Pharmacy Services

Morphine Sulfate Oral Solution

January 12, 2011

Healthcare professionals have been notified of serious adverse events due to medication use errors with morphine oral solutions. Most errors are due to mistakenly interchanging orders for milligrams (mg) of morphine for milliliters (mL) of product resulting in accidental overdose. When this type of error occurs with the high-potency morphine sulfate oral solutions (20 mg/mL) it results in a 20-fold dose increase and can be fatal.
Roxane Laboratories revised the container and carton labeling for their 100 mg per 5 mL products to more clearly differentiate them from lower concentration morphine oral solutions.  The new packaging features a yellow background with a white on red field showing the concentration.  The concentration is displayed as 100 mg per 5 mL (20 mg/mL) to distinguish it from the 20 mg per 5 mL concentration.  Images of the new packaging can be accessed through the links below. The high potency morphine oral solution (100 mg/5 mL) is labeled for use in opioid-tolerant patients only.
When writing a prescription for oral morphine solution, prescribers are advised to clearly indicate the concentration of product (mg/mL) to be dispensed, the dose in milligrams (mg), and the volume of the dose in milliliters (mL).  Morphine sulfate oral solution 100 mg/5 mL in the 30 mL and 120 mL bottles comes with a special oral syringe. Instruct patients on the proper use of the oral syringe when dispensing.  Give a medication guide to each patient when dispensing these products.
Additional information is available at the following links:

Updated
January 12, 2011; University of Utah, Drug Information Service. Copyright 2011, Drug Information Service, University of Utah, Salt Lake City, UT.