FDA-approved usage of morphine sulfate includes moderate to severe pain that may be acute or chronic. Most commonly used in pain management, morphine provides major relief to patients afflicted with pain. Clinical situations that benefit greatly by medicating with morphine include management of palliative/end-of-life care, active cancer treatment, and vaso-occlusive pain during sickle cell crisis. Morphine is widely used off-label for almost any condition that causes pain. In the emergency department, morphine is given for musculoskeletal pain, abdominal pain, chest pain, arthritis and even for headaches when patients fail to respond to first and second line agents. Morphine is rarely used for procedural sedation. However, for small procedures, physicians will sometimes combine a low dose of morphine with a low dose of benzodiazepine-like lorazepam. Patients that are actively having acute coronary syndrome are often given morphine in the emergency setting before going to the cath lab. Morphine to relieve pain during a myocardial infarction (MI) has been used since the early 1900s. Although, in 2005, an observational study brought up some concerns there are very few effective alternatives. It has been acknowledged that some concerns do exist. Morphine is a potent opioid; it decreases pain, which in turn leads to a decrease in the activation of the autonomic nervous system. These are desired effects when a patient is having an MI. Additionally, morphine has hemodynamic side effects that can be beneficial during an MI. Morphine can decrease the heart rate, blood pressure, and venous return. Morphine has also been known to stimulate local histamine-mediated processes. In theory, the combination of these can reduce myocardial oxygen demand.
Morphine is considered the classic opioid analgesic with which other painkillers are compared. Like other medications in this class, morphine has an affinity for delta, kappa, and mu opioid receptors. This drug produces the majority of its analgesic effects by binding to the mu opioid receptor within the central nervous system (CNS) and the peripheral nervous system (PNS). The net effect of morphine is activation of descending inhibitory pathways of the CNS as well as inhibition of the nociceptive afferent neurons of the PNS, which leads to an overall reduction of the nociceptive transmission.
Morphine can be administered through different vehicles. It is most often administered via the following routes: orally (PO), intravenously (IV), epidural, and intrathecal. Oral formulations are available in both immediate and extended release for treatment of acute and chronic pain. Pain that is more severe and not well controlled may be managed with single or continuous doses of IV, epidural, and intrathecal formulations. Infusion dosing can vary significantly between patients and is largely dependent on how naive or tolerant they are to opiates. It is interesting to point out that IV morphine formulation is also commonly given intramuscularly (IM). Morphine is also available as a suppository. Morphine is widely used and abused. As a result of this, people have found ways to insufflate (snort) the medication. Morphine is also available as an oral solution and can be administered sublingually. Sublingual morphine is very popular in palliative care.
Among the more common unwanted effects of morphine use is constipation. This occurs via stimulation of mu-opioid receptors on the myenteric plexus, which in turn inhibits gastric emptying and reduces peristalsis. Other common side effects include central nervous system depression, nausea, vomiting, and urinary retention. Respiratory depression is among the more serious adverse reactions with opiate use that is especially important to monitor in the post-operative patient population. Other side effects that have been reported are lightheadedness, sedation, and dizziness. Patients often report nausea and vomiting, which is why in many emergency departments morphine is administered along with an antiemetic such as ondansetron. Other effects include euphoria, dysphoria, agitation, dry mouth, anorexia, and biliary tract spasm, which is why some physicians will avoid morphine when patients present with right upper quadrant pain and they suspect possible biliary tract pathology. Morphine can also affect the cardiovascular system and has been reported to cause flushing, bradycardia, hypotension, and syncope. It is also important to note that patients can experience pruritis, urticaria, edema, and other skin rashes.
Morphine is an incredibly useful medication when used appropriately. However, in certain situations, this medication may be strongly contraindicated. Extreme caution must be used with severe cases of respiratory depression and asthma exacerbation since morphine can further decrease the respiratory drive. Additionally, morphine should be avoided in cases of previous hypersensitivity reaction and immediately discontinued in the presence of an active reaction. Caution must also be used with the concurrent use of monoamine oxidase inhibitors (MAOIs) as these medications have an additive effect with morphine. This can then trigger severe hypotension, serotonin syndrome, or increase respiratory depression in patients. GI obstruction is another important contraindication. It is also considered by many as a contraindication to provide opioids to individuals that have a history of substances abuse, especially if a patient has had a history of abusing opioids. Although this is a very controversial topic, most physicians would agree that pain needs to be managed. However, most will agree and acknowledge that there are alternatives to opioid analgesics.
The efficacy and therapeutic index of morphine may be assessed with a combination of subjective and objective findings. Controlling pain, which is usually the first symptom assessed in patients, is the ultimate goal of morphin use. Other important parameters to monitor include mental status, blood pressure, respiratory drive, and abuse/overuse. Although it may seem intuitive, it is also important to monitor what other medications a patient is taking. This includes but is not limited to prescription medications. All patients taking morphine should be advised to avoid any other substances that could lead to respiratory depression. These medications include but are not limited to alcohol, additional opioids, benzodiazepines, and barbiturates. Patients can become apneic at lower doses if morphine is combined with any of these substances.
Morphine can potentially be a lethal medication when not used properly. It causes a host of symptoms related to depression of the CNS. Severe respiratory depression is the most feared complication of morphine in cases of overdose. Immediate injection of naloxone is required to reverse the effects of morphine.
Ordering and administering morphine requires an interprofessional team of healthcare professionals that includes mostly the nurse, pharmacist, and clinician. However, patients may be transferred throughout the hospital while under the effects of these medications. Morphine use, monitoring, and administration can utilize many resources including laboratory technologists, pharmacist, and a number nurses and nursing assistants. Without proper training and careful monitoring, often starting in the emergency department, patients can develop serious side effects and have adverse reactions to morphine. The clinician is responsible for coordinating the care which includes the following:
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