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MORPHine

Classification

high alert medication

controlled and targeted substance

Opioid analgesic

Indications

PCP:

Pain management in palliative or end-of-life emergencies

Analgesia

⚠️ Requires completion of BCEHS opioid administration education.

⚠️ Requires completion of BCEHS palliative care education.

ACP:

Analgesia

Symptom relief in palliative or end-of-life patients with pain or shortness of breath

MORPHine should be used secondary to fentaNYL in long transfers or for protracted extrication events.

Contraindications

Known hypersensitivity to MORPHine or other opioid analgesics
Head injury with altered LOC (GCS < 9)
Hypotension (adult SBP < 90 mmHg; children under 12 SBP < 70 mmHg)
Respiratory depression (adults < 10 breaths/minute; children under 12 < 20 breaths/minute)

Cautions

Convulsive disorderes
Cranial injuries
Respiratory insufficiency, including asthma, COPD, and upper airway obstruction
Cardiac arrhythmias
Reduced blood volume (hypovolemia)

Adult dosages

Dosing for MORPHine is based on opioid-naive patients. For patients identified as not opioid-naive, consider consultation with CliniCall for additional analgesia planning support.

PCP: Analgesia

Intravenous
- 2.5 mg - 5 mg, may repeat every 10 minutes, titrated to patient's pain score.
- Maximum cumulative dose 20 mg
- Mixing: 10 mg/mL MORPHine in 9 mL NaCl 0.9% to make 1 mg/mL concentration
- Use the lower end of the dosing range if the patient is small, frail, elderly, or physiologically unstable
- IFT considerations for maintenance of pain management
  - ☎️ Mandatory CliniCall consultation to discuss dosing strategies
  - IFT dosing IV push dose Maximum cumulative dose
    
    Standard dose 2.5 mg - 5 mg prn 10 mg
    
    High dose 2.5 mg - 5 mg prn 20 mg
Intramuscular
- 5 mg - 10 mg undiluted every 60 minutes
- Maximum cumulative dose 20 mg
- Use the lower end of the dosing range if the patient is small, frail, elderly, or physiologically unstable

PCP: Pain management in palliative emergencies or end-of-life patients

⚠️ Requires completion of BCEHS palliative education
☎️ Mandatory CliniCall or palliative team consultation to discuss dosing strategies
Subcutaneous
- 2.5 mg - 5 mg every 10-30 minutes, as required, based on blood pressure (SBP > 100 mmHg), or as per CliniCall or palliative team care plan
- Maximum cumulative dose 20 mg

ACP: Analgesia

Intravenous
- 2.5 mg - 5 mg prn
- Consider for use in longer transport times

ACP: Symptom relief in palliative or end-of-life patients with pain or shortness of breath

⚠️ Requires completion of BCEHS palliative education
☎️ Mandatory CliniCall or palliative team consultation to discuss dosing strategies
Subcutaneous
- 2.5 mg - 5 mg
- May repeat every 10-30 minutes as required based on blood pressure (SBP > 100 mmHg) or as per CliniCall or palliative team care plan

Pediatric Considerations And Dosing

Refer to dosing charts below.

PCP: ☎️ Mandatory CliniCall consultation for patients under 12 years.

Intramuscular
- The use of IM injections is no longer recommended due to painful administration, variable absorption, and lag time to peak effect. As a last resort, and only if pain relief from Entonox and PO acetaminophen and ibuprofen is not achieved, consider morphine 0.1 mg/kg IM as a single dose

ACP:

Intravenous
- Administer one dose initially (0.05 mg/kg). May repeat after 5 minute interval as required for pain control. The dose, up to a cumulative 0.1 mg/kg, can be repeated after two hours.

Table 1. Subcutaneous dosing (palliative pediatric)

Age	Weight (kg)	Dose (0.05 mg/kg)	Volume to give (mL) of undiluted morphine*	Dosing interval
1	10	0.5 mg	0.05 mL	5 minutes
2	12	0.6 mg	0.06 mL	5 minutes
3	15	0.75 mg	0.08 mL	5 minutes
4	18	0.9 mg	0.09 mL	5 minutes
6	20	1 mg	0.1 mL	5 minutes
8	25	1.25 mg	0.13 mL	5 minutes
10	30	1.5 mg	0.15 mL	5 minutes
12	40	2 mg	0.2 mL	5 minutes

Table 2. Intramuscular (Pediatrics)

Age	Weight (kg)	Dose (0.1 mg/kg)	Volume to give (mL) of undiluted morphine*
1	10	1 mg	0.1 mL
2	12	1.2 mg	0.12 mL
3	15	1.5 mg	0.15 mL
4	18	1.8 mg	0.18 mL
6	20	2 mg	0.2 mL
8	25	2.5 mg	0.25 mL
10	30	3 mg	0.3 mL
12	40	4 mg	0.4 mL

*Based on MORPHine 10 mg/mL concentration (undiluted)

Table 3. Intravenous (Pediatrics)

Age	Weight (kg)	Initial dose (0.05 mg/kg)	*Volume to give (mL)**	Dosing interval (once)	Repeat dose (0.05 mg/kg)	*Diluted volume to give(mL)**	MAX Cumulative Dose (q 2-4 hours)**
1	10	0.5 mg	0.5 mL	5 minutes	0.5 mg	0.5 mL	2 mg
2	12	0.6 mg	0.6 mL	5 minutes	0.6 mg	0.6 mL	4 mg
3	15	0.75 mg	0.75 mL	5 minutes	0.75 mg	0.75 mL	4 mg
4	18	0.9 mg	0.9 mL	5 minutes	0.9 mg	0.9 mL	4 mg
6	20	1 mg	1 mL	5 minutes	1 mg	1 mL	4 mg
8	25	1.25 mg	1.25 mL	5 minutes	1.25 mg	1.25 mL	8 mg
10	30	1.5 mg	1.5 mL	5 minutes	1.5 mg	1.5 mL	8 mg
12	40	2 mg	2 mL	5 minutes	2 mg	2 mL	10 mg

Mechanism Of Action

Binds to opioid receptors in the CNS (primarily mu receptors) causing inhibition of ascending pain pathways, altering the perception of and response to pain and producing generalized CNS depression.

Pharmacokinetics

Intramuscular / subcutaneous:

Onset: 10 minutes
Peak: 20-60 minutes (variable)
Duration: 2-4 hours

Intravenous:

Onset: 5-10 minutes
Peak: 20 minutes
Duration: 2-4 hours

Adverse Effects

Drowsiness, dizziness, sedation, agitation, euphoria
Respiratory depression and apnea
Profound hypotension (may be increased with rapid IV injection), bradycardia
Nausea, vomiting, constipation
Pinpoint pupils
Repeated subcutaneous administration may cause local tissue irritation
Pseudoallergic reactions (itch, rash) may occur due to direct stimulation of histamine release (anaphylaxis is rare)

Overdose

Provide airway management and ventilatory support. Consider the use of naloxone to reverse opioid intoxication. Naloxone should be used judiciously in patients on long-term opioid therapy to avoid precipitating acute withdrawal syndrome.

See Naloxone guideline.

Drug Interactions

MORPHine may enhance respiratory and circulatory depression if used in combination with other opioids, sedatives such as benzodiazepines, phenothiazines, anesthetics, or alcohol.

Do not use morphine in patients taking monoamine oxidase inhibitors (MAOIs) or within 14 days of MAOI discontinuation.

IFT dosing	IV push dose	Maximum cumulative dose
Standard dose	2.5 mg - 5 mg prn	10 mg
High dose	2.5 mg - 5 mg prn	20 mg