Morphine (morphine sulphate)
Also sold as: Morphine Sulphate SR, MS Contin, Morcontin, Skenan, Sevredol
Pregnancy
Cat C
Lactation
Caution
Schedule
NDPS
Forms
tablet immediate-release 10mg, 15mg, 30mg (Sevredol) +4
Indications
- Severe acute pain (post-operative, trauma, myocardial infarction)
- Chronic severe pain — cancer pain (WHO analgesic ladder Step 3 essential medicine)
- Palliative care — dyspnea in end-stage disease, pain in terminal illness
- Patient-controlled analgesia (PCA) in hospital settings
- Breakthrough cancer pain (immediate-release formulations)
Adult Dosing
Acute pain — immediate-release oral
5–15 mg every 4 hours
Titrate to effect; reassess frequently
Always prescribe a stimulant laxative (e.g., senna) when initiating morphine therapy.
Chronic pain — sustained-release oral (SR/XR)
30–60 mg every 8–12 hours
BD or TDS; titrate based on total 24-hour immediate-release requirement from previous day
IV/IM/SC analgesia
2.5–15 mg every 4 hours
Titrate carefully; use lower end of range in opioid-naive patients
IV infusion (palliative care / ICU)
1–5 mg/h continuous infusion
Continuous; titrate to comfort
Patient-controlled analgesia (PCA)
1–5 mg bolus; background infusion 0–2 mg/h
5–10 minute lockout interval
Follow institutional PCA protocol. Review background infusion need daily.
Pediatric Dosing
Always have naloxone available. Close monitoring mandatory. Adjust for renal impairment.
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| CrCl 50–80 mL/min | No dose adjustment but monitor for accumulation |
| CrCl 10–50 mL/min | Reduce dose by 25% and extend dosing interval to every 6 hours (to reduce accumulation of active metabolite morphine-6-glucuronide, M6G) |
| CrCl <10 mL/min | Avoid — M6G accumulates severely, causing prolonged sedation and respiratory depression |
| Haemodialysis | Avoid or use only with extreme caution (M6G is partially dialyzable but clinical management is complex) |
Hepatic Adjustment
Mild-to-moderate hepatic impairment: reduce dose by 25–50%, extend dosing intervals, and titrate slowly. Severe hepatic impairment (Child-Pugh C): use with extreme caution — significantly increased bioavailability (reduced first-pass metabolism) and risk of hepatic encephalopathy precipitation. Consider alternative opioids (fentanyl or hydromorphone) in severe liver disease.
Pregnancy & Lactation
Pregnancy: Category C
Pregnancy Category C in early trimesters, D near term. Crosses the placenta freely. Near-term use or prolonged use in pregnancy may cause neonatal opioid withdrawal syndrome (NOWS) — presents 24–72h after birth with irritability, high-pitched cry, poor feeding, tremor. Respiratory depression in neonate at delivery if used near term. Neonatal monitoring mandatory. Use only if benefits outweigh risks.
Lactation: Caution
Excreted in breast milk at low levels (M/P ratio ~2.5). Low-dose, short-term maternal use is generally considered compatible with breastfeeding (WHO, LactMed). Prolonged high-dose use or use in mothers who are CYP2D6 ultra-rapid metabolizers may lead to infant sedation or respiratory depression. Monitor infant for drowsiness, difficulty feeding, and breathing changes.
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| MAO Inhibitors (phenelzine, selegiline, tranylcypromine, linezolid, methylene blue) | Risk of serotonin syndrome, respiratory depression, and hemodynamic instability. Contraindicated within 14 days of MAOI use. If unavoidable in emergency, use lowest possible dose with extreme caution. | Major |
| Benzodiazepines / CNS depressants / Alcohol | Additive CNS and respiratory depression — potentially fatal. FDA black box warning. Avoid concurrent use. If co-prescribing is unavoidable (e.g., palliative care), use lowest effective doses, limit duration, and counsel patient and family about overdose risk. | Major |
| Naloxone | Opioid antagonist — fully reverses morphine analgesia, sedation, and respiratory depression. Keep naloxone readily available whenever morphine is prescribed. Duration of naloxone (30–90 min) is shorter than morphine — re-dosing may be needed. | Major |
| Cimetidine | Cimetidine inhibits morphine metabolism, increasing plasma levels and risk of adverse effects. Prefer ranitidine or PPI alternative if H2 blocker is needed concurrently. | Moderate |
| Rifampicin | Rifampicin induces UGT enzymes, significantly increasing morphine glucuronidation and reducing plasma morphine levels. May require dose increases to maintain adequate analgesia. Monitor pain control when rifampicin is started or stopped. | Moderate |
| Muscle relaxants (baclofen, cyclobenzaprine) | Additive CNS depression and respiratory depression risk. Use lowest effective doses. | Moderate |
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Side Effects
Common
- Constipation (virtually universal — always prescribe stimulant laxative, e.g., senna)
- Nausea and vomiting (especially on initiation — often improves after 1–2 weeks; prescribe antiemetic prophylactically)
- Sedation and cognitive impairment (especially on initiation or dose escalation)
- Dry mouth (xerostomia)
- Pruritus (itching — especially with IV morphine and neuraxial routes; due to histamine release)
- Urinary retention (especially in elderly men with BPH)
- Miosis (pinpoint pupils)
- Orthostatic hypotension
Serious / Discontinue If
- Respiratory depression — KEY RISK. Manifests as respiratory rate <12 breaths/min, oxygen desaturation, decreased level of consciousness. Risk highest in opioid-naive patients, elderly, patients with sleep apnea, concurrent CNS depressants. Reverse with naloxone 0.4–2mg IV/IM/SC. Keep naloxone available.
- Physical dependence and opioid withdrawal — develop predictably with prolonged use; taper dose gradually (10–20% per week) when discontinuing to prevent acute withdrawal syndrome
- Opioid-induced hyperalgesia (OIH) — paradoxical increased pain sensitivity with chronic high-dose opioids; suspect if pain worsens despite dose increases
- Adrenal suppression and hypogonadism with long-term use (opioid endocrinopathy)
- Respiratory depression in neonate (if used near delivery)
- Serotonin syndrome (if combined with serotonergic agents or MAOIs)
- Anaphylaxis/severe hypersensitivity (rare)
Contraindications
- Acute respiratory depression / severe bronchial asthma in unmonitored setting without resuscitative equipment
- Paralytic ileus
- Acute abdomen (before diagnosis is established — may mask symptoms)
- Concurrent or recent MAOI use (within 14 days)
- Severe renal impairment (CrCl <10 mL/min) — M6G accumulation
- Head injury or raised intracranial pressure (may worsen by increasing CO2 and causing cerebral vasodilation)
- Hypersensitivity to morphine
- NDPS Act compliance: controlled drug — strict record-keeping, triplicate prescription, state narcotics department rules apply (India)
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Morcontin 30mg SR | Modi-Mundipharma | ₹85/10 tab |
| MS Contin 30mg SR | Purdue Pharma | ₹95/10 tab |
| Sevredol 10mg (immediate release) | Mundipharma | ₹45/10 tab |
Monitoring Required
- Respiratory rate at every dose change (target >12 breaths/min)
- Oxygen saturation (pulse oximetry) — especially in first 24 hours of IV use, dose escalation, or in patients with respiratory comorbidities
- Sedation score (Ramsay or PASERO scale) — excessive sedation precedes respiratory depression
- Pain score (NRS/VAS) — assess both at rest and on movement
- Bowel function — assess at every visit; prescribe and titrate laxatives proactively
- Urine output (urinary retention — especially elderly men)
- Signs of opioid toxicity: pinpoint pupils, decreased consciousness, respiratory rate <12/min
- Long-term use: testosterone, cortisol, thyroid function (opioid endocrinopathy); bone density
- Naloxone availability — confirmed at every prescription review
- NDPS prescription compliance — triplicate form, quantity limits, record keeping per state rules
Patient Counseling Points
- Morphine is a powerful painkiller for severe pain. Take exactly as prescribed — do not take extra doses without consulting your doctor.
- Constipation is almost certain with morphine. You will be given a laxative (usually senna) — take it regularly from day one, not just when constipated.
- Nausea is common when you first start this medicine. It usually improves after 1–2 weeks. An anti-nausea tablet may be prescribed to help.
- Do not drive, operate heavy machinery, or make important decisions while on morphine — it causes sedation and affects judgment.
- Do not drink alcohol while taking morphine — the combination can cause dangerous slowing of breathing.
- If you forget a dose of the extended-release tablet, skip it and take the next dose at the scheduled time. Never take double doses.
- Do NOT crush, break, or chew the sustained-release (SR) tablets — swallow whole. Crushing releases the entire dose at once and can be fatal.
- ALERT: If breathing becomes very slow or shallow, or you or someone you care for cannot be woken up — call emergency services immediately. Naloxone (a reversal agent) should be available at home if high doses are prescribed.
- This medicine causes physical dependence — do not stop suddenly. Your doctor will reduce the dose gradually when stopping.
- NDPS (Controlled Medicine): This is a controlled narcotic medication in India. Store in a safe, locked place away from children. Do not share with anyone.
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Clinically reviewed by: Dr. Arun Bhaskar, MD, DM Palliative Medicine, Tata Memorial Hospital Mumbai
Last reviewed: 2026-04-01
References
- WHO. Model List of Essential Medicines, 23rd Edition. 2023.
- WHO. Palliative Care — Cancer Pain Relief with a Guide to Opioid Availability. 2nd Ed.
- Twycross R, et al. Palliative Care Formulary (PCF6). palliativedrugs.com. 2017.
- Drugs and Cosmetics Act 1940 (India). Schedule H and NDPS Act 1985 — Controlled Substance Regulations.
- CDSCO. Morphine Prescribing Guidelines for Cancer Pain Management. India. 2020.