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THE MAJOR HAZARDS OF MORPHINE, AS OF OTHER NARCOTIC ANALGESICS, ARE RESPIRA-TORY DEPRESSION AND, TO A LESSER DEGREE, CIRCULATORY DEPRESSION, RESPIRATORY ARREST, SHOCK, AND CARDIAC ARREST HAVE OCCURRED.

The most frequently observed adverse reactions include lightheadedness, dizziness, sedation, nausea, vomiting, and sweating. These effects seem to be more prominent in ambulatory patients and in those who are suffering severe pain.

In such individuals, lower doses are available. Some adverse reactions may be alleviated in the ambulatory patient if he lies down.

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Central Nervous System: Euphoria, dysphoria, weakness, headache, insomnia, agitation, disorientation, and visual disturbances.

Gastrointestinal: Dry mouth, anorexia, constipation, and biliary tract spasm.

Cardiovascular: Flushing of the face, bradycardia, palpitation, faintness and syncope.

Allergic: Pruritus, urticaria, other skin rashes, edema, and, rarely hemorrhagic urticaria.

Treatment of the most frequent adverse reactions

Constipation

Ample intake of water or other liquids should be encouraged. Concomitant administration of a stool softener and a peristaltic stimulant with the narcotic analgesic can be an effective preventive measure for those patients in need of therapeutics.

If elimination does not occur for two days, an enema should be administered to prevent impaction.

In the event diarrhea occurs, seepage around fecal impaction is a possible cause to consider before antidiarrheal measures are employed.

Nausea and Vomiting

Phenothiazines and antihistamines can be effective treatments of nausea of the medullary and vestibular sources respectively. However, these drugs may potentiate the side effects of the narcotic or the antinauseant.

Drowsiness (sedation)

Once pain control is achieved, undesirable sedation can be minimized by titrating the dosage to a level that just maintains a tolerable pain or pain free state.

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Morphine Sulfate, a narcotic, is a Schedule II controlled substance under the Federal Controlled Substance Act. As with other narcotics, some patients may develop a physical and psychological dependence on morphine.

They may increase dosage without consulting a physician and subsequently may develop a physical dependence on the drug.

In such cases, abrupt discontinuance may precipitate typical withdrawal symptoms, including convulsions. Therefore the drug should be withdrawn gradually from any patient known to be taking excessive dosages over a long period of time.

In treating the terminally ill patient the benefit of pain relief may outweigh the possibility of drug dependence.

The chance of drug dependence is substantially reduced when the patient is placed on scheduled narcotic programs instead of a “pain to relief-of-pain” cycle typical of a PRN regimen.

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Generally, effects of morphine may be potentiated by alkalizing agents and antagonized by acidifying agents. Analgesic effect of morphine is potentiated by chlorpromazine and methocarbamol.

CNS depressants such as anaesthetics, hypnotics, barbiturates, phenothiazines, chloral hydrate, glutethimide, sedatives, MAO inhibitors (including procarbazine hydro-chloride), antihistamines, β-blockers (propranolol), alcohol, furazolidone and other narcotics may enhance the depressant effects of morphine.

Morphine may increase anticoagulant< activity of coumarin and other anticoagulants.

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Morphine can cause tolerance, psychological and physical dependence. Withdrawal will occur on abrupt discontinuation or administration of a narcotic antagonist.

Interaction with Other Central Nervous System Depressants

Morphine should be used with caution and in reduced dosage in patients who are concurrently receiving other narcotic analgesics, general anesthetics, phenothiazines, other tranquilizers, sedative-hypnotics, tricyclic antidepressants, and other CNS depressants (including alcohol). Respiratory depression, hypotension, and profound sedation or coma may result.

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General

Head Injury and Increased Intracranial Pressure

The respiratory depressant effects of morphine and its capacity to elevate cerebrospinal-fluid pressure may be markedly exaggerated in the presence of increased intracranial pressure.

Furthermore, narcotics produce side effects that may obscure the clinical course of patients with head injuries. In such patients, morphine must be used with caution and only if it is deemed essential.

Asthma and Other Respiratory Conditions

Morphine should be used with caution in patients having an acute asthmatic attack, in those with chronic obstructive pulmonary disease or cor pulmonale, and in individuals with a substantially decreased respiratory re-serve, preexisting respiratory depression, hypoxia, or hypercapnia.

In such patients, even usual therapeutic doses of narcotics may decrease respiratory drive while simultaneously increasing airway resistance to the point of apnea.

Hypotensive Effect

The administration of morphine may result in severe hypotension in an individual whose ability to maintain his blood pressure has already been compromised by a depleted blood volume or concurrent administration of such drugs as the phenothiazines or certain anesthetics.

Special-Risk Patients

Morphine should be given with caution and the initial dose should be reduced in certain patients, such as the elderly or debilitated and those with severe impairment of hepatic or renal function, hypothyroidism, Addison’s disease, prostatic hy-pertrophy, or urethral stricture.

Acute Abdominal Conditions

The administration of morphine or other narcotics may obscure the diagnosis or clinical course in patients with acute abdominal conditions.

Carcinogenicity/Mutagenicity

Long-term studies to determine the carcinogenic and mutagenic potential of morphine are not available.

Pregnancy

Teratogenic Effects

Pregnancy Category C

Animal reproduction studies have not been conducted with morphine. It is also not known whether morphine can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity.

Morphine should be given to a pregnant woman only if clearly needed.

Labor and Delivery

Morphine readily crosses the placental barrier and if administered during labor, may lead to respiratory depression in the neonate.

Nursing Mothers

Morphine has been detected in human milk. For this reason, caution should be exercised when morphine is administered to a nursing woman.

Pediatric Usage

Safety and effectiveness in children have not been established.