Blue m 15 pill

Morphine Sulfate ER Side Effects

Generic Name: morphine

Medically reviewed by Drugs.com. Last updated on Jan 18, 2019.

  • Side Effects
  • Dosage
  • Interactions
  • Pregnancy
  • Breastfeeding
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Note: This document contains side effect information about morphine. Some of the dosage forms listed on this page may not apply to the brand name Morphine Sulfate ER.

For the Consumer

Applies to morphine: oral capsule extended release, oral capsule extended release 24 hr, oral solution, oral tablet, oral tablet extended release

Other dosage forms:

  • injection solution

Warning

Oral route (Solution)

Morphine oral solution is available in 10 mg/5 mL, 20 mg/5 mL and 100 mg/5 mL (20 mg/mL) concentrations. The 100 mg/5 mL (20 mg/mL) concentration is indicated for use in opioid-tolerant patients only. Take care to avoid dosing errors due to confusion between different concentrations and between mg and mL, which could result in accidental overdose and death. Keep morphine oral solution out of the reach of children.

Oral route (Tablet; Tablet, Extended Release)

Addiction, Abuse, and MisuseMorphine sulfate exposes users to risks of addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient’s risk before prescribing, and monitor regularly for these behaviors and conditions.Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS)To ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse, the Food and Drug Administration (FDA) has required a Risk Evaluation and Mitigation Strategy (REMS) for these products.Life-Threatening Respiratory DepressionSerious, life-threatening or fatal respiratory depression may occur. Monitor closely, especially upon initiation or following a dose increase. Instruct patients to swallow morphine sulfate whole to avoid exposure to a potentially fatal dose of morphine.Accidental IngestionAccidental ingestion of morphine sulfate, especially in children, can result in fatal overdose of morphine.Neonatal Opioid Withdrawal SyndromeProlonged use of morphine sulfate during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated. If prolonged opioid use is required in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available.Risks From Concomitant Use With Benzodiazepines or Other CNS DepressantsConcomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing for use in patients for whom alternative treatment options are inadequate; limit dosages and durations to the minimum required; and follow patients for signs and symptoms of respiratory depression and sedation.

Oral route (Capsule, Extended Release)

Addiction, Abuse, and MisuseMorphine sulfate exposes users to risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient’s risk before prescribing, and monitor regularly for development of these behaviors or conditions. Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS)To ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse, the Food and Drug Administration (FDA) has required a Risk Evaluation and Mitigation Strategy (REMS) for these products.Life-Threatening Respiratory DepressionSerious, 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 sulfate.Accidental IngestionAccidental ingestion of morphine sulfate, especially in children, can result in a fatal overdose.Neonatal Opioid Withdrawal SyndromeProlonged use of morphine sulfate 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.Interaction with AlcoholAlcohol consumption should be avoided while taking morphine sulfate extended-release capsules. Consumption of alcohol may lead potentially fatal overdoses of morphine.Risks From Concomitant Use With Benzodiazepines or Other CNS DepressantsConcomitant use of opioids and benzodiazepines or other CNS depressants may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing for patients with inadequate alternative treatment options. Limit dosages and durations to the minimum required and follow patients for signs and symptoms of respiratory depression and sedation.

Along with its needed effects, morphine (the active ingredient contained in Morphine Sulfate ER) 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 while taking morphine:

Less common

  • Blurred vision
  • bulging soft spot on the head of an infant
  • burning, crawling, itching, numbness, prickling, “pins and needles”, or tingling feelings
  • change in the ability to see colors, especially blue or yellow
  • chest pain or discomfort
  • chills
  • confusion
  • cough
  • decreased urination
  • dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position
  • fainting
  • fast, pounding, or irregular heartbeat or pulse
  • headache
  • hives, itching, or skin rash
  • increased sweating
  • loss of appetite
  • nausea
  • nervousness
  • pounding in the ears
  • puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue
  • severe constipation
  • severe vomiting
  • shakiness in the legs, arms, hands, or feet
  • slow heartbeat
  • stomach pain
  • sweating
  • vomiting

Incidence not known

  • Agitation
  • black, tarry stools
  • cold, clammy skin
  • darkening of the skin
  • diarrhea
  • difficulty swallowing
  • feeling of warmth or heat
  • fever
  • flushing or redness of the skin, especially on the face and neck
  • irregular, fast or slow, or shallow breathing
  • lightheadedness
  • loss of consciousness
  • low blood pressure or pulse
  • mental depression
  • overactive reflexes
  • painful urination
  • pale or blue lips, fingernails, or skin
  • pale skin
  • pinpoint red spots on the skin
  • poor coordination
  • pounding in the ears
  • puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue
  • restlessness
  • shakiness and unsteady walk
  • shivering
  • talking or acting with excitement you cannot control
  • tightness in the chest
  • twitching
  • unsteadiness, trembling, or other problems with muscle control or coordination
  • unusual bleeding or bruising
  • unusual tiredness or weakness
  • very slow heartbeat

Get emergency help immediately if any of the following symptoms of overdose occur while taking morphine:

Symptoms of overdose

  • Constricted, pinpoint, or small pupils (black part of the eye)
  • decreased awareness or responsiveness
  • extreme drowsiness
  • fever
  • increased blood pressure
  • increased thirst
  • lower back or side pain
  • muscle cramps, spasms, pain, or stiffness
  • no muscle tone or movement
  • severe sleepiness
  • swelling of the face, fingers, or lower legs
  • weight gain

Some side effects of morphine 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

  • Cramps
  • difficulty having a bowel movement
  • drowsiness
  • false or unusual sense of well-being
  • relaxed and calm feeling
  • sleepiness or unusual drowsiness
  • weight loss

Less common

  • Absent, missed, or irregular menstrual periods
  • bad, unusual, or unpleasant (after) taste
  • change in vision
  • dry mouth
  • floating feeling
  • halos around lights
  • heartburn or indigestion
  • loss in sexual ability, desire, drive, or performance
  • muscle stiffness or tightness
  • night blindness
  • overbright appearance of lights
  • problems with muscle control
  • stomach discomfort or upset
  • trouble sleeping
  • uncontrolled eye movements

Incidence not known

  • Abnormal dreams
  • change in walking and balance
  • change or problem with discharge of semen
  • clumsiness or unsteadiness
  • confusion as to time, place, or person
  • false beliefs that cannot be changed by facts
  • feeling of constant movement of self or surroundings
  • general feeling of discomfort or illness
  • holding false beliefs that cannot be changed by fact
  • poor insight and judgment
  • problems with memory or speech
  • seeing, hearing, or feeling things that are not there
  • sensation of spinning
  • trouble recognizing objects
  • trouble thinking and planning
  • trouble walking
  • unusual excitement, nervousness, or restlessness

For Healthcare Professionals

Applies to morphine: compounding powder, injectable solution, injectable tablet soluble, intravenous solution, oral capsule, oral capsule extended release, oral concentrate, oral liquid, oral solution, oral tablet, oral tablet extended release, rectal suppository, spinal solution

Nervous system

Central nervous system side effects may be either depressant or excitatory. Excitatory symptoms are sometimes ignored as possible side effects of morphine (the active ingredient contained in Morphine Sulfate ER) Severe adverse effects such as respiratory depression can be treated with the opioid antagonist naloxone.

Patients receiving continuous infusion of morphine sulfate via indwelling intrathecal catheter should be monitored for new neurologic signs or symptoms. Further assessment or intervention should be based on the clinical condition of the individual patient.

Myoclonic spasms may occur in patients receiving high dose morphine, particularly in the setting of renal dysfunction. Hyperalgesia has also been reported with high doses.

Very common (10% or more): Drowsiness (28%)

Common (1% to 10%): Dizziness, sedation, fever, anxiety, confusion, tremor, diaphoresis, lethargy, feeling of warmth

Uncommon (0.1% to 1%): Withdrawal symptoms after either abrupt cessation or fast tapering of the drug, headache, chills, flu syndrome, malaise, withdrawal syndrome, pallor, facial flushing, syncope, loss of concentration, insomnia, amnesia, paresthesia, agitation, vertigo, foot drop, ataxia, hypesthesia, slurred speech, hallucinations, euphoria, apathy, seizures, myoclonus

Frequency not reported: Inflammatory masses including granulomas (some of which have resulted in serous neurologic impairment including paralysis) in patients receiving continuous infusion of opioids via indwelling intrathecal catheter

Respiratory

Common (1% to 10%): Respiratory depression

Gastrointestinal

Morphine may cause constriction of the common bile duct and spasm of the sphincter of Oddi, thereby increasing intrabiliary pressure and worsening, rather than relieving, biliary colic.

In addition, morphine (the active ingredient contained in Morphine Sulfate ER) may cause intense but uncoordinated duodenal contraction and decreased gastric emptying.

Common (1% to 10%): Dry mouth, constipation, nausea, diarrhea, anorexia, abdominal pain, vomiting

Uncommon (0.1% to 1%): Dysphagia, dyspepsia, stomach atony disorder, gastroesophageal reflux, delayed gastric emptying, biliary colic, increased gastroesophageal reflux, intestinal obstruction

Cardiovascular

Common (1% to 10%): Chest pain

Psychiatric

Frequency not reported: Withdrawal symptoms after abrupt cessation of therapy

Genitourinary

Uncommon (0.1% to 1%): Urinary abnormality, urinary retention, urinary hesitancy

The risk of acute urinary retention is very high when morphine is administered by epidural or intrathecal injection. Clinicians should be attentive to the increased risk of urosepsis in this setting, particularly if instrumentation of the urinary tract is necessary.

Hematologic

Common (1% to 10%): Anemia, leukopenia

Uncommon (0.1% to 1%): Thrombocytopenia

Endocrine

Musculoskeletal

Common (1% to 10%): Asthenia, accidental injury

Uncommon (0.1% to 1%): Back pain, bone pain, arthralgia

Frequency not reported: Opioid-induced involuntary muscle hyperactivity with chronic high doses

Dermatologic

Common (1% to 10%): Rash

Uncommon (0.1% to 1%): Decubitus ulcer, pruritus, skin flush

Ocular

Uncommon (0.1% to 1%): Amblyopia, conjunctivitis, miosis, blurred vision, nystagmus, diplopia

Hypersensitivity

Very rare (less than 0.01%): Hypersensitivity reactions, anaphylaxis

Hepatic

Uncommon (0.1% to 1%): Increases in hepatic enzymes

Metabolic

Common (1% to 10%): Peripheral edema

Uncommon (0.1% to 1%): Hyponatremia

1. Morley JS, Watt JWG, Wells JC, Miles JB, Finnegan MJ, Leng G “Methadone in pain uncontrolled by morphine.” Lancet 342 (1993): 1243

2. Littrell RA, Kennedy LD, Birmingham WE, Leak WD “Muscle spasms associated with intrathecal morphine therapy: treatment with midazolam.” Clin Pharm 11 (1992): 57-9

3. Westerling D, Frigren L, Hoglund P “Morphine pharmacokinetics and effects on salivation and continuous reaction times in healthy volunteers.” Ther Drug Monit 15 (1993): 364-74

5. Sjogren P, Dragsted L, Christensen CB “Myoclonic spasms during treatment with high doses of intravenous morphine in renal failure.” Acta Anaesthesiol Scand 37 (1993): 780-2

6. Covington EC, Gonsalves-Ebrahim L, Currie KO, et al “Severe respiratory depression from patient-controlled analgesia in renal failure.” Psychosomatics 30 (1989): 226-8

7. Sjogren P, Jonsson T, Jensen NH, Drenck NE, Jensen TS “Hyperalgesia and myoclonus in terminal cancer patients treated with continuous intravenous morphine.” Pain 55 (1993): 93-7

8. Etches RC “Respiratory depression associated with patient-controlled analgesia – a review of eight cases.” Can J Anaesth 41 (1994): 125-32

10. Bellville JW, Forrest WH, Elashoff J, Laska E “Evaluating side effects of analgesics in a cooperative clinical study.” Clin Pharmacol Ther 9 (1968): 303-13

11. Kwan A “Morphine overdose from patient-controlled analgesia pumps.” Anaesth Intensive Care 24 (1996): 254-6

12. Chambers FA, Mccarroll M, Macsullivan R “Polyarthralgia and amenorrhoea as a complication of intrathecally infused morphine and dilaudid in the treatment of chronic benign back pain.” Br J Anaesth 72 (1994): 734

13. Patt RB, Wu C, Bressi J, Catania JA “Accidental intraspinal overdose revisited.” Anesth Analg 76 (1993): 202

14. Ogawa K, Iranami H, Yoshiyama T, Maeda H, Hatano Y “Severe respiratory depression after epidural morphine in a patient with myotonic dystrophy.” Can J Anaesth 40 (1993): 968-70

16. “Product Information. Roxanol (morphine).” Roxane Laboratories Inc, Columbus, OH.

17. Morley AD “Profound respiratory depression with morphine patient-controlled analgesia in an elderly patient.” Anaesth Intensive Care 24 (1996): 287

18. Thorn SE, Wattwil M, Kallander A “Effects of epidural morphine and epidural bupivacaine on gastroduodenal motility during the fasted state and after food intake.” Acta Anaesthesiol Scand 38 (1994): 57-62

19. Lang DW, Pilon RN “Naloxone reversal of morphine-induced biliary colic.” Anesth Analg 59 (1980): 619-20

20. White MJ, Berghausen EJ, Dumont SW, et al “Side effects during continuous epidural infusion of morphine and fentanyl.” Can J Anaesth 39 (1992): 576-82

21. Zsigmond EK, Vieira ZEG, Duarte B, Renigers SA, Hirota K “Double-blind placebo-controlled ultrasonographic confirmation of constriction of the common bile duct by morphine.” Int J Clin Pharmacol Ther Toxicol 31 (1993): 506-9

22. Semenkovich CF, Jaffe AS “Adverse effects due to morphine sulfate: challenge to previous clinical doctrine.” Am J Med 79 (1985): 325-30

23. D’Souza M “Unusual reaction to morphine.” Lancet 07/11/87 (1987): 98

24. Christie JM, Meade WR, Markowsky S “Paranoid psychosis after intrathecal morphine.” Anesth Analg 77 (1993): 1298-9

26. Petros JG, Mallen JK, Howe K, Rimm EB, Robillard RJ “Patient-controlled analgesia and postoperative urinary retention after open appendectomy.” Surg Gynecol Obstet 177 (1993): 172-5

27. Cimo PL, Hammond JJ, Moake JL “Morphine-induced immune thrombocytopenia.” Arch Intern Med 142 (1982): 832-4

28. Paice JA, Penn RD “Amenorrhea associated with intraspinal morphine.” J Pain Symptom Manage 10 (1995): 582-3

29. Kardaun SH, de Monchy JG “Acute generalized exanthematous pustulosis caused by morphine, confirmed by positive patch test and lymphocyte transformation test.” J Am Acad Dermatol 55(2 Suppl) (2006): S21-3

30. Galea M “Morphine-induced pruritus after spinal anaesthesia.” Br J Anaesth 97 (2006): 426

31. Goldstein JH “Effects of drugs on cornea, conjunctiva, and lids.” Int Ophthalmol Clin 11 (1971): 13-34

33. Hasselstrom J, Eriksson S, Persson A, Rane A, Svensson JO, Sawe J “The metabolism and bioavailability of morphine in patients with severe liver cirrhosis.” Br J Clin Pharmacol 29 (1990): 289-97

34. Olsen GD, Bennett WM, Porter GA “Morphine and phenytoin binding to plasma proteins in renal and hepatic failure.” Clin Pharmacol Ther 17 (1975): 677-84

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Some side effects may not be reported. You may report them to the FDA.

Medical Disclaimer

More about Morphine Sulfate ER (morphine)

  • During Pregnancy or Breastfeeding
  • Dosage Information
  • Drug Images
  • Drug Interactions
  • 26 Reviews
  • Drug class: narcotic analgesics
  • FDA Alerts (9)

Consumer resources

Other brands: MS Contin, Roxanol, Kadian, Duramorph, … +10 more

Professional resources

  • Morphine Sulfate (AHFS Monograph)
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What Are the Mental and Physical Effects of a Morphine High?

Extracted from the opium found in poppy plants, morphine is one of the oldest pain medications in history.

It accounts for 8-14 percent of opium’s dry weight. Doctors have used morphine to prep their patients prior to surgery or to treat chronic pain since the time of the Byzantine Empire, and it is still used today.

Despite its widespread use, morphine’s long history in the medical community has been fraught with controversy. The drug is considered Schedule II in the United States, which means it is medically acceptable for use but with severe restrictions due to its highly addictive nature.

The addictive nature of morphine and other drugs like it presents a massive problem. Even with current government regulations, studies like this one from the 2015 Annual Review of Public Health document the rise in prescription opioid abuse, which has more than quadrupled since the start of the 21st century.

But how exactly does morphine manage to attract so many people? The answer lies at the cellular level and the way in which morphine affects the body and mind.

How Morphine Gets You High

Morphine is typically injected into the bloodstream via a syringe (in illicit scenarios) or IV drip. The drug is absorbed into the blood and carried to other organs in the body, where it affects specific receptors in the nervous system. These receptors will trigger different responses based on what they do in the body. Some of the receptors that morphine affects are m 1-receptors, causing analgesia (the inability to feel pain) and euphoria; m 2-receptors, causing drowsiness and mental clouding; k-receptors, causing dysphoria and mild respiratory depression; and d-receptors, causing delusions and hallucinations.

Depending on the dose and one’s sensitivity to drugs, a morphine high can last 1.5-7 hours. The most prominent effect of morphine is euphoria and an effective decrease in chronic pain, a sensation that psychologist John B. Murray compared to “a prefrontal lobotomy” in a 2016 issue of The Catholic Lawyer. It is this pleasant feeling (often a respite from the painful condition that merited a morphine prescription) that contributes to the vast number of people who abuse and even overdose of morphine every year.

The Symptoms of a Morphine High

The American Society of Addiction Medicine reported in 2016 that of the 20.5 million Americans suffering from an addiction disorder that year, 2 million suffered from an addiction to prescription painkillers like morphine. If a person has a legitimate prescription for morphine, addiction is a dangerous possibility that can follow a severe car accident or other chronic pain condition if the patient’s use is not carefully monitored.

If you are concerned that someone you love is using morphine, there are a few key signs to watch for. To recognize whether a loved one is currently high, observe their behavior for some of the short-term physical effects of morphine use. These include:

  • Dilated pupils
  • Nodding off
  • Slurred speech
  • Inattention
  • Shallow breathing

Your loved one may also exhibit other short-term side effects, such as apathy, nausea, itchy skin, and hallucinations. There are also some mental and behavioral symptoms that can indicate morphine abuse. These include:

  • Faking injuries or harming oneself to see a doctor for a prescription
  • Poor hygiene
  • Needle marks from injecting the drug
  • Stealing or asking for money to buy morphine
  • Changes in one’s circle of friends
  • Withdrawal from friends and family

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Dangers of the Drug

There are many serious long-term side effects to morphine abuse. While some, like fever and hives, are merely uncomfortable, others are incredibly dangerous and could result in irreparable damage to one’s health.

For example, many people who use morphine find themselves at an increased risk for blood-borne pathogens like HIV. This is because many people who use morphine illicitly take the drug intravenously, sometimes with shared needles.

Overdose resulting in death is another risk of morphine abuse. Since 2000, the Center for Disease Control has seen an increase in opioid-related overdoses (which include morphine overdoses) of 200 percent.

If you, or someone you love, are currently using morphine, it’s important to be aware of the telltale signs of long-term damage from use of the drug. If you experience any of these symptoms, or notice them in someone else, get to a hospital as soon as possible:

  • Altered heartbeat rates
  • Seizures
  • Fainting
  • Chest pain
  • Fever
  • Hives, rash, and itching
  • Swelling of the throat and face
  • Hoarseness
  • Difficulty breathing or swallowing

With prompt medical treatment, an overdose on morphine can often be reversed but early intervention is essential.

Overdose is a clear sign that addiction treatment is needed. With comprehensive care, the long-term effects of morphine abuse can be mitigated, giving one the best chances of a complete recovery.

Morphine Sulfate (MS Contin, Morphine Sulfate – Long Acting Pill)

How to Take Morphine Sulfate Sustained/Extended Release

Morphine sulfate long acting pills are available in both tablet and capsule form. The medication is released slowly over the course of the day (called extended release) and comes in a variety of doses. Your care provider will determine the exact dosage and dosing schedule. This form of morphine can be taken with or without food. The tablets should be swallowed whole. Do not break, chew or crush the tablets as this could cause an overdose of the medication. Kadian and Avinza, the capsule formulations, can be opened and sprinkled into applesauce or pudding, but the beads should not be crushed or chewed. These medications begin working in 2 to 4 hours, and reach peak effect in 15 to 30 hours (depending on the preparation). It can continue to work for a few days. This type of medication is designed to produce a long acting, steady amount of pain relief.

It is important to make sure you are taking the correct amount of medication every time. Before every dose, check that what you are taking matches what you have been prescribed.

This medication can interact with other medications that depress the central nervous system like barbituates (including phenobarbital), tranquilizers (including Haldol®, Librium® and Xanax ®), other narcotics, MAOI’s, cimitedine, and general anesthetic. Be sure to tell your healthcare provider about all medications and supplements you take.

DO NOT share this medication or give it to someone else, as severe breathing problems and death can occur.

This medication can cause dizziness, sleepiness and confusion. You should not drive or operate machinery while taking this medication until you know how it will affect you.

Storage and Handling

Store this medication at room temperature in the original container. Due to the risk of diversion (someone else taking your narcotic medication to obtain a high, rather than for symptom relief), you may want to consider keeping your medication in a lock box or other secure location. Keep this medication out of reach of children and pets.

To prevent someone accidently taking this medication, it should be disposed of when no longer needed through a medicine take-back program or by dropping them off at a DEA-authorized collector. For locations near you, check www.dea.gov. Ask your pharmacist or care team for assistance in disposal of unused medications. If you cannot use these options, you can flush these medicines down the sink or toilet as soon as they are no longer needed.

Where do I get this medication?

Morphine sulfate long acting pills are available through retail and mail order pharmacy. Your oncology team will work with your prescription drug plan to identify an in-network retail/mail order pharmacy for medication distribution. Mail order delivery must be hand delivered and signed for. This medication cannot be “called in” or electronically prescribed to your local pharmacy; you must provide the original prescription to the pharmacist. Many pharmacies do not keep this medication in stock, but will order it for you. There may be a delay in availability, so plan prescription refills accordingly.

Insurance Information

This medication may be covered under your prescription drug plan. Patient assistance may be available to qualifying individuals without prescription drug coverage. Co-pay cards, which reduce the patient’s co-pay responsibility for eligible commercially (non-government sponsored) insured patients, are also offered by the manufacturer. Your insurance company may require you to utilize other pain medications prior to authorizing a prescription for this medication. This is called step therapy. Due to risk for diversion and misuse, the quantity of medication you receive may be limited to a 2 week or 1 month supply.

Possible Side Effects of Morphine Sulfate Sustained/Extended Release Pill

There are a number of things you can do to manage the side effects of morphine sulfate (oral, sustained/extended release pill). Talk to your care team about these recommendations. They can help you decide what will work best for you. These are some of the most common or important side effects:

Slowed Breathing or Low Blood Pressure

You may experience low blood pressure or slowed breathing while taking an opioid painkiller. This usually only occurs when the dose of medication is too high or it is increased too quickly. This rarely happens to patients who have been taking opioid medications for a long time.

These side effects can also result from an overdose of opioids. If you suspect that you or someone you know has taken an overdose of opioids, call 911 immediately. If you feel extremely tired, lightheaded, dizzy, sweaty, nauseated, or short of breath, you need to see a doctor immediately. Sometimes patients who have taken too much opioid medication will be so sleepy that they can’t be awakened or aroused. These side effects are emergency situations. If any of these symptoms occur, you should seek emergency medical attention.

Sleepiness (Somnolence)

Feeling sleepy, drowsy or lightheaded may accompany the use of opioid pain medication. Some people just don’t “feel like themselves” on these medications. Avoid driving or any other potentially dangerous tasks that require your concentration and a clear head until you feel normal again. Avoid alcohol or other sedatives while using these medications unless they are specifically prescribed by your care team. Most people will begin to feel like themselves after a few days on the medications. If you continue to feel “out of it” after a couple of days, talk to your healthcare provider about adjusting your dosages.

Constipation Caused by Pain Medications

Constipation is a very common side effect of pain medications that continues as long as you are taking the medications. This side effect can often be managed well with the following preventative measures:

  • Drinking 8-10 glasses of water a day. Warm or hot fluids can be helpful.
  • Increasing physical activity when possible.
  • Attempting a bowel movement at the same time each day.
  • Eating plenty of fruits and vegetables.
    • Four ounces of prune juice or 3-4 dried prunes/plums can help promote bowel movements.
    • However, high fiber foods (ex. bran flakes, high fiber cereals) and fiber supplements (such as Metamucil) can actually make constipation from pain medications worse and should be avoided.

Your care team may recommend a bowel regimen, using stool softeners and/or laxatives, to prevent or treat constipation. Stool softeners (such as docusate sodium or Colace) work by bringing water into the stool, making it softer and easier to pass. A stimulant or laxative (such as Dulcolax (bisacodyl) or Senakot (senna)) works by stimulating the movements of stool through the bowel. Your provider may recommend Miralax (Polyethylene glycol 3350), which is an osmotic laxative. It works by causing water to be retained in the stool, softening the stool so it is easier to pass. These medications can be taken together. Untreated constipation can lead to a bowel blockage, so be sure to notify your healthcare team if you do not have a bowel movement for 3 or more days.

Concerns About Addiction, Tolerance, and Dependence

Many people who are prescribed opioid pain relievers are worried that they may become addicted to these medications. This fear stems from the fact that opioid medications can cause euphoria and pleasure when used by people who are not in pain. However, when these medications are used to treat physical pain, it is unlikely that patients will become addicted to them. Addiction is a psychological need for the drug that very rarely affects people who take opioids for pain control. People addicted to opioids use them for the purpose of getting “high”. These people also crave opioids, lack control over their use, and will continue to use opioids despite knowing they are causing them harm. People experiencing pain use opioids to relieve their pain.

A person on long-term opioids may stop getting proper pain relief after taking these medications for a while. This phenomenon is called tolerance. As patients develop tolerance, they will need higher doses to get good pain relief. Tolerance is a completely normal aspect of taking opioid pain medications, and is nothing to be concerned about. The point of using these medications is to keep pain well controlled, and the exact doses that a patient requires are not important as long as they can be kept comfortable. If you think you need to change the dose, work with your healthcare team to find the right dose to make you comfortable. Do not try to change the dose on your own, as this may cause unwanted side effects.

As a person takes regular doses of opioids, for as little as a week, their bodies will begin to adapt to the medications. This causes tolerance, but it can also cause dependence. Dependence means that the body “gets used to” the opioids. Dependence DOES NOT equal addiction. Dependence is a natural, physical phenomenon that happens to everyone on long-term opioid therapy. The important thing to know about dependence is that once a patient becomes dependent on opioids, they will feel very sick if they stop the medication abruptly. This is called withdrawal and the symptoms it causes can start within 2 days of abruptly stopping opioids and may last up to 2 weeks. Withdrawal is preventable if you lower the opioid dose slowly, generally over a week or so, with the help and guidance of your health care team. The exact amount of time to wean varies based on dose, how long you’ve been taking them, and some other individual factors. It is important to remember that dependence is normal, and happens to everyone who takes opioids for a long period of time. Talk to your provider if you have any concerns.

Nausea and/or Vomiting

Nausea, with or without vomiting, can be a side effect of opioid pain medications. For some patients it lasts just a few days to weeks after starting the medication, but for some it is a long-term side effect. Nausea and vomiting can interfere with pain management if the nausea and/or vomiting affects the patient’s ability to take the medication. You may find that eating or not eating when taking this medication may be helpful for you. Talk to your healthcare team so they can prescribe medications to help you manage nausea and vomiting.

Less common, but important side effects can include:

  • Serotonin Syndrome: This medication can cause a high level of serotonin in your body, which in rare cases, can lead to serotonin syndrome. Symptoms can include shivering, agitation, diarrhea, nausea and vomiting, fever, seizures, and changes in muscle function. Symptoms can arise hours to days after continued use, but can also occur later. This is a serious side effect and you should contact your care provider immediately if you have any of these side effects.
  • Adrenal Insufficiency: Adrenal insufficiency (inadequate function of the adrenal gland) is a rare but serious side effect of taking this medication. It most often occurs after taking the medication for one month or longer. Symptoms are not very specific, but can include nausea, vomiting, anorexia, fatigue, weakness, dizziness, and low blood pressure. It is important to contact your care provider if you experience any of these side effects.
  • Allergic Reaction: Although it is uncommon, some people are allergic reaction to certain opioid preparations. If after taking morphine or other opioids, you experience chest tightness, swelling, wheezing, fever, itching, blue skin color or cough, you need to call 911. These side effects are emergency situations. If any of these symptoms occur, you should seek emergency medical attention.

Reproductive Concerns

Chronic exposure of an unborn child to this medication could result in the child being born small and/or early, or having symptoms of withdrawal (including respiratory distress, behavioral changes and seizures) after birth. Effective birth control should be used while on this medication. Even if your menstrual cycle stops or you believe you are not producing sperm, you could still be fertile and conceive. You should not breast while receiving this medication as it is passed through a mother’s milk.

Deadly blue ‘Mexican oxy’ pills take toll on US Southwest

TUCSON, Ariz. (AP) — Aaron Francisco Chavez swallowed at least one of the sky blue pills at a Halloween party before falling asleep forever. He became yet another victim killed by a flood of illicit fentanyl smuggled from Mexico by the Sinaloa cartel into the Southwest — a profitable new business for the drug gang that has made the synthetic opioid responsible for the most fatal overdoses in the U.S.

Three others at the party in Tucson also took the pills nicknamed “Mexican oxy.” They were saved after partygoers flagged down police who administered naloxone overdose reversal medication. The treatment came too late for the 19-year-old Chavez.

The pills vary widely in strength, from a tiny amount to enough to cause lethal overdoses. Law enforcement officials say they have become a lucrative new product for the cartel, despite the conviction this week of Sinaloa kingpin Joaquin “El Chapo” Guzman Loera in New York.

The four Tucson partiers thought they were taking oxycodone, a much less powerful opioid, investigators believe. The death of Chavez and many others, officials said, illustrate how Arizona and other southwestern states bordering Mexico have become a hot spot in the nation’s fentanyl crisis. Fentanyl deaths tripled in Arizona from 2015 through 2017.

“It’s the worst I’ve seen in 30 years, this toll that it’s taken on families,” said Doug Coleman, the U.S. Drug Enforcement Administration special agent in charge of Arizona. “The crack (cocaine) crisis was not as bad.”

With plenty of pills and powder sold locally from the arriving fentanyl shipments that are also distributed around the U.S., the drug that has surpassed heroin for overdose deaths has touched all Arizona demographic groups. Chavez’ relatives say he was working as a restaurant prep cook with dreams of becoming a chef and trying to turn his life around after serving prison time for a robbery conviction.

The pills that sell for $9 to $30 each also took the lives of a 17-year-old star high school baseball pitcher from a Phoenix suburb and a pair of 19-year-old best friends and prominent former high school athletes from Arizona’s mountain town of Prescott Valley. The parents of one, Gunner Bundrick, said their son’s death left “a hole in our hearts.”

Popping the pills at parties “is a lot more widespread than we know,” said Yavapai County Sheriff’s Lt. Nate Auvenshine. “There’s less stigma to taking a pill than putting a needle in your arm, but one of these pills can have enough fentanyl for three people.”

Stamped with “M″on one side and “30” on the other to make them look like legitimate oxycodone, the pills started showing up in Arizona in recent years as the Sinaloa cartel’s newest drug product, said Tucson Police Lt. Christian Wildblood.

The fentanyl that killed Chavez was among 1,000 pills sneaked across the border crossing last year in Nogales, Arizona by a woman who was paid $200 to tote them and gave two to Chavez at the party, according to court documents. It’s unknown if he took one or both.

At the same crossing last month, U.S. officials announced their biggest fentanyl bust ever — nearly 254 pounds (115 kilograms) found in a truckload of cucumbers, enough to potentially kill millions. Valued at $3.5 million, most was in powder form and over 2 pounds (1 kilogram) was made up of pills.

The tablets in most cases are manufactured in primitive conditions with pill presses purchased online, Wildblood said. The amount of fentanyl in the counterfeit pills varies from 0.03 to 1.99 milligrams per tablet, or almost none to a lethal dose, according to the U.S. Drug Enforcement Administration.

“There is no quality control,” Wildblood said.

While Chinese shipments were long blamed for illegal fentanyl entering the U.S., Mexico’s Army in November 2017 discovered a rustic fentanyl lab in a remote part of Sinaloa state and seized precursors, finished fentanyl and production equipment — suggesting some of it is now being synthesized across the U.S. border.

Most fentanyl smuggled from Mexico is about 10 percent pure and enters hidden in vehicles at official border crossings around Nogales and San Diego, Customs and Border Protection data show. A decreasing number of smaller shipments with purity of up to 90 percent still enter the U.S. in packages sent from China.

Although 85 percent of the fentanyl from Mexico is seized at San Diego area border crossings, the DEA’s 2018 National Drug Threat Assessment said seizures have surged at Arizona’s border and elsewhere around the state.

DEA statistics show Arizona fentanyl seizures rose to 445 pounds (202 kilograms), including 379,557 pills, in the fiscal year ending in October 2018, up from 172 pounds (78 kilograms), including 54,984 pills, during the previous 12-month period.

The Sinaloa cartel’s ability to ramp up its own production of fentanyl and label it oxycodone shows the group’s business acumen and why it remains among the world’s top criminal organizations, Coleman said.

“If they see a market for their stuff, they’ll make it and bring it up,” he said.

The Centers for Disease Control and Prevention says fentanyl is now the drug involved in the most fatal overdoses in the U.S., with fatalities from synthetic opioids including fentanyl jumping more than 45 percent from 2016 to 2017, when they accounted for some 28,000 of about 70,000 overdose deaths of all kinds.

Fentanyl was also involved more than any other drug in the majority of overdose deaths in 2016, the year the pop artist Prince died after taking fake Vicodin laced with fentanyl. Heroin was responsible for the most drug overdose deaths each of the four years before that.

CDC figures for Arizona show the statewide deaths involving synthetic opioids excluding methadone, largely from fentanyl, rose from 72 in 2015 to 123 in 2016 and then skyrocketed to 267 in 2017.

In the first federal conviction of its kind in Arizona that linked a death to distribution of any drug, a woman from a Phoenix suburb last year got 12 years in prison for selling fentanyl tablets that killed a 38-year-old Arizona man.

And in Tucson, Chavez’ relatives wonder why the woman accused of smuggling the pills across the border allegedly decided to hand them out at the party, saying they were Percocet, which contains oxycodone and acetaminophen, and “something else,” according to court documents.

The woman, Jocelyn Sanchez, denied describing them that way and was charged with transporting and transferring narcotics. Her lawyer, Joel Chorny, declined to discuss the case.

Nicknamed “Sonny Boy, Chavez was the third of 10 children born to Leslie Chavez, who was brought to the U.S. as an infant and deported back to Mexico last year, two months before he died. In a phone interview, she said Mexican officials arranged to have her son’s body brought across the border so she could say goodbye.

She said she had “heard about how these pills were killing people” but never thought it would happen to one of her children.

Chavez had a 2-year-old daughter and “was trying to get his life together, he was trying to be good” for the toddler, said his sister, Seanna Leilani Chavez.

The dealers, she said, only care about profits.

“They will sell you poison, take your money, and not think twice about how they could possibly be killing someone’s son, father, brother or grandson,” she said.

Follow Anita Snow on Twitter: https://www.twitter.com/asnowreports

MS-Contin

What should I discuss with my healthcare provider before using morphine?

You should not take this medicine if you have ever had an allergic reaction to morphine or other narcotic medicines, or if you have:

  • severe asthma or breathing problems; or
  • a blockage in your stomach or intestines.

Do not use morphine if you have used an MAO inhibitor in the past 14 days. A dangerous drug interaction could occur. MAO inhibitors include isocarboxazid, linezolid, methylene blue injection, phenelzine, rasagiline, selegiline, tranylcypromine, and others.

Tell your doctor if you have ever had:

  • a head injury, brain tumor, or seizures;
  • a drug or alcohol addiction, or mental illness;
  • urination problems;
  • liver or kidney disease; or
  • problems with your gallbladder, pancreas, or thyroid.

If you use opioid medicine while you are pregnant, your baby could become dependent on the drug. This can cause life-threatening withdrawal symptoms in the baby after it is born. Babies born dependent on opioids may need medical treatment for several weeks.

Do not breast-feed while taking morphine. This medicine can pass into breast milk and cause drowsiness, breathing problems, or death in a nursing baby.

How should I use morphine?

Follow the directions on your prescription label and read all medication guides. Never use morphine in larger amounts, or for longer than prescribed. Tell your doctor if you feel an increased urge to take more of this medicine.

Never share opioid medicine with another person, especially someone with a history of drug abuse or addiction. MISUSE CAN CAUSE ADDICTION, OVERDOSE, OR DEATH. Keep the medication in a place where others cannot get to it. Selling or giving away opioid medicine is against the law.

Stop taking all other around-the-clock narcotic pain medications when you start taking morphine.

Swallow the capsule or tablet whole to avoid exposure to a potentially fatal overdose. Do not crush, chew, break, open, or dissolve.

Measure liquid medicine carefully. Use the dosing syringe provided, or use a medicine dose-measuring device (not a kitchen spoon).

Do not stop using morphine suddenly, or you could have unpleasant withdrawal symptoms. Ask your doctor how to safely stop using this medicine.

Never crush or break a morphine pill to inhale the powder or mix it into a liquid to inject the drug into your vein. This practice has resulted in death with the misuse of morphine and similar prescription drugs.

Store at room temperature, away from heat, moisture, and light. Keep track of your medicine. You should be aware if anyone is using it improperly or without a prescription.

Do not keep leftover opioid medication. Just one dose can cause death in someone using this medicine accidentally or improperly. Ask your pharmacist where to locate a drug take-back disposal program. If there is no take-back program, flush the unused medicine down the toilet.

Natasha Butler had never heard of fentanyl until a doctor told her that a single pill had pushed her eldest son to the brink of death – and he wasn’t coming back. “The doctor said fentanyl is 100 times more potent than morphine and 50 times more potent than heroin. I know morphine is really, really powerful. I’m trying to understand. All that in one pill? How did Jerome get that pill?” she asked, her voice dropping to a whisper as the tears came. “Jerome was on a respirator and he was pretty much unresponsive. The doctor told me all his organs had shut down. His brain was swelling, putting pressure on to the spine. They said if he makes it he’ll be a vegetable.”

The last picture of Jerome shows him propped immobile in a hospital bed, eyes closed, sustained only by a clutch of tubes and wires. Natasha took the near impossible decision to let him die.

“I had to remove him from life support. That’s the hardest thing to ever do. I had him at 15 so we grew together. He was 28 when he died,” she said. “I had to let him die but after that I needed some answers. What is fentanyl and how did he get it?”

That was a question asked across Sacramento after Jerome and 52 other people in and around California’s capital overdosed on the extremely powerful synthetic opioid, usually only used by hospitals to treat patients in the later stages of cancer, over a few days in late March and early April 2016. Twelve died.

Sign of the times: like most fentanyl victims, Prince probably never knew he was taking the drug. Photograph: Bertrand Guay/AFP/Getty Images

Less than a month later, this mysterious drug – largely unheard of by most Americans – killed the musician Prince and burst on to the national consciousness. Fentanyl, it turned out, was the latest and most disturbing twist in the epidemic of opioid addiction that has crept across the United States over the past two decades, claiming close to 200,000 lives. But Prince, like almost all fentanyl’s victims, probably never even knew he was taking the drug.

“The number of people overdosing is staggering,” said Lieutenant Tracy Morris, commander of special investigations who manages the narcotics task force in Orange County, which has seen a flood of the drug across the Mexican border. “It is truly scary. They don’t even know what they’re taking.”

The epidemic of addiction to prescription opioid painkillers, a largely American crisis, sprung from the power of big pharmaceutical companies to influence medical policy. Two decades ago, a small family-owned drug manufacturer, Purdue Pharma, unleashed the most powerful prescription painkiller yet sold over the pharmacist’s counter. Even though it was several times stronger than anything else on the market, and bore a close relation to heroin, Purdue claimed that OxyContin was not addictive and was safe to treat even relatively minor pain. That turned out not to be true.

It spawned an epidemic that in the US claims more lives than guns, cutting across class, race and geographic lines as it ravages communities from white rural Appalachia and Mormon Utah to black and Latino neighbourhoods of southern California. The prescription of OxyContin and other painkillers with the same active drug, oxycodone, became so widespread that entire families were hooked. Labourers who wrenched a back at work, teenagers with a sports injury, just about anyone who said they were in pain was put on oxycodone. The famous names who ended up as addicts show how indiscriminate the drug’s reach was; everyone from politician John McCain’s wife Cindy to Eminem became addicted.

Tragic loss: Jerome Butler, with his nephew Demichael. Photograph: Courtesy of the Butler family

Clinics staffed by unscrupulous doctors, known as “pill mills”, sprung up churning out prescriptions for cash payments. They made millions of dollars a year. By the time the epidemic finally started to get public and political attention, more than two million Americans were addicted to opioid painkillers. Those who finally managed to shake off the drug often did so only at the cost of jobs, relationships and homes.

After the government finally began to curb painkiller prescriptions, making it more difficult for addicts to find the pills and forcing up black market prices, Mexican drug cartels stepped in to flood the US with the real thing – heroin – in quantities not seen since the 1970s. But, as profitable as the resurgence of heroin is to the cartels, it is labour intensive and time-consuming to grow and harvest poppies. Then there are the risks of smuggling bulky quantities of the drug into the US.

The ingredients for fentanyl, on the other hand, are openly available in China and easily imported ready for manufacture. The drug was originally concocted in Belgium in 1960, developed as an anaesthetic. It is so much more powerful than heroin that only small quantities are needed to reach the same high. That has meant easy profits for the cartels. The Drug Enforcement Administration (DEA) has said that 1kg of heroin earns a return of around $50,000. A kilo of fentanyl brings in $1m.

At first the cartels laced the fentanyl into heroin to increase the potency of low-quality supplies. But prescription opioid painkillers command a premium because they are trusted and have become increasingly difficult to find on the black market. So cartels moved into pressing counterfeit tablets.

A family’s pain: loved ones remember Jerome Butler. Photograph: Alamy Stock Photo

But making pills with a drug like fentanyl is a fairly exact science. A few grammes too much can kill. “It’s very lethal in very small doses,” said Morris. “Even as little as 0.25mg can be fatal. One of our labs had a dime next to 0.25mg and you could barely see it. It’s about the size of the head of a pin. Potentially that could kill you.”

The authorities liken buying black market pills to playing Russian roulette. “These pills sold on the street, nobody knows what’s in them and nobody knows how strong they are,” said Barbara Carreno of the DEA.

After Prince died, investigators found pills labelled as prescription hydrocodone, but made of fentanyl, in his home, suggesting he bought them on the black market. The police concluded he died from a fatal mix of the opioid and benzodiazepine pills, a particularly dangerous combination. It is likely Prince did not even know he was taking fentanyl.

Others knowingly take the risk. In his long battle with addiction, Michael Jackson, used a prescription patch releasing fentanyl into his skin among the arsenal of drugs he was fed by compliant doctors. Although it was two non-opioids that killed him, adding fentanyl into the mix was hazardous.

Jerome Butler, a former driver for Budweiser beer who was training to be a security guard, thought he was taking a prescription pill called Norco. His mother’s voice breaks as she recounts what she knows of her son’s last hours. Natasha said she was aware he used cannabis, but had no idea he was hooked on opioid painkillers. She said her son at one time had a legitimate prescription and may have become addicted that way. She has since discovered he was paying a doctor, well known for freely prescribing opioids, to provide pills.

“I didn’t even know,” she said. “You find stuff out after. It’s killing me because they’re saying, ‘Well, yeah, Jerome was taking them pills all the time.’ And I’m like, ‘He was doing what?’”

Jerome may have had a prescription, but like many addicts he will have needed more and more. The pill that killed him was stamped M367, a marking used on Norco pills made of an opioid, hydrocodone. It was a fake with a high dosage of fentanyl.

“If Jerome had known it was fentanyl he would never have took that,” said Natasha. “This ain’t like crack or a recreational drug that people been doing for so many years and survived it but at 60 or 70 die from a drug overdose because their heart can’t take it no more. This is fentanyl. The first time you take it you’re not coming back. You’re gone.”

That wasn’t strictly true of the batch that hit Sacramento. It claimed 11 other lives. The youngest victim was 18-year-old George Berry from El Dorado Hills, a mostly white upscale neighbourhood. The eldest was 59. But others survived. Some were saved by quick reactions; doctors were able to hit them with an antidote before lasting damage was done. Others swallowed only enough fentanyl to leave them seriously ill but short of death.

It was a matter of luck. When investigators sent counterfeit pills seized after the Sacramento poisonings for testing at the University of California, they found a wide disparity in the amount of fentanyl each contained. Some pills had as little as 0.6mg. Others were stuffed with 6.9mg of the drug, which would almost certainly be fatal.

The DEA thinks the difference was probably the result of failing to mix the ingredients properly with other powders, which resulted in the fentanyl being distributed unevenly within a single batch of counterfeit pills.

That probably explains the unpredictable mass overdosing popping up in cities across the US. In August, 174 people overdosed on heroin in six days in Cincinnati, which has one of the fastest-growing economies in the Midwest. Investigators suspect fentanyl because the victims needed several doses of an antidote, Naloxone, where one or two will usually suffice with heroin. The same month, 26 people overdosed on fentanyl-laced heroin in a four-hour period in Huntington, a mostly white city in one of the poorest areas of West Virginia. In September seven people died from fentanyl or heroin overdoses in a single day in Cuyahoga County, Ohio.

The US authorities don’t know for sure how many people fentanyl kills because of the frequency with which it is mixed with heroin, which is then registered as the cause of death. The DEA reported 700 fatalities from fentanyl in 2014 but said it is an underestimate, and rising. In 2012, the agency’s laboratory carried out 644 tests confirming the presence of fentanyl in drug seizures. By 2015, the number of positive tests escalated to 13,002.

‘The number of people overdosing is staggering’: fentanyl. Illustration: Justin Metz/The Observer

The police did not have to look far for the source of the drug that killed Jerome. He and his girlfriend were staying at the house of her aunt, Mildred Dossman, while they waited for their own place to live. Jerome was smoking cannabis and drinking beer with Dossman’s son, William. Shortly before 1am, William went to his mother’s bedroom and came back with the fake Norco pill. Jerome took it and said he was going to bed.

Jerome’s girlfriend was in jail after being arrested for an unpaid traffic fine and so he was alone with their 18 month-old daughter, Success, lying next to him.

“The doctors explained to me that within a matter of minutes he went into cardiac arrest,” said his mother. “Then as he lay there that’s when time progressed for the organs to be poisoned by fentanyl. He was dying with his daughter next to him.” Natasha said other people in the house heard her son in distress, complaining his heart was hurting. But they did nothing because they were afraid that calling an ambulance would also bring the police.

It was not until 10 hours later that the Dossmans finally sought help from a neighbour who knew Jerome. He tried CPR and then called the medics. The police came, too, and in time Mildred Dossman, 50, was charged with distributing fentanyl and black market opioid painkillers. She was the local dealer.

The DEA is tightlipped about the investigation into the Sacramento deaths as its agents work on persuading Dossman to lead them to her suppliers. But it is likely she was getting the pills from Mexican cartels using ingredients from labs in China where production of fentanyl’s ingredients is legal.

Carreno said some Mexican cartels have long relationships with legitimate Chinese firms which for years supplied precursor chemicals to make meth amphetamine.

Packages of fentanyl are often moved between multiple freight handlers so their origins are hard to trace. Larger shipments are smuggled in shipping containers. Last year, six Chinese customs officials fell ill, one of them into a coma, after seizing 72kg of various types of fentanyl from a container destined for Mexico.

American police officers have faced similar dangers. In June, the DEA put out a video warning law enforcement officers across the US that fentanyl was different to anything they have previously encountered and they should refrain from carting seizures back to the office.

“A very small amount ingested, or absorbed through the skin, can kill you,” it said.

A New Jersey detective appears in the video after accidentally inhaling “just a little bit of fentanyl puffed into the air” during an arrest: “It felt like my body was shutting down… I thought that was it. I thought I was dying.”

Along with the Mexican connection, a home-grown manufacturing industry has sprung up in the US. Weeks after Jerome died, agents arrested a married couple pressing fentanyl tablets in their San Francisco flat.

Candelaria Vazquez and Kia Zolfaghari made the drug to look like oxycodone pills. They sold them across the country via the darknet using Bitcoin for payment – on one occasion Zolfaghari cashed in $230,000. The couple shipped the drugs through the local post office. Customers traced by the DEA thought they were buying real painkiller pills.

The couple ran the pill press in their kitchen. According to a DEA warrant, a dealer said Zolfaghari made large numbers of tablets: “He could press 100 out fast as fuck.”

The pair made so much money that agents searching their flat found luxury watches worth $70,000, more than $44,000 in cash and hundreds of “customer order slips” which included names, amounts and tracking numbers. The flat was stuffed with designer goods. The seizure warrant described Vazquez’s shoe collection as “stacked virtually from floor to ceiling”. Some still had the $1,000 price tags on them. Zolfaghari was arrested carrying a 9mm semi-automatic gun and about 500 pills he was preparing to post.

Even as Americans are getting their heads around fentanyl, it is being eclipsed. In September, the DEA issued a warning about the rise of a fentanyl variant that is 100 times more powerful – carfentanil, a drug used to tranquilise elephants.

“Carfentanil is surfacing in more and more communities,” said the DEA’s acting administrator, Chuck Rosenberg. “We see it on the streets, often disguised as heroin. It is crazy dangerous.”

The drug has already been linked to 19 deaths in Michigan. Investigators say that with its use spreading, it is almost certainly claiming other lives. Dealers are also getting it from China, where carfentanil is not a controlled drug and can be sold to anyone.

Natasha Butler is still trying to understand the drug that killed her son. She wants to know why it is that it took Jerome’s death for her to even hear of it. She accuses the authorities of failing to warn people of the danger, and politicians of shirking their responsibilities.

A bill working its way through California’s legislature stiffening sentences for fentanyl dealing died in the face of opposition from the state’s governor, Jerry Brown, because it would put pressure on the already badly crowded prisons.

“I’m so dumbfounded. How does that happen?” says Natasha. Her tears come frequently as she sits at a tiny black table barely big enough to seat three people. She talks about Jerome and the tragedy for his three children, including Success, who she is now raising.

But some of the tears are to mourn the devastating impact on her own life. “Look where I’m at. I was in Louisiana. I had a house. I had a job. I had a car. I had a life. I worked every day. I was a manager for a major company. I came here, I became homeless. I had to move into this apartment to help out my granddaughter,” she said. “You see me. This is what my kitchen table is. My son is dead. He had three kids and those two mothers of those kids are depending on me to be strong. I want answers and help. I say, you got the little fish. Where did they get it from? How did they get it here? You are my government. You are supposed to protect us.”

A 30-mg morphine pill is one of five main formulations of the drug. It is identifiable by its circular shape and purple or red hue. The drug may also be prescribed at dosages of 15 mg, 60 mg, 100 mg, and 200 mg if a patient’s pain threshold necessitates it. Still, 200 milligrams of any drug, let alone an opioid like morphine, can have serious repercussions. This massive dose amount is never recommended for anyone other than those with a longstanding relationship with opioids — individuals who have been taking strong pills for a significant time period prior.

Once ingested, morphine goes to work by binding to opioid receptors in the brain. This is how the drug quells pain, right at the chemical source. Such a process can take minutes or hours depending on the type of morphine and the means in which it was administered. Many morphine pills, including the 30-mg variety, actually come in the form of morphine sulfate. Sulfates make the morphine easier to absorb, meaning the body gets the medicine faster.

The use of all opioids, medically or recreationally, can lead to uncomfortable side effects. Side effects of morphine usually include:

  • Lethargy
  • Constipation
  • Nausea
  • Vomiting
  • Uncoordinated movement

More severe side effects include:

  • Chest pain
  • Deadly respiratory depression
  • Psychiatric disorders
  • Overdose symptoms

Overdose symptoms are particularly important to look out for. An individual without a tolerance to morphine can begin to exhibit the characteristics of an overdose after taking only 60 mg or less. Everyone’s drug tolerance is different though so it’s best to pay attention to symptoms at any point while taking morphine. Breathing problems, tiny pupils and unconsciousness are telltale signs of a dangerous overdose. The anti-overdose drug naloxone may be required whenever symptoms arise, and medical assistance is crucial.

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