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Morphine
Cheryl HunterLamar University
November 12, 2015
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Morphine
Drugso 212.1 million drugs prescribed in the ED in 2008o Analgesics most prescribed drug class in ED in 2011(Center
for Disease Control and Prevention [CDC], 2011, table 2).• Morphine is the standard (Wenderworth, Kaneda, Amini, Amini, &
Patanwala, 2013). • 8% of patients in the ED receive at least one dose! (Wenderworth
et al., 2013).
http://www.theguardian.com/science/2007/aug/04/sciencenews
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The Emergency Department
Paino Accounts for 78% of emergency room visits(Todd et al., 2007). o Complex and difficult to defineo Varied etiology (Belden, DeFriez, & Huether, 2012).
http://www.doctorramey.com/the-pain-that-is-back-pain-part-one/
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Morphine Pharmacodynamics
o Pure opioid agonisto Mimics action of opioid peptides to bind with
mu receptors in pain centers of the CNS and spinal cord• Produces analgesic effect (Foy & Peterson, 2013; Lehne, 2013).
o Effective pain reliever• Best for severe, chronic, dull pain• Generally lowers pain 2 points on pain scale (Wenderworth et al.,
2013)• Pain more tolerable and less distressing• Reduces anxiety• Creates sense of well-being (Lehne, 2013)
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Morphine Potential Drug Interactionso Alcoholo Antihistamineso Benzodiazepineso Antidepressantso Phenothiazineso Antihypertensiveso Opioid agonistso Agonist-antagonist opioid (Lehne, 2013).
http://www.fierceemr.com/story/analysis-doc-notes-ehrs-can-flag-drug-interactions/2013-04-11
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Morphine
Adverse Effectso Urinary Retentiono Constipationo Respiratory distresso Orthostatic
hypotensiono Tolerance &
Dependence
o Nausea & Vomitingo Itchingo Dizzinesso Drowsinesso Dysphoria (Foy & Peterson,
2013; Lehne, 2013; Miller, Schauer, Ganem, & Bebarta, 2015).
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Morphine Pharmacokinetics
o Administration routes• PO, Rectal, IV, IM, intrathecal or intraspinal
o Distribution• Throughout the body• Limited lipid solubility
• Small amounts cross blood brain barriero Metabolism
• Almost completely in the liver• Three hour half-life• PO administration subject to first-pass effect
• Requires higher doseso Absorption
• GI tracto Excretion
• Renal (Foy & Peterson, 2013; Lehne, 2013) http://www.thetruthaboutforensicscience.com/pharmacology-part-2-pharmacokinetics/
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Morphine Pharmacogenomics
o Variations to the mu opioid receptor gene • Changes in pharmacodynamics and pharmacokinetics
• 118G allele require higher doses than 118A allele• G genotype have decreased analgesic response (Sia et al., 2013)
o Variations to CYP2D6 • Determine rate of metabolism
• Poor metabolizers• Intermediary metabolizers• Extensive metabolizers• Ultra-rapid metabolizers
• (Chummun, 2011; Sia et al., 2013; Wu & Kearney, 2013).
http://www.brunswick.k12.me.us/bhslibrary/genetics-research-ms-kirk/
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Morphine Binding Interactions
o Naloxone (Narcan)• Pure opioid antagonist• Structurally comparable to morphine
• Competes or blocks morphine at opioid receptors• Reduces pharmacological effects
• IV,IM or Sub Q• Hepatic metabolism
• Two hour half-life• Rapid first-pass effect makes PO route ineffective (Foy & Peterson,
2013; Lehne, 2013).
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Morphine & The Emergency
Department Interprofessional Team Communication and Patient Safety o Morphine Order Sets
• Developed by interprofessional team • Physicians• Nurses• Pharmacists
• Increase safety in ordering and administrationo Incident Reporting
• Adverse drug reactions• Sentinel events• Best practice improvements
http://certification.acsm.org/blog/2013/may/interprofessional-competencies-in-healthcare-four-core-domains
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Morphine & The Emergency Department Conclusion
o The benefits of understanding the pharmacodynamics, pharmacokinetics and pharmacogenomics of Morphine. . . • Assessment
• Signs and symptoms • Adverse reactions r/t morphine administration and disease process
• Drug interactions• Efficacy• Drug toxicity
• Genetic Variation• Rate of metabolism
• Practice• Patient Advocate
• effective• Safe, competent care
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References Belden, J., DeFriez, C., & Huether, S. E. (2012). Pain, temperature, sleep and sensory function. In S. E. Huether & K. L.
McCance (Eds.), Understanding pathophysiology (5th ed., pp. 324-345). St. Louis, MO: Elsevier. Center for Disease Control and Prevention. (2011). National hospital ambulatory medical care survey: 2011 emergency
department summary tables [Report]. Retrieved from http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdf
Chummun, H. (2011). Understanding pharmacogenomics: Applications in prescribing. Nurse Prescribing, 9(8), 402-407. Retrieved from http://www.nurseprescribing.com/
Forero, R., Mohsin, M., McCarthy, S., Young, L., Leraci, S., Hillman, K., ... Phung, H. (2008). Prevalence of morphine use and time to initial analgesia in an Australian emergency department. Emergency Medicine Australasia, 20, 136-143. http://dx.doi.org/10.1111/j.1742-6723.2008.01068.x
Foy, M., & Peterson, A. M. (2013). Principles of pharmacology in pain management. In V. P. Arcangelo & A. M. Peterson (Eds.), Pharmacotherapeutics for advanced practice (3rd ed., pp. 79-95). Ambler, PA: Lippincott Williams & Wilkins.
Lehne, R. A. (2013). Pharmacology for nursing care (8th ed.). St. Louis, MO: Elsevier. Miller, J. P., Schauer, S. G., Ganem, V. J., & Bebarta, V. S. (2015). Low-dose ketamine vs morphine for acute pain in the ED: A
randomized controlled trial. American Journal of Emergency Medicine, 33, 402-408. http://dx.doi.org/10.1016/j.ajem.2014.12.058
Peterson, A. M. (2013). Pharmacokinetic basis of therapeutics and pharmacodynamic principles. In V. P. Arcangelo & A. M. Peterson (Eds.), Pharmacotherapeutics for advanced practice (3rd ed., pp. 15-29). Ambler, PA: Lippincott Williams & Wilkins.
Sia, A. T., Lim, Y., Lim, E. C., Ocampo, C. E., Lim, W., Cheong, P., & Tan, E. (2013). Influence of mu-opioid receptor variant on morphine use and self-rated pain following abdominal hysterectomy. The Journal of Pain, 14(10), 1045-1052. http://dx.doi.org/10.1016/j.jpain.2013.03.008
Wenderworth, B. R., Kaneda, E. T., Amini, A., Amini, R., & Patanwala, A. E. (2013). Morphine versus Fentanyl for pain due to traumatic injury in the emergency department. Journal of Trauma Nursing, 20(1), 10-15. http://dx.doi.org/10.1097/JTN.Ob013e31828660b5
Wu, A. H., & Kearney, T. (2013). Lack of impairment due to confirmed codeine use prior to a motor vehicle accident: Role of pharmacogenomics. Journal of Forensic and Legal Medicine, 20, 1024-1027. http://dx.doi.org/10.1016/j.jflm.2013.09.019