morphine and naltrexone

MOR-feen SUL-fate, nal-TREX-one hye-droe-KLOR-ide

Oral route(Capsule, Extended Release)

Morphine sulfate/naltrexone hydrochloride capsules contain pellets of morphine sulfate with a sequestered core of naltrexone, and is indicated for moderate to severe pain management. Drug should be swallowed whole or the capsule contents sprinkled on apple sauce. Pellets are not to be chewed, crushed, or dissolved. Misuse causes rapid release and absorption, with a resulting potentially-fatal morphine dose. Capsules are for use in opioid-tolerant patients only and are not intended for prn analgesia. Patients should not consume alcoholic beverages or medications containing alcohol while on this drug .

Commonly used brand name(s)

In the U.S.

• Embeda

Available Dosage Forms:

• Capsule, Extended Release

Pharmacologic Class: Naltrexone

Chemical Class: Morphine

Uses For morphine and naltrexone

Morphine and naltrexone combination is used to treat moderate to severe pain when around-the-clock pain relief is needed for a long period of time. morphine and naltrexone should not be used to treat pain that you only have once in a while (or "as needed").

Morphine belongs to the group of medicines called narcotic analgesics (pain medicines). It acts on the central nervous system (CNS) to relieve pain.

Naltrexone is an opioid antagonist. It blocks the effects of narcotics, especially the "high'' feeling that makes you want to use them. It will not produce any narcotic-like effects or cause mental or physical dependence.

morphine and naltrexone is available only with your doctor's prescription.

Before Using morphine and naltrexone

In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For morphine and naltrexone, the following should be considered:

Allergies

Tell your doctor if you have ever had any unusual or allergic reaction to morphine and naltrexone or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.

Pediatric

Appropriate studies have not been performed on the relationship of age to the effects of morphine and naltrexone combination in the pediatric population. Safety and efficacy have not been established.

Geriatric

Appropriate studies performed to date have not demonstrated geriatric-specific problems that would limit the usefulness of morphine and naltrexone combination in the elderly. However, elderly patients are more likely to have age-related heart, kidney, liver, or lung problems, which may require an adjustment in the dose for patients receiving morphine and naltrexone combination.

Pregnancy

	Pregnancy Category	Explanation
All Trimesters	C	Animal studies have shown an adverse effect and there are no adequate studies in pregnant women OR no animal studies have been conducted and there are no adequate studies in pregnant women.

Breast Feeding

There are no adequate studies in women for determining infant risk when using this medication during breastfeeding. Weigh the potential benefits against the potential risks before taking this medication while breastfeeding.

Interactions with Medicines

Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking morphine and naltrexone, it is especially important that your healthcare professional know if you are taking any of the medicines listed below. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.

Using morphine and naltrexone with any of the following medicines is not recommended. Your doctor may decide not to treat you with this medication or change some of the other medicines you take.

• Alfentanil


• Alphaprodine


• Brofaromine


• Clorgyline


• Codeine


• Dihydrocodeine


• Ethylmorphine


• Fentanyl


• Furazolidone


• Hydrocodone


• Hydromorphone


• Iproniazid


• Isocarboxazid


• Lazabemide


• Levorphanol


• Linezolid


• Meperidine


• Methadone


• Moclobemide


• Morphine


• Morphine Sulfate Liposome


• Naltrexone


• Nialamide


• Oxycodone


• Oxymorphone


• Pargyline


• Phenelzine


• Procarbazine


• Propoxyphene


• Rasagiline


• Selegiline


• Sufentanil


• Toloxatone


• Tranylcypromine

Using morphine and naltrexone with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

• Adinazolam


• Alfentanil


• Alprazolam


• Amobarbital


• Anileridine


• Aprobarbital


• Bromazepam


• Brotizolam


• Buprenorphine


• Butabarbital


• Butalbital


• Butorphanol


• Carisoprodol


• Chloral Hydrate


• Chlordiazepoxide


• Chlorpromazine


• Chlorzoxazone


• Cimetidine


• Clobazam


• Clonazepam


• Clorazepate


• Codeine


• Dantrolene


• Dezocine


• Diazepam


• Estazolam


• Ethchlorvynol


• Fentanyl


• Flunitrazepam


• Fluphenazine


• Flurazepam


• Halazepam


• Hydrocodone


• Hydromorphone


• Ketazolam


• Levorphanol


• Lorazepam


• Lormetazepam


• Medazepam


• Meperidine


• Mephenesin


• Mephobarbital


• Meprobamate


• Metaxalone


• Methocarbamol


• Methohexital


• Midazolam


• Morphine


• Morphine Sulfate Liposome


• Nalbuphine


• Nitrazepam


• Nordazepam


• Opium


• Oxazepam


• Oxycodone


• Oxymorphone


• Pentazocine


• Pentobarbital


• Perphenazine


• Phenobarbital


• Prazepam


• Prochlorperazine


• Promazine


• Promethazine


• Propoxyphene


• Quazepam


• Remifentanil


• Secobarbital


• Sodium Oxybate


• Sufentanil


• Tapentadol


• Temazepam


• Thiethylperazine


• Thiopental


• Thioridazine


• Triazolam


• Trifluoperazine

Using morphine and naltrexone with any of the following medicines may cause an increased risk of certain side effects, but using both drugs may be the best treatment for you. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

• Cyclosporine


• Esmolol


• Gabapentin


• Rifampin


• Somatostatin


• Yohimbine

Interactions with Food/Tobacco/Alcohol

Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.

Using morphine and naltrexone with any of the following is usually not recommended, but may be unavoidable in some cases. If used together, your doctor may change the dose or how often you use morphine and naltrexone, or give you special instructions about the use of food, alcohol, or tobacco.

• Ethanol

Other Medical Problems

The presence of other medical problems may affect the use of morphine and naltrexone. Make sure you tell your doctor if you have any other medical problems, especially:

• Addison's disease (adrenal gland problem) or


• Brain tumor or


• Breathing problems (e.g., chronic obstructive pulmonary disease [COPD], cor pulmonale, hypoxia) or


• CNS depression or


• Enlarged prostate (BPH, prostatic hypertrophy) or


• Head injuries or


• Kyphoscoliosis (curvature of spine that can cause breathing problems) or


• Mental illness or


• Problems with passing urine or


• Thyroid problems—Use with caution. May increase risk for more serious side effects.

• Alcohol abuse, or history of or


• Drug dependence, especially narcotic abuse or dependence, history of—Dependence may be more likely to develop.

• Breathing problems (e.g., asthma, hypercapnia), severe or


• Not opioid-tolerant (if you are not already taking a certain amount of morphine, oxycodone, hydromorphone or other opioid medicine) or


• Respiratory depression (hypoventilation or slow breathing)—Should not be used in patients with these conditions. It could cause very serious breathing problems.

• Hypotension (low blood pressure) or


• Pancreatitis (inflammation of the pancreas) or


• Seizures, history of—Use with caution. May make these conditions worse.

• Kidney disease or


• Liver disease (including cirrhosis)—Use with caution. The effects may be increased because of slower removal of the medicine from the body.

• Paralytic ileus (intestinal blockage)—Should not be used in patients with this condition.

Proper Use of morphine and naltrexone

Morphine and naltrexone combination extended-release capsules are for use in opioid-tolerant patients only. If you are uncertain whether or not you are opioid-tolerant, check with your doctor before using morphine and naltrexone.

morphine and naltrexone should come with a medication guide. Read and follow these instructions carefully. Ask your doctor if you have any questions.

Swallow the extended-release capsules whole. Do not break, crush, or chew it.

If you cannot swallow the extended-release capsule, you may open it and pour the medicine into a small amount of soft food such as applesauce. Stir this mixture well and swallow it without chewing.

Dosing

The dose of morphine and naltrexone will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of morphine and naltrexone. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.

• For oral dosage form (extended-release capsules):
  
  • For pain:
    
    • For patients taking Embeda® as the first pain medicine:
      
      • Adults—At first, one capsule once a day. Your doctor may increase your dose as needed.
      
      
      • Children—Use and dose must be determined by your doctor.
      
      
    
    
    • For patients switching from other oral morphine to Embeda®:
      
      • Adults—The dose is half of the total morphine dose that you are taking every 12 hours, or the same total morphine dose that you are taking once a day.
      
      
      • Children—Use and dose must be determined by your doctor.
      
      
    
    
  
  

Missed Dose

If you miss a dose of morphine and naltrexone, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Storage

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.

Keep out of the reach of children.

Do not keep outdated medicine or medicine no longer needed.

Ask your healthcare professional how you should dispose of any medicine you do not use.

Flush the unused Embeda® capsules down the toilet.

Precautions While Using morphine and naltrexone

It is very important that your doctor check your progress while you are taking morphine and naltrexone. This will allow your doctor to see if the medicine is working properly and to decide if you should continue to take it.

morphine and naltrexone will add to the effects of alcohol and other CNS depressants (medicines that can make you drowsy or less alert). Some examples of CNS depressants are antihistamines or medicine for allergies or colds; sedatives, tranquilizers, or sleeping medicine; other prescription pain medicine or narcotics; medicine for seizures or barbiturates; muscle relaxants; or anesthetics, including some dental anesthetics. Check with your doctor before taking any of the other medicines listed above while you are using morphine and naltrexone.

morphine and naltrexone may be habit-forming. If you feel that the medicine is not working as well, do not use more than your prescribed dose. Call your doctor for instructions.

Dizziness, lightheadedness, or fainting may occur when you get up suddenly from a lying or sitting position. Getting up slowly may help lessen this problem. Also, lying down for a while may relieve dizziness or lightheadedness.

Using narcotics for a long time can cause severe constipation. To prevent this, your doctor may direct you to take laxatives, drink a lot of fluids, or increase the amount of fiber in your diet. Be sure to follow the directions carefully, because continuing constipation can lead to more serious problems.

Before having any kind of surgery (including dental surgery) or emergency treatment, tell the medical doctor or dentist in charge that you are using morphine and naltrexone. Serious side effects can occur if your medical doctor or dentist gives you certain other medicines without knowing that you are using morphine and naltrexone combination.

morphine and naltrexone may make you dizzy, drowsy, or lightheaded. Make sure you know how you react to morphine and naltrexone before you drive, use machines, or do anything else that could be dangerous if you are dizzy or not alert.

morphine and naltrexone may cause a serious type of allergic reaction called anaphylaxis. Anaphylaxis can be life-threatening and requires immediate medical attention. Call your doctor right away if you have a rash; itching; hoarseness; trouble breathing; trouble swallowing; or any swelling of your hands, face, or mouth while you are using morphine and naltrexone.

If you have been using morphine and naltrexone regularly for several weeks or more, do not suddenly stop using it without first checking with your doctor. You may be directed to gradually reduce the amount you are using before stopping treatment completely, or to take another narcotic for a while, to lessen the chance of withdrawal side effects.

Using morphine and naltrexone while you are pregnant may cause neonatal withdrawal syndrome in your newborn babies. Tell your doctor right away if you child has the following symptoms: abnormal sleep pattern, diarrhea, high-pitched cry, irritability, shakiness or tremor, weight loss, vomiting, or failure to gain weight.

Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines and herbal or vitamin supplements.

morphine and naltrexone Side Effects

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

More common

• Bloating or swelling of the face, arms, hands, lower legs, or feet


• chills


• confusion


• constipation


• drowsiness


• feeling of warmth


• irritability


• mental depression


• mood or other mental changes


• rapid weight gain


• redness of the face, neck, arms, and occasionally, upper chest


• relaxed and calm


• restlessness


• shakiness in the legs, arms, hands, or feet


• sleepiness


• sudden sweating


• tingling of the hands or feet


• trembling or shaking of the hands or feet


• unusual weight gain or loss

Rare

• Abnormal dreams


• being forgetful


• blurred vision


• burning while urinating


• burning, crawling, itching, numbness, prickling, "pins and needles", or tingling feelings


• clumsiness or unsteadiness


• confusion about identity, place, and time


• darkened urine


• decrease in frequency of urination


• decrease in urine volume


• decreased awareness or responsiveness


• delusions


• dementia


• difficult or labored breathing


• difficult or painful urination


• difficulty in passing urine (dribbling)


• dizziness, faintness, or lightheadedness when getting up from a lying or sitting position suddenly


• fast heartbeat


• feeling of warmth


• fever


• indigestion


• loss of appetite


• nausea


• nervousness


• pains in the stomach, side, or abdomen, possibly radiating to the back


• redness of the face, neck, arms, and occasionally, upper chest


• seeing, hearing, or feeling things that are not there


• severe nausea or vomiting


• severe sleepiness


• shortness of breath


• stomach pain


• sweating


• tightness in the chest


• unusual tiredness or weakness


• vomiting


• wheezing


• yellow eyes or skin

Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

More common

• Acid or sour stomach


• anxiety


• belching


• decreased appetite


• diarrhea


• difficulty with moving


• excess air or gas in the stomach or intestines


• full feeling


• heartburn


• itching skin


• muscle pain or stiffness


• muscle spasm


• pain in the joints


• passing gas


• sleepiness or unusual drowsiness


• stomach discomfort, upset, or pain


• unusual drowsiness, dullness, tiredness, weakness, or feeling of sluggishness


• weight loss

Rare

• Cold sweats


• decreased interest in sexual intercourse


• dizziness


• dry mouth


• general feeling of discomfort or illness


• goosebumps


• headache


• inability to have or keep an erection


• increased sweating


• lack or loss of strength


• loss in sexual ability, desire, drive, or performance


• night sweats


• pressure in the stomach


• rash


• sleeplessness


• stomach tenderness


• swelling of the abdominal or stomach area


• trouble sleeping


• unable to sleep


• upper abdominal or stomach pain

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

See also: morphine and naltrexone side effects (in more detail)

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