Can morphine be crushed?

Morphine Crushing Guidelines

Controlled release morphine tablets should not be crushed or used for rectal or vaginal administration. 1

Types of Morphine Formulations and Administration

• Morphine is available in two main oral formulations: immediate release (for dose titration) and controlled/modified release (for maintenance treatment) 1
• The optimal route of administration for morphine is by mouth, which is the simplest and most acceptable to patients 1
• If patients are unable to take drugs orally, the preferred alternative routes are rectal and subcutaneous 1

Crushing Considerations for Different Formulations

Immediate Release Morphine

• While not explicitly stated in the guidelines, immediate release morphine formulations may be crushed if a patient has difficulty swallowing, though this should be confirmed with product-specific information
• The simplest method of dose titration is with immediate release morphine given every four hours 1

Controlled/Modified Release Morphine

• Controlled release morphine tablets should not be crushed as this destroys the extended-release mechanism 1
• Crushing modified release formulations can lead to dose dumping, where the entire dose intended for extended release is delivered immediately, potentially causing overdose 2

Abuse-Deterrent Formulations

• Some newer morphine formulations (like morphine ARER and MS-sNT) have abuse-deterrent properties 2, 3
• When these formulations are crushed, they:
  • Form a viscous material that is difficult or impossible to draw into a syringe 2
  • May release sequestered naltrexone that can precipitate withdrawal in opioid-dependent patients 3, 4
• In one study, crushing MS-sNT capsules precipitated moderate-to-severe signs of opioid withdrawal in 50% of opioid-dependent patients 4

Alternative Administration Options

• For patients who have difficulty swallowing, some extended-release morphine formulations can be opened and the contents sprinkled over applesauce without crushing the pellets 5
• This method maintains the extended-release properties and bioavailability similar to taking the capsule whole 5
• The contents must be consumed without chewing to preserve the extended-release mechanism 5

Clinical Implications and Pitfalls

• Crushing controlled-release morphine can lead to rapid release of the full dose, potentially causing respiratory depression, overdose, and death 2, 6
• For patients requiring alternative administration routes, consider:
  • Subcutaneous administration (bolus injections every four hours or continuous infusion) 1, 7
  • Rectal administration (with the same potency ratio as oral: 1:1) 1
  • Appropriate formulations designed for sprinkling 5

Key Safety Considerations

• Always verify the specific product information before crushing any morphine formulation
• Never crush controlled/modified release formulations 1
• For patients unable to take oral medications, consider changing to an appropriate alternative formulation or route rather than crushing 1, 7