Morphine sulfate

Actavis Elizabeth LLC

HIGHLIGHTS OF PRESCRIBING INFORMATION BOXED WARNING WARNING: ADDICTION, ABUSE, AND MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; NEONATAL OPIOID WITHDRAWAL SYNDROME; and INTERACTION WITH ALCOHOL See full prescribing information for complete boxed warning . Morphine sulfate extended-release exposes users to risks of addiction, abuse, and misuse, w hich can lead to overdose and death. Assess each patient’s risk before prescribing, and monitor regularly for development of these behaviors or conditions. (5.1) Serious, life-threatening, or fatal respiratory depression may occur. Monitor closely, especially upon initiation or following a dose increase. Instruct patients to swallow morphine sulfate extended-release capsules whole to avoid exposure to a potentially fatal dose of morphine. (5.2) Accidental ingestion of morphine sulfate extended-release capsules, especially in children, can result in fatal overdose of morphine. (5.2) Prolonged use of morphine sulfate extended-release during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available. (5.3) Instruct patients not to consume alcohol or any products containing alcohol while taking morphine sulfate extended-release because co-ingestion can result in fatal plasma morphine levels. (5.4) RECENT MAJOR CHANGES Boxed WarningIndications and Usage (1)Dosage and Administration (2)     Warnings and Precautions (5)  04/201404/201404/201404/2014 INDICATIONS AND USAGEMorphine sulfate extended-release is an opioid agonist intended for once-daily administration indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. (1) Limitations of Use Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve morphine sulfate extended-release for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain.(1) Morphine sulfate extended-release is not indicated as an as-needed (prn) analgesic. (1) DOSAGE AND ADMINISTRATION Morphine sulfate extended-release 90 mg and 120 mg capsules are only for patients in whom tolerance to an opioid of comparable potency is established. Patients considered opioid-tolerant are those taking, for one week or longer, at least 60 mg of morphine daily, at least 30 mg of oral oxycodone daily, at least 8 mg of oral hydromorphone daily, or an equianalgesic dose of another opioid. (2.1) For opioid-naïve and opioid non-tolerant patients, initiate with 30 mg capsules orally every 24 hours. Dose can be increased every 3 to 4 days using increments of 30 mg. (2.1, 2.2) Do not abruptly discontinue morphine sulfate extended-release in a physically-dependent patient. (2.3, 5.11) Instruct patients to swallow morphine sulfate extended-release capsules intact, or to sprinkle the capsule contents on applesauce and immediately swallow without chewing. (2.4) DOSAGE FORMS AND STRENGTHSExtended-release capsules: 30 mg, 45 mg, 60 mg, 75 mg, 90 mg, 120 mg (3)CONTRAINDICATIONS Significant respiratory depression (4) Acute or severe bronchial asthma (4) Known or suspected paralytic ileus (4) Hypersensitivity to morphine (4) WARNINGS AND PRECAUTIONS Interactions with CNS depressants: Concomitant use may cause profound sedation, respiratory depression, and death. If coadministration is required, consider dose reduction of one or both drugs because of additive pharmacological effects. (5.4, 7.2) Elderly, cachectic, debilitated patients, and those with chronic pulmonary disease: Monitor closely because of increased risk for life-threatening respiratory depression. (5.5, 5.6) Hypotensive effect: Monitor during dose initiation and titration. (5.7) Patients with head injury or increased intracranial pressure: Monitor for sedation and respiratory depression. Avoid use of morphine sulfate extended-release in patients with impaired consciousness or coma susceptible to intracranial effects of CO2 retention. (5.8) Side EffectsMost common adverse reactions (greater than or equal to 10%) are constipation, nausea, somnolence, vomiting and headache. (6.1) To report SUSPECTED ADVERSE REACTIONS, contact Actavis at 1-800-432-8534 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch DRUG INTERACTIONS Mixed agonist/antagonist and partial agonist opioid analgesics: Avoid use with morphine sulfate extended-release because they may reduce analgesic effect of morphine sulfate extended-release or precipitate withdrawal symptoms. (5.11, 7.3) Monoamine oxidase inhibitors (MAOIs): Avoid morphine sulfate extended-release in patients taking MAOIs or within 14 days of stopping such treatment. (7.5) USE IN SPECIFIC POPULATIONS Pregnancy: Based on animal data, may cause fetal harm. (8.1) Nursing mothers: Morphine has been detected in human milk. Closely monitor infants of nursing women receiving morphine sulfate extended-release. (8.3)

FULL PRESCRIBING INFORMATION: CONTENTS*

• Medication Guide

FULL PRESCRIBING INFORMATION

Morphine sulfate extended-release capsules, USP (once daily) are indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.

Limitations of Use

• Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve morphine sulfate extended-release for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain.
• Morphine sulfate extended-release is not indicated as an as-needed (prn) analgesic.

Morphine sulfate extended-release should be prescribed only by healthcare professionals who are knowledgeable in the use of potent opioids for the management of chronic pain.

Morphine sulfate extended-release 90 mg and 120 mg capsules are for use only in patients in whom tolerance to an opioid of comparable potency has been established. Patients who are opioid tolerant are those receiving, for one week or longer, at least 60 mg oral morphine per day, 25 mcg transdermal fentanyl per hour, 30 mg oral oxycodone per day, 8 mg oral hydromorphone per day, 25 mg oral oxymorphone per day, or an equianalgesic dose of another opioid.

Initiate the dosing regimen for each patient individually, taking into account the patient's prior analgesic treatment experience and risk factors for addiction, abuse, and misuse [ see Warnings and Precautions (5.1)]. Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of initiating therapy with morphine sulfate extended-release [ see Warnings and Precautions (5.2)].

Morphine sulfate extended-release capsules must be taken whole. Crushing, chewing, or dissolving the pellets in morphine sulfate extended-release capsules will result in uncontrolled delivery of morphine and can lead to overdose or death [see Warnings and Precautions (5.2)]. Patients who are unable to swallow morphine sulfate extended-release should be instructed to sprinkle the capsule contents on applesauce and immediately swallow without chewing [see Administration of Morphine Sulfate Extended-Release Capsules (2.4)].

Morphine sulfate extended-release is administered at a frequency of once daily (every 24 hours).

Use of Morphine Sulfate Extended-Release as the First Opioid Analgesic
Initiate treatment with morphine sulfate extended-release with 30 mg capsule orally every 24 hours. Adjust the dose of morphine sulfate extended-release in increments not greater than 30 mg every 3 to 4 days.

Use of Morphine Sulfate Extended-Release in Patients who are not Opioid Tolerant
The starting dose for patients who are not opioid tolerant is morphine sulfate extended-release 30 mg orally every 24 hours. Patients who are opioid tolerant are those receiving, for one week or longer, at least 60 mg oral morphine per day, 25 mcg transdermal fentanyl per hour, 30 mg oral oxycodone per day, 8 mg oral hydromorphone per day, 25 mg oral oxymorphone per day, or an equianalgesic dose of another opioid.

Use of higher starting doses in patients who are not opioid tolerant may cause fatal respiratory depression.

Conversion from Other Opioids to Morphine Sulfate Extended-Release
There are no established conversion ratios from other opioids to morphine sulfate extended-release defined by clinical trials. Discontinue all other around-the-clock opioid drugs when morphine sulfate extended-release therapy is initiated and initiate dosing using morphine sulfate extended-release 30 mg orally every 24 hours.

While there are useful tables of opioid equivalents readily available, there is substantial inter-patient variability in the relative potency of different opioid drugs and products. As such, it is safer to underestimate a patient’s 24-hour oral morphine requirements and provide rescue medication (e.g., immediate-release morphine) than to overestimate the 24-hour oral morphine requirements which could result in adverse reactions.

Conversion from Other Oral Morphine Formulations to Morphine Sulfate Extended-Release
Patients receiving other oral morphine formulations may be converted to morphine sulfate extended-release by administering the patient's total daily oral morphine dose as morphine sulfate extended-release once-daily. Morphine sulfate extended-release should not be given more frequently than every 24 hours.

Conversion from Parenteral Morphine or Other Non-Morphine Opioids (Parenteral or Oral) to Morphine Sulfate Extended-Release
When converting from parenteral morphine or other non-morphine opioids (parenteral or oral) to morphine sulfate extended-release, consider the following general points:

Parenteral to oral morphine ratio: Between 2 to 6 mg of oral morphine may be required to provide analgesia equivalent to 1 mg of parenteral morphine. Typically, a dose of morphine that is approximately three times the previous daily parenteral morphine requirement is sufficient.

Other parenteral or oral non-morphine opioids to oral morphine sulfate: Specific recommendations are not available because of a lack of systematic evidence for these types of analgesic substitutions. Published relative potency data are available, but such ratios are approximations. In general, begin with half of the estimated daily morphine requirement as the initial dose, managing inadequate analgesia by supplementation with immediate-release morphine.

Conversion from Methadone to Morphine Sulfate Extended-Release
Close monitoring is of particular importance when converting from methadone to other opioid agonists. The ratio between methadone and other opioid agonists may vary widely as a function of previous dose exposure. Methadone has a long half-life and can accumulate in the plasma.

The first dose of morphine sulfate extended-release may be taken with the last dose of any immediate-release opioid medication due to the extended-release characteristics of the morphine sulfate extended-release formulation.

Individually titrate morphine sulfate extended-release to a dose that provides adequate analgesia and minimizes adverse reactions. Continually reevaluate patients receiving morphine sulfate extended-release to assess the maintenance of pain control and the relative incidence of adverse reactions, as well as monitoring for the development of addiction, abuse, or misuse. Frequent communication is important among the prescriber, other  members of the healthcare team, the patient, and the caregiver/family during periods of changing analgesic requirements, including initial titration. During chronic therapy, periodically reassess the continued need for opioid analgesics.

If the level of pain increases, attempt to identify the source of increased pain, while adjusting the morphine sulfate extended-release dose to decrease the level of pain. Because steady-state plasma concentrations are approximated within 2 to 3 days, morphine sulfate extended-release dosage adjustments may be done every 3 to 4 days.

Patients who experience breakthrough pain may require a dose increase of morphine sulfate extended-release, or may need rescue medication with an appropriate dose of an immediate-release analgesic. If the level of pain increases after dose stabilization, attempt to identify the source of increased pain before increasing the morphine sulfate extended-release dose.

The daily dose of morphine sulfate extended-release must be limited to a maximum of 1600 mg/day. Morphine sulfate extended-release doses of over 1600 mg/day contain a quantity of fumaric acid that has not been demonstrated to be safe, and which may result in serious renal toxicity.

If unacceptable opioid-related adverse reactions are observed, the subsequent doses may be reduced. Adjust the dose to obtain an appropriate balance between management of pain and opioid-related adverse reactions.

When a patient no longer requires therapy with morphine sulfate extended-release, use a gradual downward titration of the dose every 2 to 4 days, to prevent signs and symptoms of withdrawal in the physically-dependent patient. Do not abruptly discontinue morphine sulfate extended-release.

Morphine sulfate extended-release capsules must be taken whole. Crushing, chewing, or dissolving the pellets in morphine sulfate extended-release will result in uncontrolled delivery of morphine and can lead to overdose or death [see Warnings and Precautions (5.2)].

Alternatively, the contents of the morphine sulfate extended-release capsules (pellets) may be sprinkled over applesauce and then swallowed. This method is appropriate only for patients able to reliably swallow the applesauce without chewing. Other foods have not been tested and should not be substituted for applesauce. Instruct the patient to:

• Sprinkle the pellets onto a small amount of applesauce and consume immediately without chewing.
• Rinse the mouth to ensure all pellets have been swallowed.
• Discard any unused portion of the morphine sulfate extended-release capsules after the contents have been sprinkled on applesauce.

Do not administer morphine sulfate extended-release pellets through a nasogastric or gastric tubes.

Morphine sulfate extended-release capsules, USP (once daily) contain pellets of morphine sulfate and are available as follows:
30 mg capsule has a dark blue opaque cap and body, printed with and 3090 on both the cap and body in black ink.
45 mg capsule has a violet opaque cap and body, printed with and 3116 on both the cap and body in black ink.
60 mg capsule has a light green opaque cap and body, printed with and 3091 on both the cap and body in black ink.
75 mg capsule has a brown opaque cap and body, printed with and 3117 on both the cap and body in black ink.
90 mg capsule has a green opaque cap and body, printed with  and 3092 on both the cap and body in black ink.
120 mg capsule has a light blue opaque cap and body, printed with and 3093 on both the cap and body in black ink.

Morphine sulfate extended-release is contraindicated in patients with:

• Significant respiratory depression
• Acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment
• Known or suspected paralytic ileus
• Hypersensitivity (e.g., anaphylaxis) to morphine [see Adverse Reactions (6.1)]

Morphine sulfate extended-release contains morphine, a Schedule II controlled substance. As an opioid, morphine sulfate extended-release exposes users to the risks of addiction, abuse, and misuse [see Drug Abuse and Dependence (9)]. As modified-release products such as morphine sulfate extended-release deliver the opioid over an extended period of time, there is a greater risk for overdose and death due to the larger amount of morphine present.

Although the risk of addiction in any individual is unknown, it can occur in patients appropriately prescribed morphine sulfate extended-release and in those who obtain the drug illicitly. Addiction can occur at recommended doses and if the drug is misused or abused.

Assess each patient’s risk for opioid addiction, abuse, or misuse prior to prescribing morphine sulfate extended-release, and monitor all patients receiving morphine sulfate extended-release for the development of these behaviors or conditions. Risks are increased in patients with a personal or family history of substance abuse (including drug or alcohol addiction or abuse) or mental illness (e.g., major depression). The potential for these risks should not, however, prevent the prescribing of morphine sulfate extended-release for the proper management of pain in any given patient. Patients at increased risk may be prescribed modified-release opioid formulations such as morphine sulfate extended-release, but use in such patients necessitates intensive counseling about the risks and proper use of morphine sulfate extended-release along with intensive monitoring for signs of addiction, abuse, and misuse.

Abuse or misuse of morphine sulfate extended-release by crushing, chewing, snorting, or injecting the dissolved product will result in the uncontrolled delivery of the morphine and can result in overdose and death [see Overdosage (10)].

Opioid agonists such as morphine sulfate extended-release are sought by drug abusers and people with addiction disorders and are subject to criminal diversion. Consider these risks when prescribing or dispensing morphine sulfate extended-release. Strategies to reduce these risks include prescribing the drug in the smallest appropriate quantity and advising the patient on the proper disposal of unused drug [see Patient Counseling Information (17)]. Contact local state professional licensing board or state controlled substances authority for information on how to prevent and detect abuse or diversion of this product.

Serious, life-threatening, or fatal respiratory depression has been reported with the use of modified-release opioids, even when used as recommended. Respiratory depression from opioid use, if not immediately recognized and treated, may lead to respiratory arrest and death. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status [ see Overdosage (10)]. Carbon dioxide (CO₂) retention from opioid-induced respiratory depression can exacerbate the sedating effects of opioids.

While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of morphine sulfate extended-release, the risk is greatest during the initiation of therapy or following a dose increase. Closely monitor patients for respiratory depression when initiating therapy with morphine sulfate extended-release and following dose increases.

To reduce the risk of respiratory depression, proper dosing and titration of morphine sulfate extended-release are essential [see Dosage and Administration (2)]. Overestimating the morphine sulfate extended-release dose when converting patients from another opioid product can result in fatal overdose with the first dose.

Accidental ingestion of even one dose of morphine sulfate extended-release capsules, especially by children, can result in respiratory depression and death due to an overdose of morphine.

Prolonged use of morphine sulfate extended-release during pregnancy can result in withdrawal signs in the neonate. Neonatal opioid withdrawal syndrome, unlike opioid withdrawal syndrome in adults, may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available.

Neonatal opioid withdrawal syndrome presents as irritability, hyperactivity and abnormal sleep pattern, high pitched cry, tremor, vomiting, diarrhea and failure to gain weight. The onset, duration, and severity of neonatal opioid withdrawal syndrome vary based on the specific opioid used, duration of use, timing and amount of last maternal use, and rate of elimination of the drug by the newborn.

Patients must not consume alcoholic beverages or prescription or non-prescription products containing alcohol while on morphine sulfate extended-release therapy. The co-ingestion of alcohol with morphine sulfate extended-release may result in increased plasma levels and a potentially fatal overdose of morphine [see Clinical Pharmacology (12.3)].

Hypotension, profound sedation, coma, respiratory depression, and death may result if morphine sulfate extended-release is used concomitantly with alcohol or other central nervous system (CNS) depressants (e.g., sedatives, anxiolytics, hypnotics, neuroleptics, other opioids).

When considering the use of morphine sulfate extended-release in a patient taking a CNS depressant, assess the duration of use of the CNS depressant and the patient’s response, including the degree of tolerance that has developed to CNS depression. Additionally, evaluate the patient’s use of alcohol or illicit drugs that cause CNS depression. If the decision to begin morphine sulfate extended-release is made, start with morphine sulfate extended-release 30 mg every 24 hours, monitor patients for signs of sedation and respiratory depression, and consider using a lower dose of the concomitant CNS depressant [see Drug Interactions (7.2)].

Life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients as they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients. Monitor such patients closely, particularly when initiating and titrating morphine sulfate extended-release and when morphine sulfate extended-release is given concomitantly with other drugs that depress respiration [see Warnings and Precautions (5.2)].

Monitor patients with significant chronic obstructive pulmonary disease or cor pulmonale, and patients having a substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression for respiratory depression, particularly when initiating therapy and titrating with morphine sulfate extended-release, as in these patients, even usual therapeutic doses of morphine sulfate extended-release may decrease respiratory drive to the point of apnea [see Warnings and Precautions (5.2)]. Consider the use of alternative non-opioid analgesics in these patients if possible.

Morphine sulfate extended-release may cause severe hypotension including orthostatic hypotension and syncope in ambulatory patients. There is an increased risk in patients whose ability to maintain blood pressure has already been compromised by a reduced blood volume or concurrent administration of certain CNS depressant drugs (e.g. phenothiazines or general anesthetics) [see Drug Interactions (7.2)]. Monitor these patients for signs of hypotension after initiating or titrating the dose of morphine sulfate extended-release. In patients with circulatory shock, morphine sulfate extended-release may cause vasodilation that can further reduce cardiac output and blood pressure. Avoid the use of morphine sulfate extended-release in patients with circulatory shock.

Monitor patients taking morphine sulfate extended-release who may be susceptible to the intracranial effects of CO₂ retention (e.g., those with evidence of increased intracranial pressure or brain tumors) for signs of sedation and respiratory depression, particularly when initiating therapy with morphine sulfate extended-release. Morphine sulfate extended-release may reduce respiratory drive, and the resultant CO₂ retention can further increase intracranial pressure. Opioids may also obscure the clinical course in a patient with a head injury.

Avoid the use of morphine sulfate extended-release in patients with impaired consciousness or coma.

Morphine sulfate extended-release is contraindicated in patients with paralytic ileus. Avoid the use of morphine sulfate extended-release in patients with other GI obstruction.

The morphine in morphine sulfate extended-release may cause spasm of the sphincter of Oddi. Monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms. Opioids may cause increases in the serum amylase.

The morphine in morphine sulfate extended-release may aggravate convulsions in patients with convulsive disorders, and may induce or aggravate seizures in some clinical settings. Monitor patients with a history of seizure disorders for worsened seizure control during morphine sulfate extended-release therapy.

Avoid the use of mixed agonist/antagonist (i.e., pentazocine, nalbuphine, and butorphanol) or partial agonist (buprenorphine) analgesics in patients who have received or are receiving a course of therapy with a opioid agonist analgesic, including morphine sulfate extended-release.  In these patients, mixed agonist/antagonist and partial agonist analgesics may reduce the analgesic effect and/or may precipitate withdrawal symptoms.

When discontinuing morphine sulfate extended-release, gradually taper the dose [see Dosage and Administration (2.3)]. Do not abruptly discontinue morphine sulfate extended-release.

Morphine sulfate extended-release may impair the mental or physical abilities needed to perform potentially hazardous activities such as driving a car or operating machinery. Warn patients not to drive or operate dangerous machinery unless they are tolerant to the effects of morphine sulfate extended-release and know how they will react to the medication.

The following serious adverse reactions are discussed elsewhere in the labeling:

• Addiction, Abuse, and Misuse [see Warnings and Precautions (5.1)]
• Life Threatening Respiratory Depression [ see Warnings and Precautions (5.2)]
• Neonatal Opioid Withdrawal Syndrome [see Warnings and Precautions (5.3)]
• Interactions with Other CNS Depressants [ see Warnings and Precautions (5.4)]
• Hypotensive Effect [see Warnings and Precautions (5.7)]
• Gastrointestinal Effects [see Warnings and Precautions (5.9)]
• Seizures [ see Warnings and Precautions (5.10)]

The most common adverse reactions with morphine sulfate extended-release include constipation, nausea and somnolence.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice.

In controlled and open-label clinical studies, 560 patients with chronic malignant or non-malignant pain were treated with morphine sulfate extended-release. The most common serious adverse events reported with administration of morphine sulfate extended-release were vomiting, nausea, death, dehydration, dyspnea, and sepsis. (Deaths occurred in patients treated for pain due to underlying malignancy.) Serious adverse events caused by morphine include respiratory depression, apnea, and to a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest.

The most common adverse events (seen in greater than 10%) reported by patients treated with morphine sulfate extended-release during the clinical trials at least once during therapy were constipation, nausea, somnolence, vomiting, and headache. Adverse events occurring in 5 to 10% of study patients were peripheral edema, diarrhea, abdominal pain, infection, urinary tract infection, accidental injury, flu syndrome, back pain, rash, sweating, fever, insomnia, depression, paresthesia, anorexia, dry mouth, asthenia and dyspnea. Other less common side effects expected from opioid analgesics, including morphine, or seen in fewer than 5% of patients taking morphine sulfate extended-release in the clinical trials were:

Body as a Whole: malaise, withdrawal syndrome.
Cardiovascular System: bradycardia, hypertension, hypotension, palpitations, syncope, tachycardia.
Digestive System: biliary pain, dyspepsia, dysphagia, gastroenteritis, abnormal liver function tests, rectal disorder, thirst.
Hemic and Lymphatic System: anemia, thrombocytopenia. Metabolic and Nutritional Disorders: edema, weight loss. Musculoskeletal: skeletal muscle rigidity.
Nervous System: abnormal dreams, abnormal gait, agitation, amnesia, anxiety, ataxia, confusion, convulsions, coma, delirium, euphoria, hallucinations, lethargy, nervousness, abnormal thinking, tremor, vasodilation, vertigo. Respiratory System: hiccup, hypoventilation, voice alteration.
S kin and Appendages: dry skin, urticaria.
Special Senses: amblyopia, eye pain, taste perversion.
Urogenital System: abnormal ejaculation, dysuria, impotence, decreased libido, oliguria, urinary retention.

Anaphylaxis has been reported with ingredients contained in morphine sulfate extended-release.  Advise patients how to recognize such a reaction and when to seek medical attention.

Concomitant use of alcohol with morphine sulfate extended-release can result in an increase of morphine plasma levels and potentially fatal overdose of morphine. Instruct patients not to consume alcoholic beverages or use prescription or non-prescription products containing alcohol while on morphine sulfate extended-release therapy [see Clinical Pharmacology (12.3)].

The concomitant use of morphine sulfate extended-release with other CNS depressants including sedatives, hypnotics, tranquilizers, general anesthetics, phenothiazines, other opioids, and alcohol, can increase the risk of respiratory depression, profound sedation, coma and death. Monitor patients receiving CNS depressants and morphine sulfate extended-release for signs of respiratory depression, sedation and hypotension.

When combined therapy with any of the above medications is considered, the dose of one or both agents should be reduced [see Dosage and Administration (2.2) and Warnings and Precautions (5.4)].

Mixed agonist/antagonist (i.e., pentazocine, nalbuphine, and butorphanol) and partial agonist (buprenorphine) analgesics may reduce the analgesic effect of morphine sulfate extended-release or may precipitate withdrawal symptoms. Avoid the use of agonist/antagonist and partial agonist analgesics in patients receiving morphine sulfate extended-release.

Morphine may enhance the neuromuscular blocking action of skeletal muscle relaxants and produce an increased degree of respiratory depression. Monitor patients receiving muscle relaxants and morphine sulfate extended-release for signs of respiratory depression that may be greater than otherwise expected.

The effects of morphine may be potentiated by MAOIs. Monitor patients on concurrent therapy with an MAOI and morphine sulfate extended-release for increased respiratory and central nervous system depression. MAOIs have been reported to potentiate the effects of morphine anxiety, confusion, and significant depression of respiration or coma. Morphine sulfate extended-release should not be used in patients taking MAOIs or within 14 days of stopping such treatment.

Cimetidine can potentiate morphine-induced respiratory depression. There is a report of confusion and severe respiratory depression when a patient undergoing hemodialysis was concurrently administered morphine and cimetidine. Monitor patients for respiratory depression when morphine sulfate extended-release and cimetidine are used concurrently.

Morphine can reduce the efficacy of diuretics by inducing the release of antidiuretic hormone. Morphine may also lead to acute retention of urine by causing spasm of the sphincter of the bladder, particularly in men with enlarged prostates.

Anticholinergics or other medications with anticholinergic activity when used concurrently with opioid analgesics may result in increased risk of urinary retention and/or severe constipation, which may lead to paralytic ileus. Monitor patients for signs of urinary retention or reduced gastric motility when morphine sulfate extended-release is used concurrently with anticholinergic drugs.

PGP inhibitors (e.g. quinidine) may increase the absorption/exposure of morphine sulfate by about two-fold. Therefore, monitor patients for signs of respiratory and central nervous system depression when morphine sulfate extended-release is used concurrently with PGP inhibitors.

Clinical Considerations
Fetal/neonatal adverse reactions
Prolonged use of opioid analgesics during pregnancy for medical or nonmedical purposes can result in physical dependence in the neonate and neonatal opioid withdrawal syndrome shortly after birth. Observe newborns for symptoms of neonatal opioid withdrawal syndrome, such as poor feeding, diarrhea, irritability, tremor, rigidity, and seizures, and manage accordingly [see Warnings and Precautions (5.3)].

Teratogenic Effects - Pregnancy Category C
There are no adequate and well-controlled studies in pregnant women. Morphine sulfate extended-release should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

In humans, the frequency of congenital anomalies has been reported to be no greater than expected among the children of 70 women who were treated with morphine during the first four months of pregnancy or in 448 women treated with morphine anytime during pregnancy. Furthermore, no malformations were observed in the infant of a woman who attempted suicide by taking an overdose of morphine and other medication during the first trimester of pregnancy.

Several literature reports indicate that morphine administered subcutaneously during the early gestational period in mice and hamsters produced neurological, soft tissue and skeletal abnormalities. With one exception, the effects that have been reported were following doses that were maternally toxic and the abnormalities noted were characteristic of those observed when maternal toxicity is present. In one study, following subcutaneous infusion of doses greater than or equal to 0.15 mg/kg to mice, exencephaly, hydronephrosis, intestinal hemorrhage, split supraoccipital, malformed sternebrae, and malformed xiphoid were noted in the absence of maternal toxicity.  In the hamster, morphine sulfate given subcutaneously on gestation day 8 produced exencephaly and cranioschisis. In rats treated with subcutaneous infusions of morphine during the period of organogenesis, no teratogenicity was observed.  No maternal toxicity was observed in this study, however, increased mortality and growth retardation were seen in the offspring.  In two studies performed in the rabbit, no evidence of teratogenicity was reported at subcutaneous doses up to 100 mg/kg.

Nonteratogenic Effects
Infants born to mothers who have taken opioids chronically may exhibit neonatal withdrawal syndrome [see W arnings and Precautions (5.3)], reversible reduction in brain volume, small size, decreased ventilatory response to CO₂ and increased risk of sudden infant death syndrome.  Morphine sulfate should be used by a pregnant woman only if the need for opioid analgesia clearly outweighs the potential risks to the fetus.

Controlled studies of chronic in utero morphine exposure in pregnant women have not been conducted.  Published literature has reported that exposure to morphine during pregnancy in animals is associated with reduction in growth and a host of behavioral abnormalities in the offspring.  Morphine treatment during gestational periods of organogenesis in rats, hamsters, guinea pigs and rabbits resulted in the following treatment-related embryotoxicity and neonatal toxicity in one or more studies: decreased litter size, embryo-fetal viability, fetal and neonatal body weights, absolute brain and cerebellar weights, delayed motor and sexual maturation, and increased neonatal mortality, cyanosis and hypothermia.  Decreased fertility in female offspring, and decreased plasma and testicular levels of luteinizing hormone and testosterone, decreased testes weights, seminiferous tubule shrinkage, germinal cell aplasia, and decreased spermatogenesis in male offspring were also observed. Decreased litter size and viability were observed in the offspring of male rats administered morphine (25 mg/kg, IP) for 1 day prior to mating.  Behavioral abnormalities resulting from chronic morphine exposure of fetal animals included altered reflex and motor skill development, mild withdrawal, and altered responsiveness to morphine persisting into adulthood.

Opioids cross the placenta and may produce respiratory depression in neonates. Morphine sulfate extended-release is not for use in women during and immediately prior to labor, when shorter acting analgesics or other analgesic techniques are more appropriate. Opioid analgesics can prolong labor through actions that temporarily reduce the strength, duration, and frequency of uterine contractions. However this effect is not consistent and may be offset by an increased rate of cervical dilatation, which tends to shorten labor.

Morphine is excreted in breast milk, with a milk to plasma morphine AUC ratio of approximately 2.5:1. The amount of morphine received by the infant varies depending on the maternal plasma concentration, the amount of milk ingested by the infant, and the extent of first pass metabolism. Closely monitor infants of nursing women receiving morphine sulfate extended-release.

Withdrawal symptoms can occur in breast-feeding infants when maternal administration of morphine is stopped.

Because of the potential for adverse reactions in nursing infants from morphine sulfate extended-release, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.

The safety and effectiveness of morphine sulfate extended-release in pediatric patients below the age of 18 have not been established.

The pharmacokinetics of morphine sulfate extended-release have not been studied in elderly patients. In clinical studies of morphine sulfate extended-release, 100 patients who received morphine sulfate extended-release were age 65 and over, including 37 patients over the age of 74. No overall differences in safety were observed between these subjects and younger subjects. [ see Clinical Pharmacology (12.3)].

Morphine sulfate extended-release contains morphine, a Schedule II controlled substance with a high potential for abuse similar to other opioids including fentanyl, hydromorphone, methadone, oxycodone, and oxymorphone. Morphine sulfate extended-release can be abused and is subject to misuse, addiction, and criminal diversion [see Warnings and Precautions (5.1)].

The high drug content in extended-release formulations adds to the risk of adverse outcomes from abuse and misuse.

All patients treated with opioids require careful monitoring for signs of abuse and addiction, since use of opioid analgesic products carries the risk of addiction even under appropriate medical use.

Drug abuse is the intentional non-therapeutic use of an over-the-counter or prescription drug, even once, for its rewarding psychological or physiological effects. Drug abuse includes, but is not limited to,  the following examples: the use of  a prescription or over-the-counter drug to get “high”, or the use of steroids for performance enhancement and muscle build up.

Drug addiction is a cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and include: a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal.

"Drug-seeking" behavior is very common to addicts and drug abusers. Drug-seeking tactics include emergency calls or visits near the end of office hours, refusal to undergo appropriate examination, testing or referral, repeated claims of loss of prescriptions, tampering with prescriptions and reluctance to provide prior medical records or contact information for other treating physician(s). “Doctor shopping” (visiting multiple prescribers) to obtain additional prescriptions is common among drug abusers and people suffering from untreated addiction.  Preoccupation with achieving adequate pain relief can be appropriate behavior in a patient with poor pain control.

Abuse and addiction are separate and distinct from physical dependence and tolerance. Physicians should be aware that addiction may not be accompanied by concurrent tolerance and symptoms of physical dependence in all addicts. In addition, abuse of opioids can occur in the absence of true addiction.

Morphine sulfate extended-release, like other opioids, can be diverted for non-medical use into illicit channels of distribution. Careful record-keeping of prescribing information, including quantity, frequency, and renewal requests, as required by state law, is strongly advised.

Proper assessment of the patient, proper prescribing practices, periodic re-evaluation of therapy, and proper dispensing and storage are appropriate measures that help to reduce abuse of opioid drugs.

Risks Specific to Abuse of Morphine Sulfate Extended-Release
Morphine sulfate extended-release is for oral use only. Abuse of morphine sulfate extended-release poses a risk of overdose and death. This risk is increased with concurrent abuse of morphine sulfate extended-release with alcohol and other substances. Taking cut, broken, chewed, crushed, or dissolved morphine sulfate extended-release enhances drug release and increases the risk of overdose and death.

Due to the presence of talc as one of the excipients in morphine sulfate extended-release, parenteral abuse can be expected to result in local tissue necrosis, infection, pulmonary granulomas, and increased risk of endocarditis and valvular heart injury. Parenteral drug abuse is commonly associated with transmission of infectious diseases such as hepatitis and HIV.

Both tolerance and physical dependence can develop during chronic opioid therapy. Tolerance is the need for increasing doses of opioids to maintain a defined effect such as analgesia (in the absence of disease progression or other external factors). Tolerance may occur to both the desired and undesired effects of drugs, and may develop at different rates for different effects.

Physical dependence results in withdrawal symptoms after abrupt discontinuation or a significant dose reduction of a drug. Withdrawal also may be precipitated through the administration of drugs with opioid antagonist activity, e.g., naloxone, nalmefene, mixed agonist/antagonist analgesics (pentazocine, butorphanol, nalbuphine), or partial agonists (buprenorphine). Physical dependence may not occur to a clinically significant degree until after several days to weeks of continued opioid usage.

Morphine sulfate extended-release should not be abruptly discontinued [see Dosage and Administration (2.3)]. If morphine sulfate extended-release is abruptly discontinued in a physically-dependent patient, an abstinence syndrome may occur. Some or all of the following can characterize this syndrome: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis. Other signs and symptoms also may develop, including: irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate.

Infants born to mothers physically dependent on opioids will also be physically dependent and may exhibit respiratory difficulties and withdrawal symptoms [see Use in Specific Populations (8.2)].

Clinical Presentation
Acute overdosage with morphine is manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, and, in some cases, pulmonary edema, bradycardia, hypotension, and death. Marked mydriasis rather than miosis may be seen due to severe hypoxia in overdose situations.

Treatment of Overdose
In case of overdose, priorities are the re-establishment of a patent and protected airway and institution of assisted or controlled ventilation if needed.  Employ other supportive measures (including oxygen, vasopressors) in the management of circulatory shock and pulmonary edema as indicated. Cardiac arrest or arrhythmias will require advanced life support techniques.

The opioid antagonists, naloxone or nalmefene, are specific antidotes to respiratory depression resulting from opioid overdose. Opioid antagonists should not be administered in the absence of clinically significant respiratory or circulatory depression secondary to morphine overdose. Such agents should be administered cautiously to persons who are known, or suspected to be physically dependent on morphine sulfate extended-release. In such cases, an abrupt or complete reversal of opioid effects may precipitate an acute withdrawal syndrome.

Because the duration of reversal would be expected to be less than the duration of action of morphine in morphine sulfate extended-release, carefully monitor the patient until spontaneous respiration is reliably re-established. Morphine sulfate extended-release will continue to release morphine and add to the morphine load for 36 to 48 hours or longer following ingestion necessitating prolonged monitoring.  If the response to opioid antagonists is suboptimal or not sustained, additional antagonist should be administered as directed in the product’s prescribing information.

In an individual physically dependent on opioids, administration of the usual dose of the antagonist will precipitate an acute withdrawal syndrome. The severity of the withdrawal symptoms experienced will depend on the degree of physical dependence and the dose of the antagonist administered. If a decision is made to treat serious respiratory depression in the physically dependent patient, administration of the antagonist should be begun with care and by titration with smaller than usual doses of the antagonist.

Morphine sulfate extended-release capsules, USP (once daily) are for oral use and contain pellets of morphine sulfate. Morphine sulfate is an agonist at the mu-opioid receptor.

Each morphine sulfate extended-release capsule contains either 30, 45, 60, 75, 90, or 120 mg of morphine sulfate, USP and the following inactive ingredients: diethyl phthalate, ethylcellulose, gelatin, hydroxypropyl cellulose, methacrylic acid copolymer, polyethylene glycol, sugar spheres, talc, and titanium dioxide. The 30 mg capsules also contain FD&C blue #1. The 45 mg capsules also contain FD&C blue #1 and FD&C red #3. The 60 mg capsules also contain D&C yellow #10 and FD&C green #3. The 75 mg capsules also contain black iron oxide, red iron oxide, and yellow iron oxide. The 90 mg capsules also contain black iron oxide, FD&C blue #1, and yellow iron oxide. The 120 mg capsules also contain FD&C blue #1.The ink ingredients are common for all strengths: Tek-Print SW-9008 or SW-9009 black contains: black iron oxide, butyl alcohol, dehydrated alcohol,  isopropyl alcohol, potassium hydroxide, propylene glycol, purified water, shellac, and strong ammonia solution.

The chemical name of morphine sulfate is 7,8-didehydro-4,5 alpha-epoxy-17-methylmorphinan-3,6 alpha-diol sulfate (2:1) (salt) pentahydrate with a molecular weight of 758.83. The molecular formula is (C₁₇H₁₉NO₃)₂●H₂SO₄●5H₂O.

Morphine sulfate is an odorless, white, crystalline powder. It is soluble in water and slightly soluble in alcohol, but is practically insoluble in chloroform or ether. The octanol:water partition coefficient of morphine is 1.42 at physiologic pH and the pKa is 7.9 for the tertiary nitrogen (the majority is ionized at pH 7.4).  Its structural formula is:

USP dissolution test is pending.

Morphine sulfate, an opioid agonist, is relatively selective for the mu receptor, although it can interact with other opioid receptors at higher doses. In addition to analgesia, the widely diverse effects of morphine include drowsiness, changes in mood, respiratory depression, decreased gastrointestinal motility, nausea, vomiting, and alterations of the endocrine and autonomic nervous system.

Morphine produces both its therapeutic and its adverse effects by interaction with one or more classes of specific opioid receptors located throughout the body. Morphine acts as a full agonist, binding with and activating opioid receptors at sites in the peri-aqueductal and peri-ventricular grey matter, the ventro-medial medulla and the spinal cord to produce analgesia.

Plasma Level-Analgesia Relationships
While plasma morphine-efficacy relationships can be demonstrated in non-tolerant individuals, they are influenced by a wide variety of factors and are not generally useful as a guide to the clinical use of morphine. The effective dose in opioid-tolerant patients may be 10 to 50 times as great (or greater) than the appropriate dose for opioid-naïve individuals. Dosages of morphine should be chosen and must be titrated on the basis of clinical evaluation of the patient and the balance between therapeutic and adverse effects.

CNS Depressant/Alcohol Interaction
Additive pharmacodynamic effects may be expected when morphine sulfate extended-release is used in conjunction with alcohol, other opioids, or illicit drugs that cause central nervous system depression.

Effects on the Central Nervous System
The principal therapeutic action of morphine is analgesia. Other therapeutic effects of morphine include anxiolysis, euphoria, and feelings of relaxation. Although the precise mechanism of the analgesic action is unknown, specific CNS opiate receptors and endogenous compounds with morphine-like activity have been identified throughout the brain and spinal cord and are likely to play a role in the expression and perception of analgesic effects. In common with other opioids, morphine causes respiratory depression, in part by a direct effect on the brainstem respiratory centers. Morphine and related opioids depress the cough reflex by direct effect on the cough center in the medulla. Antitussive effects may occur with doses lower than those usually required for analgesia. Morphine causes miosis, even in total darkness. Pinpoint pupils are a sign of opioid overdose; however, when asphyxia is present during opioid overdose, marked mydriasis occurs.

Effects on the Gastrointestinal Tract and Other Smooth Muscle
Gastric, biliary, and pancreatic secretions are decreased by morphine. Morphine causes a reduction in motility and is associated with an increase in tone in the antrum of the stomach and duodenum. Digestion of food in the small intestine is delayed and propulsive contractions are decreased. Propulsive peristaltic waves in the colon are decreased, while tone is increased to the point of spasm. The end result may be constipation. Morphine can cause a marked increase in biliary tract pressure as a result of spasm of the sphincter of Oddi. Morphine may also cause spasm of the sphincter of the urinary bladder.

Effects on the Cardiovascular System
In therapeutic doses, morphine does not usually exert major effects on the cardiovascular system. Morphine produces peripheral vasodilation which may result in orthostatic hypotension and fainting. Release of histamine can occur, which may play a role in opioid-induced hypotension. Manifestations of histamine release and/or peripheral vasodilation may include pruritus, flushing, red eyes, and sweating.

Effects on the Endocrine System
Opioids inhibit the secretion of ACTH, cortisol, and luteinizing hormone (LH) in humans. They also stimulate prolactin, growth hormone (GH) secretion, and pancreatic secretion of insulin and glucagon. Chronic use of opioids may influence the hypothalamic-pituitary-gonadal axis, leading to hormonal changes that may manifest as symptoms of hypogonadism.

Effects on the Immune System
Opioids have been shown to have a variety of effects on components of the immune system in in vitro and animal models. The clinical significance of these findings is unknown. Overall, the effects of opioids appear to be modestly immunosuppressive.

Absorption
Morphine sulfate extended-release consists of two components, an immediate-release component and an extended-release component.

The oral bioavailability of morphine is less than 40% and shows large inter-individual variability due to extensive pre-systemic metabolism.

Following single-dose oral administration of a 60 mg dose of morphine sulfate extended-release under fasting conditions, morphine concentrations of approximately 3 to 6 ng/mL were achieved within 30 minutes after dosing and maintained for the 24-hour dosing interval. The pharmacokinetics of morphine sulfate extended-release were shown to be dose-proportional over a single oral dose range of 30 to 120 mg in healthy volunteers and a multiple oral dose range of at least 30 to 180 mg in patients with chronic moderate to severe pain.

Food Effect: When a 60 mg dose of morphine sulfate extended-release was administered immediately following a high fat meal, peak morphine concentrations and AUC values were similar to those observed when the dose of morphine sulfate extended-release was administered in a fasting state, although achievement of initial concentrations was delayed by approximately 1 hour under fed conditions. Therefore, morphine sulfate extended-release can be administered without regard to food. When the contents of morphine sulfate extended-release were administered by sprinkling on applesauce, the rate and extent of morphine absorption were found to be bioequivalent to the same dose when administered as an intact capsule.

Steady State: Steady-state plasma concentrations of morphine are achieved 2 to 3 days after initiation of once-daily administration of morphine sulfate extended-release.

Morphine sulfate extended-release 60 mg capsules (once-daily) and 10 mg morphine oral solution (6 times daily) were equally bioavailable.

A once-daily dose of morphine sulfate extended-release provided similar C_max, C_min, and AUC values and peak-trough fluctuations (% FL, C_max-C_min/C_av) compared to 6-times daily administration of the same total daily dose of morphine oral solution (Table 1).

Distribution
Once absorbed, morphine is distributed to skeletal muscle, kidneys, liver, intestinal tract, lungs, spleen and brain. Although the primary site of action is the CNS, only small quantities cross the blood-brain barrier. Morphine also crosses the placental membranes and has been found in breast milk [see Use in Specific Populations (8.1, 8.3)]. The volume of distribution of morphine is approximately 1 to 6 L/kg, and morphine is 20 to 35% reversibly bound to plasma proteins.

Metabolism
The major pathways of morphine metabolism include glucuronidation to produce metabolites including morphine-3-glucuronide, M3G (about 50%) and morphine-6-glucuronide, M6G (about 5 to 15%) and sulfation in the liver to produce morphine-3-etheral sulfate. A small fraction (less than 5%) of morphine is demethylated. M6G has been shown to have analgesic activity but crosses the blood-brain barrier poorly, while M3G has no significant analgesic activity.

Excretion
Approximately 10% of a morphine dose is excreted unchanged in the urine. Elimination of morphine is primarily via hepatic metabolism to glucuronide metabolites M3G and M6G which are then renally excreted. A small amount of the glucuronide metabolites is excreted in the bile and there is some minor enterohepatic recycling. Seven to 10% of administered morphine is excreted in the feces. The mean adult plasma clearance of morphine is about 20 – 30 mL/minute/kg. The effective terminal half-life of morphine after IV administration is reported to be approximately 2 hours. The terminal elimination half-life of morphine following single dose of morphine sulfate extended-release administration is approximately 24 hrs.

Specific Populations
Geriatric Patients
The pharmacokinetics of morphine sulfate extended-release have not been studied in elderly patients.

Pediatric Patients
The pharmacokinetics of morphine sulfate extended-release have not been studied in pediatric patients below the age of 18. The range of dose strengths available may not be appropriate for treatment of very young pediatric patients. Sprinkling on applesauce is NOT a suitable alternative for these patients.

Gender
A gender analysis of pharmacokinetic data from healthy subjects taking morphine sulfate extended-release indicated that morphine concentrations were similar in males and females.

Race
Chinese subjects given intravenous morphine had a higher clearance when compared to Caucasian subjects (1852 +/- 116 mL/min compared to 1495 +/- 80 mL/min).

Hepatic Impairment
Morphine pharmacokinetics are altered in individuals with cirrhosis. Clearance was found to decrease with a corresponding increase in half-life. The M3G and M6G to morphine plasma AUC ratios also decreased in these subjects, indicating diminished metabolic activity.  Adequate studies of the pharmacokinetics of morphine in patients with severe hepatic impairment have not been conducted.

Renal Impairment
Morphine pharmacokinetics are altered in patients with renal failure. The AUC is increased and clearance is decreased and the metabolites, M3G and M6G, may accumulate to much higher plasma levels in patients with renal failure as compared to patients with normal renal function. Adequate studies of the pharmacokinetics of morphine in patients with severe renal impairment have not been conducted.

Drug Interaction/Alcohol Interaction
In in vitro studies of the dissolution of morphine sulfate extended-release 30 mg mixed with 900 mL of buffer solutions containing ethanol (20% and 40%), the amount of morphine released increased in an alcohol concentration-dependent manner. While the relevance of in vitro lab tests regarding morphine sulfate extended-release to the clinical setting remains to be determined, this acceleration of release may correlate with in vivo rapid release of the total morphine dose, which could result in the absorption of a potentially fatal dose of morphine.

Carcinogenesis :  Studies in animals to evaluate the carcinogenic potential of morphine sulfate have not been conducted.

Mutagenesis : No formal studies to assess the mutagenic potential of morphine have been conducted. In the published literature, morphine was found to be mutagenic in vitro increasing DNA fragmentation in human T-cells. Morphine was reported to be mutagenic in the in vivo mouse micronucleus assay and positive for the induction of chromosomal aberrations in mouse spermatids and murine lymphocytes. Mechanistic studies suggest that the in vivo clastogenic effects reported with morphine in mice may be related to increases in glucocorticoid levels produced by morphine in this species. In contrast to the above positive findings, i n vitro studies in the literature have also shown that morphine did not induce chromosomal aberrations in human leukocytes or translocations or lethal mutations in Drosophila.

Impairment of Fertility :  No formal nonclinical studies to assess the potential of morphine to impair fertility have been conducted. Several nonclinical studies from the literature have demonstrated adverse effects on male fertility in the rat from exposure to morphine. One study in which male rats were administered morphine sulfate subcutaneously prior to mating (up to 30 mg/kg twice daily) and during mating (20 mg/kg twice daily) with untreated females, a number of adverse reproductive effects including reduction in total pregnancies, higher incidence of pseudopregnancies, and reduction in implantation sites were seen. Studies from the literature have also reported changes in hormonal levels (i.e., testosterone, luteinizing hormone, serum corticosterone) following treatment with morphine. These changes may be associated with the reported effects on fertility in the rat.

Morphine sulfate extended-release was studied in a double-blind, placebo-controlled, fixed-dose, parallel group trial in 295 patients with moderate to severe pain due to osteoarthritis. These patients had either a prior sub-optimal response to acetaminophen, NSAID therapy, or previously received intermittent opioid analgesic therapy. Thirty-milligrams morphine sulfate extended-release capsules administered once-daily, either in the morning or the evening, were more effective than placebo in reducing pain.

This study was not designed to assess the effects of morphine sulfate extended-release on the course of the osteoarthritis.

Morphine sulfate extended-release capsules, USP (Once Daily) are available as follows:

30 mg – Size 3 capsule with dark blue opaque cap and body, printed with and 3090 on both the cap and body in black ink. Capsules are supplied in bottles of 30 (NDC 0228-3090-03), 90 (NDC 0228-3090-09), 100 (NDC 0228-3090-11) with a child-resistant closure, and 500 (NDC 0228-3090-50) without a child-resistant closure.

45 mg – Size 3 capsule with violet opaque cap and body, printed with and 3116 on both the cap and body in black ink. Capsules are supplied in bottles of 100 (NDC 0228-3116-11) with a child-resistant closure.

60 mg – Size 2 capsule with light green opaque cap and body, printed with and 3091 on both the cap and body in black ink. Capsules are supplied in bottles of 30 (NDC 0228-3091-03), 90 (NDC 0228-3091-09), 100 (NDC 0228-3091-11) with a child-resistant closure, and 500 (NDC 0228-3091-50) without a child-resistant closure.

75 mg – Size 1 capsule with brown opaque cap and body, printed with and 3117 on both the cap and body in black ink. Capsules are supplied in bottles of 100 (NDC 0228-3117-11) with a child-resistant closure.

90 mg – Size 1 capsule with green opaque cap and body, printed with and 3092 on both the cap and body in black ink. Capsules are supplied in bottles of 30 (NDC 0228-3092-03), 90 (NDC 0228-3092-09), 100 (NDC 0228-3092-11) with a child-resistant closure, and 500 (NDC 0228-3092-50) without a child-resistant closure.

120 mg – Size 0 capsule with light blue opaque cap and body, printed with and 3093 on both the cap and body in black ink. Capsules are supplied in bottles of 30 (NDC 0228-3093-03), 90 (NDC 0228-3093-09), 100 (NDC 0228-3093-11) with a child-resistant closure, and 500 (NDC 0228-3093-50) without a child-resistant closure.

Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature]

Protect from light and moisture.

Dispense in a tight, light-resistant container as defined in USP.

CAUTION: DEA Order Form Required.

Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use).

Addiction, Abuse, and Misuse
Inform patients that the use of morphine sulfate extended-release, even when taken as recommended, can result in addiction, abuse, and misuse, which can lead to overdose or death [see Warnings and Precautions (5.1)]. Instruct patients not to share morphine sulfate extended-release with others and to take steps to protect morphine sulfate extended-release from theft or misuse.

Life-threatening Respiratory Depression
Inform patients of the risk of life-threatening respiratory depression, including information that the risk is greatest when starting morphine sulfate extended-release or when the dose is increased, and that it can occur even at recommended doses [see Warnings and Precautions (5.2)]. Advise patients how to recognize respiratory depression and to seek medical attention if breathing difficulties develop.

Accidental Ingestion
Inform patients that accidental ingestion, especially in children, may result in respiratory depression or death [ see Warnings and Precautions (5.2)]. Instruct patients to take steps to store morphine sulfate extended-release securely and to dispose of unused morphine sulfate extended-release by flushing the capsules down the toilet.

Neonatal Opioid Withdrawal Syndrome
Inform female patients of reproductive potential that prolonged use of morphine sulfate extended-release during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated [ see Warnings and Precautions (5.3)].

Interactions with Alcohol and other CNS Depressants
Instruct patients not to consume alcoholic beverages, as well as prescription and over-the-counter products that contain alcohol, during treatment with morphine sulfate extended-release. The co-ingestion of alcohol with morphine sulfate extended-release may result in increased plasma levels and a potentially fatal overdose of morphine [see Warnings and Precautions (5.4)].

Inform patients that potentially serious additive effects may occur if morphine sulfate extended-release is used with alcohol or other CNS depressants, and not to use such drugs unless supervised by a healthcare provider.

Important Administration Instructions
Instruct patients how to properly take morphine sulfate extended-release, including the following:

• Swallowing morphine sulfate extended-release capsules whole or sprinkling the capsule contents on applesauce and then swallowing immediately without chewing
• Not crushing, chewing, or dissolving the pellets in the capsules
• Using morphine sulfate extended-release exactly as prescribed to reduce the risk of life-threatening adverse reactions (e.g., respiratory depression)
• Not discontinuing morphine sulfate extended-release without first discussing the need for a tapering regimen with the prescriber

Hypotension
Inform patients that morphine sulfate extended-release may cause orthostatic hypotension and syncope.  Instruct patients how to recognize symptoms of low blood pressure and how to reduce the risk of serious consequences should hypotension occur (e.g., sit or lie down, carefully rise from a sitting or lying position).

Driving or Operating Heavy Machinery
Inform patients that morphine sulfate extended-release may impair the ability to perform potentially hazardous activities such as driving a car or operating heavy machinery. Advise patients not to perform such tasks until they know how they will react to the medication.

C on stipation
Advise patients of the potential for severe constipation, including management instructions and when to seek medical attention.

Anaphylaxis
Inform patients that anaphylaxis has been reported with ingredients contained in morphine sulfate extended-release. Advise patients how to recognize such a reaction and when to seek medical attention.

Pregnancy
Advise female patients that morphine sulfate extended-release can cause fetal harm and to inform the prescriber if they are pregnant or plan to become pregnant.

Disposal of Unused Morphine Sulfate Extended-Release Capsules
Advise patients to flush the unused capsules down the toilet when morphine sulfate extended-release is no longer needed.

Manufactured by:
Actavis Elizabeth LLC
200 Elmora Avenue
Elizabeth, NJ 07207 USA

40-9072

Revised – April 2014

Medication Guide

Morphine Sulfate ( MOR-feen SUL-fate) Extended-Release Capsules, USP (Once Daily) CII

Morphine sulfate extended-release capsules are :

• A strong prescription pain medicine that contains an opioid (narcotic) that is used to manage pain severe enough to require daily around-the-clock, long-term treatment with an opioid, when other pain treatments such as non-opioid pain medicines or immediate-release opioid medicines do not treat your pain well enough or you cannot tolerate them.
• A long-acting (extended-release) opioid pain medicine that can put you at risk for overdose and death. Even if you take your dose correctly as prescribed you are at risk for opioid addiction, abuse, and misuse that can lead to death.
• Not for use to treat pain that is not around-the-clock.

Imp o r tant information about morphine sulfate extended-release capsules:

• Get emergency help right away if you take too many morphine sulfate extended-release capsules (overdose). When you first start taking morphine sulfate extended-release capsules, when your dose is changed, or if you take too much (overdose), serious or life-threatening breathing problems that can lead to death may occur.
• Never give anyone your morphine sulfate extended-release capsules. They could die from taking it. Store morphine sulfate extended-release capsules away from children and in a safe place to prevent stealing or abuse. Selling or giving away morphine sulfate extended-release capsules is against the law.

Do not take morphine sulfate extended-release capsules if you have:

• severe asthma, trouble breathing, or other lung problems.
• a bowel blockage or have narrowing of the stomach or intestines.

Before taking morphine sulfate extended-release capsules, tell your healthcare provider if you have a history of:

●   head injury, seizures                     ●   liver, kidney, thyroid problems

●   problems urinating                        ●   pancreas or gallbladder problems

●   abuse of street or prescription drugs, alcohol addiction, or mental health problems.

T ell your healthcare provider if you are:

• pregnant or planning to become pregnant. Prolonged use of morphine sulfate extended-release capsules during pregnancy can cause withdrawal symptoms in your newborn baby that could be life-threatening if not recognized and treated.
• breastfeeding. Morphine sulfate extended-release passes into breast milk and may harm your baby.
• taking prescription or over-the-counter medicines, vitamins, or herbal supplements. Taking morphine sulfate extended-release capsules with certain other medicines can cause serious side effects.

Whe n taking morphine sulfate extended-release capsules :

• Do not change your dose. Take morphine sulfate extended-release capsules exactly as prescribed by your healthcare provider.
• Take your prescribed dose every 24 hours, at the same time every day. Do not take more than your prescribed dose in 24 hours. If you miss a dose, take your next dose at your usual time the next day.
• Swallow morphine sulfate extended-release capsules whole. Do not cut, break, chew, crush, dissolve, snort, or inject morphine sulfate extended-release capsules because this may cause you to overdose and die.
• If you cannot swallow morphine sulfate extended-release capsules, see the detailed Instructions for Use.
• Call your healthcare provider if the dose you are taking does not control your pain.
• Do not stop taking morphine sulfate extended-release capsules without talking to your healthcare provider.
• After you stop taking morphine sulfate extended-release capsules, flush any unused capsules down the toilet.

Wh i l e taking morphine sulfate extended-release capsules DO NOT:

• Drive or operate heavy machinery, until you know how morphine sulfate extended-release capsules affect you. Morphine sulfate extended-release capsules can make you sleepy, dizzy, or lightheaded.
• Drink alcohol, or use prescription or over-the-counter medicines containing alcohol. Using products containing alcohol during treatment with morphine sulfate extended-release capsules may cause you to overdose and die.

This Medication Guide has been approved by the U.S. Food and Drug Administration

Morphine Sulfate Extended-Release Capsules, USP (Once Daily)  CII

• If you cannot swallow morphine sulfate extended-release capsules, tell your healthcare provider. There may be another way to take morphine sulfate extended-release capsules that may be right for you. If your doctor tells you that you can take morphine sulfate extended-release capsules using this other way, follow these steps:

Morphine sulfate extended-release capsules can be opened and the pellets inside the capsule can be sprinkled over applesauce, as follows:

		● Open the morphine sulfate extended-release capsule and sprinkle the pellets over approximately one tablespoon of applesauce (See Figure 1).
Figure 1
		● Swallow all of the applesauce and pellets right away. Do not save any of the applesauce and pellets for another dose (See Figure 2).
Figure 2
		● Rinse your mouth to make sure you have swallowed all of the pellets. Do not chew the pellets (See Figure 3).
Figure 3
		● Flush the empty capsule down the toilet right away (See Figure 4).
Figure 4

You should not receive morphine sulfate extended-release capsules through a nasogastric tube or gastric tube (stomach tube).

This Instructions for Use has been approved by the U.S. Food and Drug Administration.

Manufactured by:
Actavis Elizabeth LLC
200 Elmora Avenue
Elizabeth, NJ 07207 USA

40-9072
(MG 41-1185/0414)

PRINCIPAL DISPLAY PANEL
NDC 0228-3090-11
Rx Only
(Once Daily)
Morphine Sulfate
Extended-Release
Capsules, USP
30 mg
100 capsules

PRINCIPAL DISPLAY PANEL
NDC 0228-3116-11
Rx Only
(Once Daily)
Morphine Sulfate
Extended-Release
Capsules, USP
45 mg
100 capsules

PRINCIPAL DISPLAY PANEL
NDC 0228-3091-11
Rx Only
(Once Daily)
Morphine Sulfate
Extended-Release
Capsules, USP
60 mg
100 capsules

PRINCIPAL DISPLAY PANEL
NDC 0228- 3117 -11
Rx Only
(Once Daily)
Morphine Sulfate
Extended-Release
Capsules, USP
75 mg
100 capsules

PRINCIPAL DISPLAY PANEL
NDC 0228-3092-11
Rx Only
(Once Daily)
Morphine Sulfate
Extended-Release
Capsules, USP
90 mg
100 capsules

PRINCIPAL DISPLAY PANEL
NDC 0228-3093-11
Rx Only
(Once Daily)
Morphine Sulfate
Extended-Release
Capsules, USP
120 mg
100 capsules