Opioid · Analgesic
Morphine
Indications
- Acute severe pain needing an IV opioid, including PCA
- Analgesia in ventilated ICU patients (fentanyl or hydromorphone is often preferred)
- Intrathecal or epidural analgesia with preservative-free morphine, as after cesarean delivery
- ACS chest pain not relieved by nitrates
- End-of-life dyspnea (off-label)
Dosing
| Where | Dose |
|---|---|
| Other common pushes | Morphine: 2–4 mg IV every 5–15 min; histamine release, hypotension |
| Opioid equianalgesic doses | Morphine: 10 mg IV = 30 mg PO |
| Other ICU drugs | Morphine: Avoid: active metabolites accumulate (sedation, respiratory depression) |
On the quick cards
- Other common pushesPush and Emergency Meds: Analgesia, antiemetics, steroids, diuretics, TXA
- Opioid equianalgesic dosesEquivalents and Conversions: Equal to morphine 10 mg IV
Mechanism of action
Morphine, the prototype opioid, is a full agonist relatively selective for the μ-opioid receptor, with weaker κ and δ activity. Through Gi/o proteins it lowers cAMP, opens GIRK potassium channels that hyperpolarize postsynaptic neurons and closes presynaptic calcium channels, so pain fibers release less transmitter. Being hydrophilic, it reaches brain and spinal receptors slowly, and its active metabolite M6G adds to and prolongs the effect.
Pharmacology
- CNS: analgesia, sedation, euphoria or dysphoria, miosis, nausea, cough suppression
- Respiratory: slower rate and blunted CO₂ response; histamine can provoke bronchospasm in asthma
- Cardiovascular: histamine release and vasodilation lower preload and BP, worse with fast pushes or hypovolemia
- GI: constipation, slowed gastric emptying (delays oral P2Y12 inhibitors, IMPRESSION), biliary spasm
- Other: itching and flushing, worst after neuraxial doses; urinary retention
Pharmacokinetics
| Onset | About 5 min IV; it crosses the BBB slowly |
|---|---|
| Peak | About 15–30 min IV |
| Duration | 3–5 h IV; up to 24 h after one neuraxial dose (Duramorph label) |
| Half-life | Usually 1.5–2 h (range 1.5–4.5 h, label) |
| Distribution | Vd 1.0–4.7 L/kg; little first-pass lung uptake; crosses the placenta |
| Protein binding | About 36% (label); other sources 20–35% |
| Metabolism | UGT2B7 glucuronidation, mainly hepatic, to M3G (about 90% of glucuronides; no analgesia, neuroexcitatory) and M6G (about 10%; an active μ agonist) |
| Elimination | Urine as glucuronides; 2–12% unchanged; about 10% in feces (label) |
| Organ failure | Kidney failure: M6G (sedation, respiratory depression) and M3G (myoclonus, seizures) accumulate; avoid or reduce |
| Bioavailability | Oral 20–40% (first pass), hence IV:PO about 1:3 |
Chemistry
- Natural phenanthrene alkaloid from the opium poppy: a rigid five-ring 4,5-epoxymorphinan whose 3-phenol and 6-alcohol carry the glucuronides
- Five chiral centers; only the natural (−) isomer is active
- pKa 7.9 (label), so about a quarter is un-ionized at pH 7.4; octanol:water partition only 1.42, so it enters the brain slowly and spreads upward in CSF after neuraxial doses
- Injection pH 2.5–6.5; neuraxial use needs preservative-free products (Duramorph, Infumorph); protect from light and discard if darker than pale yellow (label)
Adverse effects and cautions
In the one-pagers
- Sedation, Pain and Delirium ScalesPharmacology and ICU pitfalls: Morphine: 2–30 mg/h: Histamine release; M6G builds up in AKI
- Acute Kidney InjuryNursing actions: Pharmacist review: full loading doses, adjusted maintenance, drug levels; avoid morphine and NSAIDs
- End of Life, Brain Death and Organ DonationWithdrawing life support: Morphine: 2–10 mg: 0.05–0.5 mg/kg/h
- Right Heart Failure and Pulmonary HypertensionCauses in the ICU: RV infarction (inferior STEMI with ST elevation in V4R): a stunned RV facing a normal PVR is preload-dependent, so cautious fluid, AV synchrony and reperfusion help, and nitrates, diuretics and morphine harm.
- Acute Abdomen and GI Surgical EmergenciesReading the acute abdomen: High-risk groups are the very old, the very young and anyone on corticosteroids or other immunosuppressants. These drugs blunt the inflammatory response, so a perforation can cause less pain, less tenderness and a smaller WBC rise than expected; a new tachycardia may be the main clue. Merck states that moderate IV analgesia (fentanyl 50-100 mcg or morphine 4-6 mg) does n
- Asthma and COPD ExacerbationsSedation, paralysis and rescue therapies: Deep sedation early suppresses the air hunger that drives a fast rate and dyssynchrony. Propofol (bronchodilating, but hypotensive) with fentanyl is common; ketamine adds bronchodilation with less hypotension but more secretions; avoid morphine, which releases histamine. Lighten sedation as obstruction resolves.
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Sources
- FDA label: Morphine Sulfate Injection, Hikma (2026)
- FDA label: Duramorph (2025)
- PubChem: morphine
- Gabel 2022 (morphine glucuronides)
For education and exam preparation only. Follow your institution’s protocols. Typical adult values for study. Follow the order, the label and your institution's protocols.