Slow-release oral morphine

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(Redirected from SROM)

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
  • Alcohol use, including intoxication and withdrawal
  • MAOI use within 14 days