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Uses

Pain (Acute or Chronic)

Strong analgesic used in the relief of severe, acute pain or moderate to severe, chronic pain (e.g., in terminally ill patients).

Extended-release preparations are used orally for management of moderate to severe pain when a continuous, around-the-clock analgesic is needed for an extended period of time. Extended-release preparations are not indicated for relief of acute pain, for use on an as-needed (“prn”) basis, for preoperative administration to control postoperative pain, or routinely for postoperative use. Patients who were receiving one of these preparations prior to surgery may reinitiate such use after they are able to resume oral therapy. Extended-release preparations (Kadian^®) may be used postoperatively if pain is expected to be moderate to severe and persist for an extended period of time.

Pain (Severe, Neuraxial Analgesia)

Used epidurally or intrathecally for relief of severe pain (neuraxial analgesia); administration of the drug by these routes reportedly provides pain relief for prolonged periods without attendant loss of motor, sensory, or sympathetic function.

Chronic epidural or intrathecal analgesia is indicated only when adequate pain relief cannot be obtained with less invasive therapies. The drug should only be administered epidurally or intrathecally by qualified individuals familiar with the techniques and patient management problems associated with these routes of morphine administration. (See Precautions Associated with Epidural or Intrathecal Administration under Cautions.)

Extended-release liposomal injection (DepoDur^®) is used epidurally for relief of severe pain following major surgery.

Pain (MI)

Relief of pain related to AMI. Drug of choice.

IV morphine should be initiated promptly at the time of diagnosis (e.g., in the emergency department) and should not be delayed simply to avoid obscuring the ability to evaluate results of anti-ischemic therapy, which also can provide pain relief.

Careful attention to maximum pain relief should continue as a general measure in early hospital management of AMI, even after the patient leaves the emergency department.

Patients with AMI typically exhibit overactivity of the sympathetic nervous system, which adversely increases myocardial oxygen demand via acceleration of heart rate, elevation in arterial blood pressure, augmentation of cardiac contractility, and heightened tendency to development of ventricular tachyarrhythmias. Principal objective in these patients is to administer sufficient doses of an analgesic such as morphine to relieve what many patients describe as a feeling of impending doom.

Administering morphine in small increments to avoid paradoxical augmentation of sympathetic activity and respiratory depression may result in inadequate cumulative doses of the drug; fear of inducing hypotension, which is not a particular threat to supine patients, also may unnecessarily limit administration of adequate doses.

To avoid hypotension, it may be more prudent to avoid concomitant use of vasodilators (e.g., IV nitroglycerin) in patients with severe unremitting pain.

Patients should be advised to notify their caretakers (e.g., nurse) immediately when discomfort occurs and describe its severity on a numeric scale (e.g., 1–10).

Although the depressant action of opiate agonists on ventilation is centrally mediated and well appreciated, respiratory depression in the setting of AMI usually is not a substantial clinical problem because of sympathetic discharge associated with ischemic-type chest discomfort or pulmonary edema.

If respiratory depression occurs, naloxone hydrochloride (up to three 0.4-mg IV doses at up to 3-minute intervals) may be used to provide relief.

Some experts also recommend IV morphine for any patient with unstable angina whose symptoms are not controlled after 3 serial sublingual nitroglycerin doses, or whose symptoms recur with adequate anti-ischemic therapy (unless contraindicated by hypotension or intolerance).

Analgesia during Labor

Used parenterally for analgesia during labor.

Acute Pulmonary Edema

Used in patients with acute pulmonary edema for its cardiovascular effects and to allay anxiety. Should not be used in the treatment of pulmonary edema resulting from a chemical respiratory irritant.