MORPHINE SULPHATE (Oral) v01 1/8 MORPHINE SULPHATE (Oral) PGD Details Version 1.0 Legal category Staff grades Approved by POM Paramedic (Non-ECP) Nurse (Non-ECP) Emergency Care Practitioner (Paramedic) Emergency Care Practitioner (Nurse) Medicines Management Group Date issued 01/02/2013 Review date 31/01/2015 Clinical Publication Category Mandatory - No deviation from document permissible Clinical Requirements Competencies Continuing education Successful completion of a competency assessment in the use of this medicine for the indications stated. Completion of education in both the legal and professional aspects of PGD administration and the supply of medicines. The clinician is responsible for keeping him/herself aware of any changes to the recommendations for the medicine listed. It is the responsibility of the individual to keep up-to-date with continued professional development and to work within the limitations of their own individual scope of practice.
MORPHINE SULPHATE (Oral) v01 2/8 Clinical Situation Clinical situation Inclusion criteria Exclusion criteria The treatment of moderate to severe pain Adults and children aged 1 year and over with moderate to severe pain. Children under 1 year old. Patients unable to swallow or protect own airway. Delayed gastric emptying Phaeochromocytoma (tumour on adrenal gland) Heart failure secondary to chronic lung disease Acute respiratory depression (Adults <10 breaths per minute, child < 20 breaths per minute) or inadequate tidal volume. Asthma (during an acute exacerbation) Hypotension (actual not estimated) where systolic <90mmHg (adults), <80mmHg (school children), <70mmHg (pre-school children) Head injury with a significantly reduced level of consciousness (GCS<12). Hypersensitivity to morphine or other opiates Risk of paralytic ileus (associated clinical features are little or no abdominal pain/local tenderness, abdominal distension, failure to pass flatus or faeces, vomiting, significantly reduced or absent bowel sounds) Severe hepatic or renal impairment
MORPHINE SULPHATE (Oral) v01 3/8 Cautions Naloxone must be available and the appropriate dose for the age/weight of patient must be known before morphine is administered. Histamine is released following morphine administration, this may contribute to its vasodilator effects and may also cause bronchoconstriction, particularly in asthmatics. Patients with: Adrenocortical insufficiency Decreased respiratory reserve (ie COPD) Prostatic hypertrophy Gallstones Myasthenia gravis Cardiac arrhythmias Acute abdomen Pancreatitis Obstructive or inflammatory bowel disorders History of substance misuse (treat only if there is a genuine clinical need) Elderly and debilitated patients who may require a reduced dose. Acute alcohol intoxication and alcoholism. All opioid drugs potentiate the central nervous system depressant effects of alcohol and they should therefore be used with great caution in patients who have consumed a significant amount of alcohol Use with extreme caution (minimal doses) during pregnancy. NOTE not to be used for pain associated with labour where Entonox is the analgesic of choice. Morphine should be given with great caution to patients with chest injuries particularly those with any respiratory difficulty, although if respiration is inhibited by pain, morphine may actually improve respiratory status. Agitation following head injury may be due to acute brain injury, hypoxia or pain. The decision to administer analgesia to agitated head injured patients is a clinical one. It is essential however; that any such patient who receives analgesia is closely monitored as opiates may cause a disproportionate respiratory depression and hence increase intracranial pressure.
MORPHINE SULPHATE (Oral) v01 4/8 Patients taking monoamine oxidase inhibitors (MAOIs) should not be given morphine until their drug information card has been checked. Patients taking antidepressants, anxiolytics, sedatives or major tranquilliser drugs, as these will potentiate the respiratory and cardiovascular depressant effects of morphine. In cardiac pain entonox and IV morphine are the analgesics of choice. Only consider oral morphine when IV access cannot be obtained, and Entonox either cannot be administered or is in. Patients taking other opioid-containing preparations (see NPSA guidance below). Reducing Dosing Errors with Opioid Drugs: Opioid medicines are invaluable in the treatment of acute and chronic pain but there are risks if clinicians who supply or administer opioid drugs have insufficient knowledge of the dosage and the requirements of the individual patient concerned. The nature of urgent and emergency care increases this risk as practitioners do not usually have access to the patient notes and will have to rely on the information that they are given by the patient or their carer(s). Opioid drugs include: buphrenorphine, codeine, diamorphine, dipipanone, fentanyl, hydromorphone, meptazinol, methadone, morphine, oxycodone, papaveretum, pethidine and tramadol. These drugs are found in a wide variety of presentations including patches which release opioid over a prolonged period. The patient response to opioid drugs can vary widely and is partly dependent on previous doses received. Particular care needs to be taken when checking the safety of increased doses. When supplying or administering an opioid drug clinicians should confirm and record in the patient s notes any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient. This may be done for example
MORPHINE SULPHATE (Oral) v01 5/8 by discussion with the patient and /or their representative, contacting the prescriber or through available medical records. The source of this information must be recorded in the patient s notes. NB When assessing opioid use remember that over the counter medicines may also contain opioid drugs such as codeine, including some cough medicines. Codeine can also be prescribed for diarrhoea so ask about drugs by name. Clinicians must ensure that where a dose increase is intended, that the calculated dose is safe for the patient. The practitioner must record the check in the patient s notes. Clinicians must ensure that they are familiar with the following characteristics of an opioid drug before they prescribe it for a patient: Usual starting dose Frequency of administration Standard dosing increments Symptoms of overdose Common side-effects Side effects Nausea and vomiting Respiratory and cardiovascular depression Pupillary constriction Abdominal pain Seizures Malaise, drowsiness Hypothermia Muscle fasciculation Hypotension Muscle rigidity Other side-effects include constipation, anorexia, difficulty in micturation, ureteric or biliary spasm, dry mouth, headache, facial flushing, vertigo, bradycardia, tachycardia, palpitations, postural hypotension, hallucinations, hypothermia, dysphoria, mood changes, dependence, decreased libido or potency, rashes, pruritis.
MORPHINE SULPHATE (Oral) v01 6/8 Action if excluded Action if patient declines If patient meets exclusion criteria: Explain reason to patient/carer Consider alternative pain management Refer to an ECP or Doctor Document the specific exclusion and any action taken on the PCR. If patient declines treatment or advice ensure that the PCR details: The advice given by the clinician Details of any referral made The intended actions of the patient (including parent or guardian)
MORPHINE SULPHATE (Oral) v01 7/8 Description of Treatment Generic name Presentation Route Morphine sulphate Oral solution 10mg in 5ml (2mg in 1ml) Oral Method Administration Supply Dose Adults and children aged 12 years and over: 10mg to 20mg (NB Total quantity of morphine administered by one paramedic, parenteral and/or oral, to an individual patient must not exceed 20mg) Frail elderly patients may require a reduced dose of 5mg Children 11 years and under: AGE DOSE VOLUME 11 years 7 milligrams 3.5ml 10 years 6 milligrams 3.0ml 9 years 6 milligrams 3.0ml 8 years 5 milligrams 2.5ml 7 years 5 milligrams 2.5ml 6 years 4 milligrams 2.0ml 5 years 4 milligrams 2.0ml 4 years 3 milligrams 1.5ml 3 years 3 milligrams 1.5ml 2 years 2.0 milligrams 1.0ml 1 years 2.0 milligrams 1.0ml
MORPHINE SULPHATE (Oral) v01 8/8 Frequency Duration of treatment The onset of action will be longer for oral morphine than parenteral morphine. Side-effects will not become immediately apparent and may occur up to 15 minutes after administration. For children and adults aged 12 years and over administer up to 10mg oral dose initially. This dose may be reduced to 5mg in frail elderly patients and those with reduced body mass. Note the response and if needed give a further dose of 10mg (5mg frail elderly) after 30 minutes. Single episode of care
MORPHINE SULPHATE (Oral) v01 9/8 Follow Up Referral arrangements and safety netting Advice to patients Records References All children given oral morphine sulphate must be admitted. There is no requirement to admit adults, where their condition can be managed in the community. However, the clinician must consider the onward plan after the single dose of oral morphine. The patient should be referred to an ECP, their GP or out-of-hours Doctor for consideration of on-going analgesia. Monitor the patient for pain relief and side-effects Adults who are not admitted must be monitored for at least 20 minutes before they are left at home. If a patient is left at home they must have another adult at home with them. The patient and the responsible adult with them must be told to seek further medical advice if they become generally unwell, if there is no improvement within 48hrs or if there is deterioration in their condition. May cause drowsiness. Adults who are left at home should not drive or operate machinery if affected. Avoid alcoholic drink as this may increase drowsiness Warn that morphine may cause nausea Complete patient clinical record (PCR) Morphine sulphate oral solution 10mg in 5ml is a Schedule 5 controlled drug. Staff must carry out a stock check when issuing morphine sulphate oral solution 10mg in 5ml and ensure that the supply, and the remaining stock balance are recorded as necessary. Any discrepancy in the stock level that is discovered must be reported to your line manager and an investigation instigated as detailed in the Trust s Medicines Management Policy. British National Formulary 64 September 2012 (BNF) JRCALC Guidelines National Patient Safety Agency, Rapid Response Report NPSA/2008/RRR05. Reducing dosage errors with opioid medicines. July 2008.
MORPHINE SULPHATE (Oral) v01 10/8 Authorisation Chief Executive Officer Ken Wenman Signature Date 01/02/2013 Medical Director Dr Andy Smith Signature Date 01/02/2013 Pharmaceutical Advisor Sue Oakley Signature Date 01/02/2013 This must be signed by the Chief Executive Officer, Medical Director and Pharmaceutical Advisor to be legally valid.
MORPHINE SULPHATE (Oral) v01 11/8 Individual Authorisation (Staff Copy) Individual Signature Date / / Authorising officer Signature Date / / I have read and understood the Patient Group Direction and agree to administer this medicine only in accordance with this document. PGDs do not remove inherent professional obligations or accountability. It is the responsibility of each professional to practice only within the bounds of their own competence and in accordance with their own Code of Professional Conduct. This signed page must be retained by the member of staff, together with the full PGD, which must be available in clinical practice.
MORPHINE SULPHATE (Oral) v01 12/8 Individual Authorisation (Trust Copy) Individual Signature Date / / Authorising officer Signature Date / / I have read and understood the Patient Group Direction and agree to administer this medicine only in accordance with this document. PGDs do not remove inherent professional obligations or accountability. It is the responsibility of each professional to practice only within the bounds of their own competence and in accordance with their own Code of Professional Conduct. This signed page copy of the PGD must be retained by the station Clinical Support Officer, Clinical Team Leader or Lead Paramedic in a station file which is available for inspection upon request.