Download Morphine (oral)

MORPHINE SULPHATE (Oral) | v01 | 1/8
patient group direction
M O R P H I N E S U L P H AT E ( O r a l )
PGD Details
Version
1.0
Legal category
POM
Staff grades
Paramedic (Non-ECP)
Nurse (Non-ECP)
Emergency Care Practitioner (Paramedic)
Emergency Care Practitioner (Nurse)
Approved by
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.
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Clinical Situation
Clinical
situation
❙❙ The treatment of moderate to severe pain
Inclusion
criteria
❙❙ Adults and children aged 1 year and over with moderate to
severe pain.
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Exclusion
criteria
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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
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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.
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❙❙ 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 ineffective.
❙❙ 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
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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
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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.
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Action if
excluded
❙❙ 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.
Action if
patient
declines
❙❙ 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)
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Description of Treatment
Generic name
❙❙ Morphine sulphate
Presentation
❙❙ Oral solution 10mg in 5ml (2mg in 1ml)
Route
❙❙ Oral
Method
Administration Supply
❙❙ 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:
Dose
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
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Frequency
❙❙ 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.
Duration of
treatment
❙❙ Single episode of care
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Follow Up
Referral
arrangements
and safety
netting
❙❙ 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.
Advice to
patients
❙❙ 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
Records
❙❙ 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.
References
❙❙ 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.
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Authorisation
Chief Executive
Officer
Name
Ken Wenman
Signature
Medical
Director
Name
01/02/2013
Date
01/02/2013
Date
01/02/2013
Dr Andy Smith
Signature
Name
Date
Sue Oakley
Pharmaceutical
Advisor
Signature
❙❙ This patient group direction must be signed by the Chief Executive Officer,
Medical Director and Pharmaceutical Advisor to be legally valid.
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Individual Authorisation (Staff Copy)
Name
Individual
Signature
Date
/ / Date
/ / Name
Authorising officer
Signature
❙❙ 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.
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Individual Authorisation (Trust Copy)
Name
Individual
Signature
Date
/ / Date
/ / Name
Authorising officer
Signature
❙❙ 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.
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