What is the recommended protocol for ordering a morphine (opioid) drip?

How to Order a Morphine Drip

For continuous intravenous morphine infusion, start with 0.1-0.2 mg/kg every 4 hours (or as a continuous infusion at equivalent hourly rates) in opioid-naïve adults, with careful titration based on pain response and side effects. 1

Initial Assessment and Route Selection

• Intravenous morphine is indicated for severe pain requiring rapid titration, particularly in patients unable to take oral medications or those with pain intensity NRS ≥5. 2
• The IV route achieves peak effects within 15-30 minutes, making it superior to oral administration for rapid pain control. 3
• Prescribe morphine sulfate injection with both the total dose in mg AND total volume to prevent fatal dosing errors between different concentrations. 1

Starting Doses for IV Morphine

For Opioid-Naïve Patients:

• Start with 0.1-0.2 mg/kg every 4 hours as the FDA-approved initial dose. 1
• For severe cancer pain requiring rapid titration: 1.5 mg IV bolus every 10 minutes until pain relief or adverse effects occur. 2, 4
• The median dose to achieve pain relief with this protocol is 4.5 mg (range 1.5-34.5 mg). 2

For Patients Transitioning from Weak Opioids:

• Consider starting at the lower end of the dosing range (0.1 mg/kg). 1
• Oral to IV conversion ratio is 2:1 to 3:1 (e.g., 30 mg oral morphine = 10-15 mg IV morphine). 2

Continuous Infusion Protocol

• After initial bolus titration, convert to continuous infusion by calculating the total IV morphine required in the first 24 hours. 2
• Divide the 24-hour total by 24 to get the hourly infusion rate.
• Provide breakthrough doses equal to 10-15% of the total daily dose, available every 15-30 minutes for IV administration. 2, 3

Titration and Dose Adjustment

• Review total morphine consumption (basal infusion plus breakthrough doses) every 24 hours. 2, 5
• If more than 4 breakthrough doses are needed per day, increase the baseline infusion rate. 2
• Steady state is achieved within 24 hours after dose changes, making this the appropriate interval for reassessment. 2
• Administer all IV morphine slowly—rapid injection can cause chest wall rigidity. 1

Critical Safety Measures

Monitoring Requirements:

• Have naloxone and resuscitative equipment immediately available before initiating therapy. 1
• Morphine administration should be limited to clinicians experienced in managing respiratory depression. 2, 1
• Monitor for respiratory depression, particularly in elderly, debilitated patients, or those with COPD. 1

Dose Modifications:

• In renal impairment (eGFR <30 mL/min), start with lower doses and titrate slowly—morphine metabolites accumulate and cause toxicity. 2
• In hepatic cirrhosis, start cautiously with reduced doses. 1
• For patients >70 years old, consider starting at the lower end of the dosing range. 6

Concurrent Medications

• Prescribe laxatives routinely for prophylaxis of opioid-induced constipation. 2
• Prescribe antiemetics (metoclopramide or antidopaminergics) for opioid-related nausea/vomiting. 2
• Avoid combining with mixed agonist-antagonist opioids, which can precipitate withdrawal. 5

Common Pitfalls to Avoid

• Do not use modified-release formulations for initial titration—their delayed peak (2-6 hours) and prolonged duration make rapid dose adjustment impossible. 2, 5
• Do not prescribe morphine drips without specifying both mg dose and volume—concentration confusion causes fatal overdoses. 1
• Do not adjust doses more frequently than every 24 hours for IV morphine—steady state requires this time interval. 2, 5
• Avoid buccal, sublingual, or nebulized routes—absorption is unpredictable with no clinical advantage. 3

Transition to Oral Therapy

• Once pain is controlled on IV morphine, convert to oral immediate-release morphine every 4 hours using a 1:2 to 1:3 IV:oral ratio. 2
• After stabilization on immediate-release oral morphine, transition to sustained-release formulations for convenience. 2