{"id":493,"date":"2019-12-01T20:17:11","date_gmt":"2019-12-02T01:17:11","guid":{"rendered":"https:\/\/opentextbc.ca\/nursingpharmacology\/chapter\/10-7-opioid-analgesics-and-antagonists\/"},"modified":"2023-08-01T13:04:23","modified_gmt":"2023-08-01T17:04:23","slug":"10-7-opioid-analgesics-and-antagonists","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/nursingpharmacology\/chapter\/10-7-opioid-analgesics-and-antagonists\/","title":{"raw":"10.7 Opioid Analgesics and Antagonists","rendered":"10.7 Opioid Analgesics and Antagonists"},"content":{"raw":"Opioid analgesics are prescribed for moderate and severe pain. There are several types of opioids, and routes of administration that are listed in Table 10.7a ranging from use for moderate to severe pain.[footnote]Vallerand, A. & Sanoski, C. A. (2019). Davis\u2019s Drug Guide for Nurses <\/em>(16th ed.).<\/em> F.A. Davis Company.[\/footnote]\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
Table 10.7a Common Opioid Analgesics<\/caption>\r\n
Generic Name<\/th>\r\nTrade Name(s)<\/th>\r\nRoute<\/th>\r\nAdult Dosage<\/th>\r\n<\/tr>\r\n
morphine<\/a><\/th>\r\nMS Contin,\r\n\r\nStatex\r\n\r\nM.O.S<\/td>\r\nPO & Rectal\r\n\r\nSubQ, IM, & IV<\/td>\r\n30 mg (may be increased)\r\n\r\n4-10 mg (may be increased)<\/td>\r\n<\/tr>\r\n
codeine<\/a>\/acetaminophen<\/a><\/th>\r\nTylenol #3<\/td>\r\nPO<\/td>\r\n30 mg\/300 mg<\/td>\r\n<\/tr>\r\n
fentanyl<\/a><\/th>\r\nDuragesic\r\n\r\nAbstral<\/td>\r\nTransdermal\r\n\r\nIM\r\n\r\nIV<\/td>\r\n12 mcg-100mcg\/hr\r\n\r\n0.5-1 mcg\/kg\r\n\r\n0.5-1 mcg\/kg<\/td>\r\n<\/tr>\r\n
hydromorphone<\/a><\/th>\r\nDilaudid<\/td>\r\nPO\r\n\r\nRectal\r\n\r\nSubQ, IM & IV<\/td>\r\n4-8 mg\r\n\r\n3 mg\r\n\r\n1.5 mg (may be increased)<\/td>\r\n<\/tr>\r\n
oxycodone<\/a>\r\n\r\n <\/th>\r\nOxycontin\r\n\r\nPercocet<\/td>\r\nPO\r\n\r\nPO<\/td>\r\n5 mg-10 mg (may be increased)\r\n\r\n5 mg\/325 mg<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nOpioids are delivered through a variety of routes. For instance, opioids are commonly used in [pb_glossary id=\"749\"]patient controlled analgesia (PCA)[\/pb_glossary] including morphine, hydromorphone and fentanyl. To receive the opioid using a PCA device, the client pushes a button, which releases a specific dose but also has a lockout mechanism to prevent an overdose.[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach.<\/em> pp. 268-270, 324, 332. Elsevier.[\/footnote]\r\n\r\nRead more about opioid usage in Canada<\/a> at this Health Canada<\/a> website.\r\n\r\nTable 10.7a also displays a medication card for several types of opioids including morphine, hydromorphone, and fentanyl.\r\n

Safety Considerations for Opioid Use<\/h1>\r\n

Selecting Opioid Routes and Drugs<\/h2>\r\nIt is important to consider that the type of opioid and their route have different effects on the client. For instance, hydromorphone is five times more potent than morphine. Fentanyl is 80-100 times more potent than morphine.[footnote] UptoDate. (2021). Dose conversion guide for commonly used opioids. https:\/\/www.uptodate.com\/contents\/image?imageKey=PALC\/111216<\/a>[\/footnote]\r\n

The Opioid Crisis in Canada<\/h2>\r\nAlmost 25% of Canadians experience chronic pain and opioids have been commonly used for chronic pain management. Opioid prescriptions are also used for treating opioid dependence. However, there is debate about the effectiveness of treating chronic non-cancer pain with opioids based on concerns related to the safe usage of these medications.\r\n\r\nThe past 30 years have seen waves of opioid-related deaths starting in the 1990s when overdose deaths were linked to a dramatic increase in prescription opioids for chronic pain. The wave increased again in 2010 when overdose deaths were more commonly related to illicit drug use.[footnote]Centers for Disease Control and Prevention. (2018, December 19). Opioid Overdose, Understanding the Epidemic. https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html<\/a>.[\/footnote] Currently, most of the harm related to opioid use is due to the synthetic opioid, fentanyl, which is extremely potent and significantly increases the risk of overdose even in trace amounts. Figure 10.7a <\/span>depicts the waves of opioid-related deaths in the United States, which closely mirrors the trend in Canada.[footnote]3 Waves of the Rise of Opioid Overdose Deaths<\/a>\u00a0by National Vital Statics System, CDC is licensed under CC0<\/a>.[\/footnote]<\/a><\/span>\r\n\r\n[caption id=\"attachment_1374\" align=\"alignnone\" width=\"960\"]\"A Figure 10.7a Three Waves of Opioid Overdose Deaths [Figure 10.7a Image Description]<\/a>[\/caption]From 2016 to 2019, there were more than 14,700 opioid-related deaths in Canada.[footnote]Government of Canada. (2021). Opioid-related harms in Canada: Integrating Emergency Medical Service, hospitalization, and death data. https:\/\/www.canada.ca\/en\/health-canada\/services\/opioids\/data-surveillance-research\/integrating-emergency-medical-hospitalization-death-data.html.[\/footnote] In 2016 in British Columbia, the provincial health officer declared a public health emergency under the Public Health Act due to the rise in opioid-related overdose deaths.[footnote]Government of British Columbia. (2020). Statistical Reports on Deaths in British Columbia. https:\/\/www2.gov.bc.ca\/gov\/content\/life-events\/death\/coroners-service\/statistical-reports<\/a>[\/footnote]\r\n\r\nIn response to the public health emergency, the College of Physicians and Surgeons of British Columbia developed Professional Standards and Guidelines: Safe Prescribing of Drugs with Potential for Misuse\/Diversion<\/a>, based on the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.[footnote]CDC. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain. https:\/\/www.cdc.gov\/mmwr\/volumes\/65\/rr\/rr6501e1.htm<\/a>[\/footnote] Improving the prescription of opioids through clinical practice guidelines is intended to ensure clients have access to safer, effective pain treatment while also reducing the number of people who [pb_glossary id=\"753\"]misuse[\/pb_glossary]\u00a0or overdose from these drugs. In light of the overdose crises, is important for nurses to provide safe and equitable care for clients experiencing pain.\r\n\r\nTo learn more about substance use, refer to the British Columbia Center on Substance Use<\/a> and the Canadian Center on Substance Use and Addiction.\u00a0<\/a>\r\n

Morphine Sulfate<\/h1>\r\nMorphine<\/a> is an opioid analgesic used to treat moderate to severe pain. Morphine is at the top of the WHO ladder and is used to treat severe pain. It is also commonly used to treat cancer pain and for pain at end of life because there is no \u201cceiling effect,\u201d meaning the higher the dose, the higher the level of analgesia. The information provided below relates specifically to morphine, but can also be applied to other opioids such as hydromorphone and fentanyl.\r\n

Mechanism of Action<\/h2>\r\nMorphine binds to opioid receptors in the CNS and alters the perception of and response to painful stimuli while producing generalized CNS depression.\r\n

Indications for Use<\/h2>\r\nMorphine is indicated for the relief of moderate to severe acute and chronic pain and for pulmonary edema.\r\n

Nursing Considerations Across the Lifespan<\/h2>\r\nMorphine can be used in all ages. It should be used cautiously in pregnant and breastfeeding women. Use cautiously with clients with liver and renal impairment. Elderly clients are more susceptible to toxic levels of opiates which can increase negative effects on the central nervous system, cardiovascular system, and gastrointestinal system.\r\n

Adverse\/Side Effects<\/h2>\r\nAdverse effects include respiratory depression, hypotension, light-headedness, dizziness, sedation, constipation, nausea, vomiting, sweating, and pruritis.\r\n

Client Teaching & Education<\/h2>\r\nIt is important to provide accurate information to clients about how to safely use opioids. This is especially true if clients are opiate naive. Additionally, clients might be worried about becoming addicted to opioids even with short-term usage. You can teach your client that most patients who use opioids do not become addicted.\r\n

Safety Warning<\/h2>\r\nThe risk of serious adverse reactions, including slowed or difficulty breathing and death, have been reported with the combined effects of morphine with other CNS depressants. Long-term usage of morphine may result in drug tolerance, dependence, and\/or misuse. Naloxone is used to reverse opioid overdose.\r\n

Special Considerations
<\/strong><\/h2>\r\n

Respiratory Depression<\/em><\/h3>\r\nRespiratory depression is the primary risk of morphine sulfate. Respiratory depression occurs more frequently in the elderly or those suffering from conditions accompanied by hypoxia, hypercapnia, or upper airway obstruction, for whom even moderate therapeutic doses may significantly decrease pulmonary ventilation.\r\n\r\nUse morphine with extreme caution in clients with chronic obstructive pulmonary disease or cor pulmonale and in clients having a substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression. In such clients, even usual therapeutic doses of morphine sulfate may increase airway resistance and decrease respiratory drive to the point of apnea. Consider alternative non-opioid analgesics, and use morphine sulfate only under careful medical supervision at the lowest effective dose in such patients.\r\n

Misuse of Opioids<\/em><\/h3>\r\nMorphine sulfate is an opioid agonist and is a controlled substance. Morphine can be used in a manner similar to other opioid agonists, legal or illicit. This should be considered when prescribing or dispensing morphine sulfate in situations where there is an increased risk of misuse.\r\n

Interactions with Alcohol and Drugs of Abuse<\/em><\/h3>\r\nMorphine has addictive effects when used in conjunction with alcohol, other opioids, or illicit drugs that cause central nervous system depression because respiratory depression, hypotension, profound sedation, coma, or death may result.\r\n

Use In Head Injury and Increased Intracranial Pressure<\/em><\/h3>\r\nIn the presence of head injury, intracranial lesions, or a preexisting increase in intracranial pressure, the possible respiratory depressant effects of morphine and its potential to elevate cerebrospinal fluid pressure may be markedly exaggerated. Furthermore, morphine can produce effects on pupillary response and consciousness, which may obscure neurologic signs of increased intracranial pressure in clients with head injuries.\r\n

Hypotensive Effect<\/em><\/h3>\r\nMorphine may cause severe hypotension in individuals unable to maintain blood pressure who have already been compromised by a depleted blood volume or drug administration of phenothiazines or general anesthetics. Administer morphine sulfate with caution to clients in circulatory shock, as vasodilation produced by the drug may further reduce cardiac output and blood pressure.\r\n

Gastrointestinal Effects<\/em><\/h3>\r\nDo not administer morphine to clients with gastrointestinal obstruction, especially paralytic ileus because morphine diminishes propulsive peristaltic waves in the gastrointestinal tract and may prolong the obstruction. The administration of morphine sulfate may obscure the diagnosis or clinical course in clients with an acute abdominal condition.\r\n

Use in Pancreatic\/Biliary Tract Disease<\/em><\/h3>\r\nUse morphine with caution in clients with biliary tract disease, including acute pancreatitis, as morphine sulfate may cause spasming and diminished biliary and pancreatic secretions.\r\n

Special Risk Groups<\/em><\/h3>\r\nUse morphine with caution and in reduced dosages in clients with severe renal or hepatic impairment, Addison\u2019s disease, hypothyroidism, prostatic hypertrophy, or urethral stricture, and in elderly or debilitated clients. Exercise caution in the administration of morphine sulfate to clients with CNS depression, toxic psychosis, acute alcoholism, and delirium tremens. All opioids may aggravate convulsions in clients with convulsive disorders, and all opioids may induce or aggravate seizures.\r\n

Driving and Operating Machinery<\/em><\/h3>\r\nCaution clients that morphine sulfate could impair the mental and\/or physical abilities needed to perform potentially hazardous activities such as driving a car or operating machinery.\r\n\r\nCaution clients about the potential combined effects of morphine sulfate with other CNS depressants, including other opioids, phenothiazines, sedative\/hypnotics, and alcohol.\r\n

Opioid Analgesic Medication Card<\/h1>\r\nNow let's take a closer look at the medication card for opioid analgesics.[footnote]This work is a derivative of Daily Med<\/a> by U.S. National Library of Medicine<\/a> in the public domain<\/a>.[\/footnote] Medication cards like this are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below.\u00a0 Prototype or generic medication examples are also hyperlinked to a free resource at Daily Med<\/a>. On the home page, enter the drug name in the search bar to read more about the medication.\r\n
\r\n

Medication Card 10.7.1: Opioid Analgesic<\/h2>\r\n<\/header>\r\n
\r\n\r\nGeneric Name (Prototype\/Brand Name): <\/strong>\r\n\r\nmorphine sulfate<\/a> (M-ESlon, MS Contin)\r\n\r\nhydromorphone<\/a> (Dilaudid)\r\n\r\nfentanyl<\/a> (Duragesic)\r\n\r\nMechanism: <\/strong>Binds to opioid receptors in the CNS and alters the perception of and response to painful stimuli while producing generalized CNS depression.\r\n

Therapeutic Effects<\/h3>\r\n