Fast Fact and Concept #053: Sublingual Morphine

Author(s): Debra B. Gordon; David E. Weissman

The preferred route of analgesia for most patients in pain is oral ( PO), but alternative routes are used when patients cannot tolerate oral analgesics or when parenteral analgesics are required to provide a more rapid onset of pain relief. Sublingual (SL) morphine is an effective route of administration at end of life when patients can no longer swallow and parenteral opioids are not feasible or indicated.

The onset, peak, and duration of action of SL morphine is similar to oral morphine. Several studies conclude that much of the SL drug may actually be swallowed and absorbed in the GI tract. Some authors believe that SL administration provides a faster onset of pain relief compared to oral, but this has not been proven. One advantage of SL morphine over intermittent IV boluses, is a prolonged duration of action; an IV bolus may last only 1-2 hours, whereas SL morphine may provide relief for up to 4 hours.

There are two formulations of short acting morphine tablets, only one of which is intended for SL use, available in 10, 15, and 30 mg strengths. Note: liquid morphine preparations (e.g. 20 mg/cc concentrate) can also be delivered under the tongue. A usual starting dose for an opioid naïve patient is 10-15 mg SL or PO Q 3-4 hours. Remember, 30 mg of SL/PO morphine is approximately equianalgesic to 10 mg of parenteral morphine. Although orders are typically written as PRN, you should plan to offer and administer analgesics on a scheduled basis (around-the-clock) in the first several days, based on a patient's response, to provide ongoing analgesia.

As a rule, all published opioid starting doses and equianalgesic ratios should be thought of as a general reference guide to help avoid under or over dosing. Once chosen, the calculated dose is just a starting point for upward or downward dose titration based on the patient's individual response.

References:
Colluzzi PH. Sublingual morphine: efficacy reviewed. Journal of Pain and Symptom Management 1998 ;16(3):184-192.
Robinson JM, Wilkie DJ, Campbell Sublingual and oral morphine administration. Review and new findings. Nursing Clinics of North America 1995 ;30(4):725-743.

This Fast Fact was adopted with permission from: Pain Management Fast Facts; from the Pain Patient Care Team, University of Wisconsin Hospital & Clinics, Madison, WI, July 2001.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Fact and Concept #53 Gordon DB and Weissman DE. Sublingual Morphine. October, 2001. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.
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Please e-mail suggested future topics for Fast Facts; Let us know how you used this material-send an e-mail describing the educational format and the learner reaction. Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 10/2001

Purpose: Instructional Aid, Self-Study Guide

Audience(s)

Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice

Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery

Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Pain treatment