drug for a long time may develop severe (possibly fatal) withdrawal symptoms. Tell the doctor right away if you notice any symptoms in your newborn baby such as crying that doesn't stop, slow/shallow breathing, irritability, shaking, vomiting, diarrhea, poor feeding, or difficulty gaining weight.
USES: This medication is used to help relieve severe ongoing pain (such as due to cancer). Morphine belongs to a class of drugs known as opioid analgesics. It works in the brain to change how your body feels and responds to pain.The higher strengths of this drug (100 milligrams per capsule and higher) should be used only if you have been regularly taking moderate to large amounts of an opioid pain medication. These strengths may cause overdose (even death) if taken by a person who has not been regularly taking opioids.Do not use the sustained-action form of morphine to relieve pain that is mild or that will go away in a few days. This medication is not for occasional ("as needed") use.
HOW TO USE: See also Warning section.Read the Medication Guide provided by your pharmacist before you start using morphine and each time you get a refill. If you have any questions, consult your doctor or pharmacist.Take this medication on a regular schedule as directed by your doctor, not as needed for sudden (breakthrough) pain. Take this drug with or without food, usually once or twice daily (every 12 or 24 hours). If you have nausea, it may help to take this drug with food. Ask your doctor or pharmacist about other ways to decrease nausea (such as lying down for 1 to 2 hours with as little head movement as possible).Swallow the capsules whole. Adults who have trouble swallowing the capsule may open the capsule and carefully sprinkle its contents on a spoonful of soft, cool applesauce. Swallow all of the drug/food mixture right away without chewing. Then rinse your mouth and swallow the rinse liquid to make sure that you have swallowed all of the dose. Do not chew the mixture or prepare a supply in advance. Do not give this medication to a child this way, since they might chew the mixture and overdose. For children who have trouble swallowing the capsule, ask the doctor about using a different form of morphine instead.The dosage is based on your medical condition and response to treatment. Do not increase your dose, take the medication more frequently, or take it for a longer time than prescribed. Properly stop the medication when so directed.If you are giving this medication through a certain tube into the stomach (gastric tube), ask your health care professional for detailed instructions on how to give it.Before you start taking this medication, ask your doctor or pharmacist if you should stop or change how you use your other opioid medication(s). Other pain relievers (such as acetaminophen, ibuprofen) may also be prescribed. Ask your doctor or pharmacist about using morphine safely with other drugs.Suddenly stopping this medication may cause withdrawal, especially if you have used it for a long time or in high doses. To prevent withdrawal, your doctor may lower your dose slowly. Tell your doctor or pharmacist right away if you have any withdrawal symptoms such as restlessness, mental/mood changes (including anxiety, trouble sleeping, thoughts of suicide), watering eyes, runny nose, nausea, diarrhea, sweating, muscle aches, or sudden changes in behavior.When this medication is used for a long time, it may not work as well. Talk with your doctor if this medication stops working well.Though it helps many people, this medication may sometimes cause addiction. This risk may be higher if you have a substance use disorder (such as overuse of or addiction to drugs/alcohol). Take this medication exactly as prescribed to lower the risk of addiction. Ask your doctor or pharmacist for more details.Tell your doctor if your pain does not get better or if it gets worse.
SIDE EFFECTS: See also Warning section.Nausea, vomiting, constipation, lightheadedness, dizziness, or drowsiness may occur. Some of these side effects may decrease after you have been using this medication for a while. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.To prevent constipation, eat dietary fiber, drink enough water, and exercise. You may also need to take a laxative. Ask your pharmacist which type of laxative is right for you.To reduce the risk of dizziness and lightheadedness, get up slowly when rising from a sitting or lying position.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor right away if you have any serious side effects, including: interrupted breathing during sleep (sleep apnea), mental/mood changes (such as agitation, confusion, hallucinations), severe stomach/abdominal pain, difficulty urinating, signs of your adrenal glands not working well (such as loss of appetite, unusual tiredness, weight loss).Get medical help right away if you have any very serious side effects, including: fainting, seizure, slow/shallow breathing, severe drowsiness/difficulty waking up.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
PRECAUTIONS: Before taking morphine, tell your doctor or pharmacist if you are allergic to it; or to other opioid pain medications (such as codeine); or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: brain disorders (such as head injury, tumor, seizures), breathing problems (such as asthma, sleep apnea, chronic obstructive pulmonary disease-COPD), kidney disease, liver disease, mental/mood disorders (such as confusion, depression), personal or family history of a substance use disorder (such as overuse of or addiction to drugs/alcohol), stomach/intestinal problems (such as blockage, constipation, diarrhea due to infection, paralytic ileus), difficulty urinating (such as due to enlarged prostate), disease of the pancreas (pancreatitis), gallbladder disease.This drug may make you dizzy or drowsy. Alcohol or marijuana (cannabis) can make you more dizzy or drowsy. Do not drive, use machinery, or do anything that needs alertness until you can do it safely. Avoid alcoholic beverages. Talk to your doctor if you are using marijuana (cannabis).Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).Older adults may be more sensitive to the side effects of this drug, especially confusion, dizziness, drowsiness, and slow/shallow breathing.During pregnancy, this medication should be used only when clearly needed. It may harm an unborn baby. Discuss the risks and benefits with your doctor. (See also Warning section.)This drug passes into breast milk and may have undesirable effects on a nursing infant. Tell the doctor right away if your baby develops unusual sleepiness, difficulty feeding, or trouble breathing. Consult your doctor before breast-feeding.
DRUG INTERACTIONS: See also Warning section.Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.Some products that may interact with this drug include: certain pain medications (mixed opioid agonist-antagonists such as pentazocine, nalbuphine, butorphanol), naltrexone.The risk of serious side effects (such as slow/shallow breathing, severe drowsiness/dizziness) may be increased if this medication is taken with other products that may also cause drowsiness or breathing problems. Tell your doctor or pharmacist if you are taking other products such as other opioid pain or cough relievers (such as codeine, hydrocodone), alcohol, marijuana (cannabis), drugs for sleep or anxiety (such as alprazolam, lorazepam, zolpidem), muscle relaxants (such as carisoprodol, cyclobenzaprine), or antihistamines (such as cetirizine, diphenhydramine).Check the labels on all your medicines (such as allergy or cough-and-cold products) because they may contain ingredients that cause drowsiness. Ask your pharmacist about using those products safely.This medication may interfere with certain laboratory tests (including amylase/lipase levels), possibly causing false test results. Make sure laboratory personnel and all your doctors know you use this drug.
OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, give them naloxone if available, then call 911. If the person is awake and has no symptoms, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: slow/shallow breathing, slow heartbeat, coma.
NOTES: Do not share this medication with others. Sharing it is against the law.This medication has been prescribed for your current condition only. Do not use it later for another condition unless told to do so by your doctor. A different medication may be necessary in that case.Ask your doctor or pharmacist if you should have naloxone available to treat opioid overdose. Teach your family or household members about the signs of an opioid overdose and how to treat it.
MISSED DOSE: If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose. Take your next dose at the regular time. Do not double the dose to catch up.
STORAGE: Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets. See also Warning section.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. For more details, read the Medication Guide, or consult your pharmacist or local waste disposal company.
Information last revised August 2021. Copyright(c) 2021 First Databank, Inc.
IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.
Formulary
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