Preservative-free morphine sulfate injection is an opioid agonist, indicated for:

1.

the management of pain severe enough to require use of an opioid analgesic by intravenous administration and for which alternative treatments are not expected to be adequate.

2.

the epidural or intrathecal management of pain without attendant loss of motor, sensory, or sympathetic function. (1)

Limitations of Use

Preservative-free morphine sulfate injection is not for use in Continuous Microinfusion Devices.

Because of the risks of addiction, abuse, misuse, overdose, and death, which can occur at any dosage or duration and persist over the course of therapy, reserve opioid analgesics, including preservative-free morphine sulfate injection for use in patients for whom alternative treatment options are ineffective, not tolerated or would be otherwise inadequate to provide sufficient management of pain.‎ (1, 5.2)

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Preservative-free morphine sulfate injection should be prescribed only by healthcare professionals who are knowledgeable about the use of opioids and how to mitigate the associated risks. (2.1)

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Should be administered by or under the direction of a physician experienced in the techniques of epidural or intrathecal administration. (2.1)

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Use the lowest effective dosage for the shortest duration of time consistent with individual patient treatment goals. Reserve titration to higher doses of preservative-free morphine sulfate injection for patients in whom lower doses are insufficiently effective and in whom the expected benefits of using a higher dose opioid clearly outweigh the substantial risks. (2.2, 5)

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Initiate the dosing regimen for each patient individually, taking into account the patient’s underlying cause and severity of pain, prior analgesic treatment and response, and risk factors for addiction, abuse, and misuse. (2.1,5.2)

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Respiratory depression can occur at any time during opioid therapy, especially when initiating and following dosage increases with preservative-free morphine sulfate injection. Consider this risk when selecting an initial dose and when making dose adjustments. (2, 5.3)

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Dosage for Intravenous Administration: 2 mg to 10 mg/70 kg of body weight. (2.3)

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Dosage for Epidural Administration: Initial injection of 5 mg in the lumbar region may provide satisfactory pain relief for up to 24 hours. If adequate pain relief is not achieved within one hour, carefully administer incremental doses of 1 to 2 mg at intervals sufficient to assess effectiveness. Administer no more than 10 mg/24 hr. (2.4)

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Dosage for Intrathecal Administration: A single injection of 0.2 to 1 mg may provide satisfactory pain relief for up to 24 hours. Repeated intrathecal injections of preservative-free morphine sulfate injection are not recommended. (2.5)

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Periodically reassess patients receiving preservative-free morphine sulfate injection to evaluate the continued need for opioid analgesics to maintain pain control, for the signs or symptoms of adverse reactions, and the development of addiction, abuse or misuse. (2.6)

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Do not rapidly reduce or abruptly discontinue preservative-free morphine sulfate injection abruptly in a physically-dependent patient. (2.6, 5.16)

Injection: 5 mg/10 mL (0.5 mg/mL) Preservative-free fliptop vials (3)

Injection: 10 mg/10 mL (1 mg/mL) Preservative-free fliptop vials (3)

Preservative-free morphine sulfate injection is contraindicated in patients with:

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Significant respiratory depression (4)

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Acute or severe bronchial asthma in an unmonitored setting in absence of resuscitative equipment (4)

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Concurrent use of monoamine oxidase inhibitors (MAOIs) or use of MAOIs within the last 14 days (4)

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Known or suspected gastrointestinal obstruction, including paralytic ileus (4)

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Hypersensitivity or intolerance to morphine (4)

Neuraxial administration of preservative-free morphine sulfate injection is contraindicated in patients with:

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Infection at the injection microinfusion site (4)

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Concomitant anticoagulant therapy (4)

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Uncontrolled bleeding diathesis (4)

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The presence of any other concomitant therapy or medical condition which would render epidural or intrathecal administration of medication especially hazardous. (4)

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Risk of Tolerance and Myoclonic Activity: Monitor patients for unusual acceleration of neuraxial morphine, which may cause myoclonic-like spasm of lower extremities. Detoxification may be required. (5.6)

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Chest Wall Rigidity: Rapid intravenous administration may result in chest wall rigidity. (5.7)

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Opioid Induced Hyperalgesia and Allodynia: Opioid Induced Hyperalgesia (OIH) occurs when an opioid analgesic paradoxically causes an increase in pain, or an increase in sensitivity to pain. If a patient is suspected to be experiencing OIH, carefully consider appropriately decreasing the dose of the current opioid analgesic, or opioid rotation (safely switching the patient to a different opioid moiety). (5.8)

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Life-Threatening Respiratory Depression in Patients with Chronic Pulmonary Disease or in Elderly, Cachectic, or Debilitated Patients: Monitor closely, particularly during initiation and titration. (5.9)

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Adrenal Insufficiency: If diagnosed, treat with physiologic replacement of corticosteroids, and wean patient off of the opioid. (5.11)

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Severe Hypotension: Monitor during dosage initiation and titration. Avoid use of preservative-free morphine sulfate injection in patients with circulatory shock. (5.12)

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Risks of Use in Patients with Increased Intracranial Pressure, Brain Tumors, Head Injury, or Impaired Consciousness: Monitor for sedation and respiratory depression. Avoid use of preservative-free morphine sulfate injection in patients with impaired consciousness or coma. (5.13)

Most serious adverse reactions were respiratory depression and/or respiratory arrest. (6)

To report SUSPECTED ADVERSE REACTIONS, contact Pfizer, Inc. at 1-800-438-1985 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

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Serotonergic Drugs: Concomitant use may result in serotonin syndrome. Discontinue preservative-free morphine sulfate injection if serotonin syndrome is suspected. (7)

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Mixed Agonist/Antagonist and Partial Agonist Opioid Analgesics: Avoid use with preservative-free morphine sulfate injection because they may reduce the analgesic effect of preservative-free morphine sulfate injection or precipitate withdrawal symptoms. (7)

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Pregnancy: May cause fetal harm. (8.1)