Background
- Morphine sulphate sustained release capsules (Kadian)
- Beads contain both immediate release and slow release morphine
- IR released by stomach acid and SR released in bowels at higher pH
- Capsules themselves may pass in the stool
- Full opioid agonist
- Approved for chronic pain, but used off-label for opioid use disorder
- Appears likely to be equivalent to methadone, but higher patient satisfaction
- Peak plasma level 8.5 to 10 hours
- Elimination half life 11 13 hours
Dosing
- For daily dispensed, often opened and sprinkled on apple sauce or yoghurt, or water
- Capsule sizes include 10, 20, 50, and 100 mg
- Specify on the prescription if it is being used for OUD or chronic pain
BC OUD Guidelines
- Eligible in age >19 and switching from methadone or actively using opioids
- When transitioning from methadone, the eventual dose will usually be 8 times higher, but generally should start with a 4-times higher dose to be safe
- Increase by 30 to 60 mg daily q48h
- For other opioids, start with dose of 30 to 60 mg
- Increase doses q48h based on withdrawal symptoms
- Average stable doses are 60 to 1200 mg daily
Missed Doses
| Number missed | Action |
|---|---|
| 1 | no change |
| 2 | 40% reduction |
| 3 | 60% reduction |
| 4 | 80% reduction |
| 5 | re-initiate |
St. Michael's Protocol
| Day | Slow-release morphine | Instant-release morphine |
|---|---|---|
| 1 | 200-300 mg | 30-50 mg po q2h while awake + 30-50 mg po q3h prn |
| 2 | SR dose from Day 1 + 50% of IR dose from Day 3 | 30-50 mg po q2h while awake + 30-50 mg po q3h prn |
| 3 | SR dose from Day 2 | 30-50 mg po q3h prn |
| 4 | SR dose from Day 3 + 50% of IR dose from Day 3 | 30-50 mg po q3h prn |
| 5 | SR dose from Day 4 | 30-50 mg po q3h prn |
| 6 | SR dose from Day 5 + 50% of IR dose from Day 5 | 30-50 mg po q3h prn |
Off-Guideline
- For induction from methadone or non-methadone opioids with high opioid tolerance
- Start at 200 to 300 mg, then increase by 100 to 150 q48h
- Missed days
- 1: full
- 2: 50% reduction
- 3: 75% reduction or resume at initiation dose
- 4: resume at initiation dose
Carries
- Per guidelines, doses should be indefinitely witness ingestion
- However, may be reasonable to do same for methadone
- No carrier x 8 weeks, then one carry per week every month with weekly urine drug screens
Switch to Methadone
- Must stop SROM and start methadone titration from 30 mg
Switch to M-Eslon
- Split SROM dose for BID M-Eslon
- Dosages include 10, 15, 30, 60, 100, and 200 mg
Safety
- Adverse effects include GI cramping, abdominal pain, headache, hyperhidrosis, constipation, frequent urination, nausea/vomiting, and insomnia
- Risk of respiratory depression and other forms of opioid toxicity
- Safe in pregnancy
- Small RCT suggests no difference from methadone in neonatal outcomes but possibly lower unprescribed drug use in SROM
Contraindications
- Hypersensitivity to morphine
- Respiratory
- Significant respiratory depression
- Acute or severe bronchial asthma
- Severe respiratory compromise or obstructive disease
- Gastrointestinal
- Known or suspected paralytic ileus
- Short gut syndrome of transit time abnormalities
- Alcohol use, including intoxication and withdrawal
- MAOI use within 14 days
