{"id":430,"date":"2019-12-01T20:17:11","date_gmt":"2019-12-01T20:17:11","guid":{"rendered":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/10-7-opioid-analgesics-and-antagonists\/"},"modified":"2025-01-16T22:29:16","modified_gmt":"2025-01-16T22:29:16","slug":"10-7-opioid-analgesics-and-antagonists","status":"publish","type":"chapter","link":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/10-7-opioid-analgesics-and-antagonists\/","title":{"raw":"10.7 Opioid Analgesics and Antagonists","rendered":"10.7 Opioid Analgesics and Antagonists"},"content":{"raw":"<div class=\"1.7-opioid-analgesics-and-antagonists\">\n\nOpioid analgesics are prescribed for moderate and severe pain. There are several types of opioids, as listed in Table 10.4 in the previous \"<a href=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/10-4-applying-the-nursing-process-to-pain-management\/\" target=\"_blank\" rel=\"noopener\">Applying the Nursing Process to Pain Management<\/a>\" section. Before discussing morphine, the prototype opioid analgesic, and its antagonist, naloxone, let's discuss the opioid epidemic in the United States, efforts to stop this epidemic, and the dangers of drug diversion.\n<h2>Understanding the Opioid Epidemic<\/h2>\nThe drug overdose epidemic continues to worsen in the United States. Overdose deaths remain a leading cause of injury-related death. In the United States, drug overdoses have claimed over 932,000 lives over the past 21 years. The majority of overdose deaths involve opioids. Deaths involving synthetic opioids (i.e., illicitly made fentanyl)\u00a0 have increased in recent years, especially during the COVID-19 pandemic.<sup>[footnote]Centers for Disease Control and Prevention. (2022). <em>Understanding drug overdoses and deaths.<\/em> <a href=\"https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html<\/a>[\/footnote]<\/sup>\n\nThe rise in opioid overdose deaths can be outlined in three distinct waves. See Figure 10.7<sup>[footnote]\u201c<a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/cc0\/\" target=\"_blank\" rel=\"noopener noreferrer\">3 Waves of the Rise of Opioid Overdose Deaths<\/a>\u201d by National Vital Statistics System, CDC is licensed under\u00a0<a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/cc0\/\" target=\"_blank\" rel=\"noopener noreferrer\">CC0<\/a><span style=\"font-size: 12.8px\">[\/footnote]<\/span><\/sup>\u00a0for a graphic representation of the waves of opioid deaths.\n\n[caption id=\"\" align=\"aligncenter\" width=\"617\"]<img class=\"\" title=\"&quot;3 Waves of the Rise of Opioid Overdose Deaths&quot; by National Vital Statics System, CDC is licensed under CC0\" src=\"https:\/\/pressbooks.ccconline.org\/accdigitalmarketing\/wp-content\/uploads\/sites\/219\/2019\/12\/image10.png\" alt=\"Graph showing three waves of opioid overdose deaths\" width=\"617\" height=\"435\"> Figure 10.7 Three Waves of Opioid Overdose Deaths[\/caption]\n\nThe first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone). The second wave began in 2010 with rapid increases in overdose deaths involving heroin. The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, especially those involving illicitly manufactured fentanyl.<sup>[footnote]Centers for Disease Control and Prevention. (2018, December 19). <em>Opioid overdose, Understanding the epidemic.<\/em> <a href=\"https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html<\/a>[\/footnote]<\/sup>\n<h2>CDC's Educational Campaigns<\/h2>\nTo save lives from drug overdose, the Centers for Disease Control and Prevention (CDC) launched four education campaigns to reach young adults (ages 18-34). The campaigns provide information that can save the lives and highlight actions the public can take to help prevent overdose. Specifically, the campaigns provide critical information about these topics<sup>[footnote]Centers for Disease Control and Prevention. (2022). <em>Understanding drug overdoses and deaths.<\/em> <a href=\"https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html<\/a>[\/footnote]<\/sup>:\n<ul>\n \t<li>Dangers of fentanyl<\/li>\n \t<li>Risks and consequences of mixing drugs<\/li>\n \t<li>Life-saving power of naloxone to reverse an opioid overdose<\/li>\n \t<li>Importance of reducing stigma to support treatment and recovery<\/li>\n<\/ul>\n<div class=\"textbox\">\n<p class=\"arrow\">Read more information about the <a href=\"https:\/\/www.cdc.gov\/drugoverdose\/featured-topics\/overdose-prevention-campaigns.html\" target=\"_blank\" rel=\"noopener\">CDC campaigns to stop overdose deaths<\/a>.<\/p>\n\n<\/div>\n<h2>CDC Guidelines for Prescribing Opioids for Chronic Pain<\/h2>\nIn addition to establishing educational campaigns to prevent opioid deaths, the CDC has also established new clinical practice guidelines regarding the prescription of opioids to ensure clients have access to safer, effective pain treatment while also reducing the number of people who misuse or overdose from these drugs. The CDC's <em>Clinical Practice Guidelines for Prescribing Opioids<\/em> - <em>United States, 2022<\/em> was developed for the prescribing of opioid pain medication for clients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating acute pain (pain lasting less than one month), subacute pain (pain lasting one to three months, and chronic pain (pain lasting longer than three months). This clinical practice guideline is intended to improve communication between clinicians and clients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for clients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.<sup>[footnote]Centers for Disease Control and Prevention. (2022). <i>Clinical practice guidelines for prescribing opioids - United States, 2022. <\/i>\u00a0<a href=\"https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w<\/a>[\/footnote]<\/sup> Nurses also play an important component in advocating for these outcomes.\n\nFour key areas are covered in the CDC's <em>Clinical Practice Guidelines for Prescribing Opioids<sup>[footnote]Centers for Disease Control and Prevention. (2022). <i>Clinical practice guidelines for prescribing opioids - United States, 2022. <\/i>\u00a0<a href=\"https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w<\/a>[\/footnote]<\/sup><\/em>:\n<ol>\n \t<li>Determining whether or not to initiate opioids for pain<\/li>\n \t<li>Selecting opioids and determining opioid dosages<\/li>\n \t<li>Deciding duration of initial opioid prescription and conducting follow-up<\/li>\n \t<li>Assessing risk and addressing potential harms of opioid use<\/li>\n<\/ol>\nIn addition, five guiding principles were identified<sup>[footnote]Centers for Disease Control and Prevention. (2022). <i>Clinical practice guidelines for prescribing opioids - United States, 2022. <\/i>\u00a0<a href=\"https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w<\/a>[\/footnote]<\/sup>:\n<ol>\n \t<li>Appropriate treatment of pain<\/li>\n \t<li>Flexibility to meet the care needs and clinical circumstances of each client<\/li>\n \t<li>A multimodal and multidisciplinary approach to pain management<\/li>\n \t<li>Avoiding misapplication of the clinical practice guideline beyond its intended use<\/li>\n \t<li>Vigilance in attending to health inequities and ensuring access to appropriate, affordable, diversified, coordinated, and effective nonpharmacologic and pharmacologic pain treatment for all persons<\/li>\n<\/ol>\nImproving the way opioids are prescribed through clinical practice guidelines can ensure clients have access to safer, more effective pain treatment while also reducing the risk of opioid use disorder, overdose, and death.\n<h2>Drug Diversion and Impaired Health Care Workers<\/h2>\nDrug diversion is a potential threat to patient safety in every health care organization. Drug diversion involves the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for illicit use. The most commonly diverted substances in health care facilities are opioids.\n\nRisks to clients from drug diversion include inadequate pain relief compounded by potentially unsafe care due to the health care worker\u2019s impaired performance.<sup>[footnote]The Joint Commission, Division of Healthcare Improvement. (2019). Drug diversion and impaired health care workers.<em> Quick Safety (48)<\/em>. <a href=\"https:\/\/www.jointcommission.org\/resources\/news-and-multimedia\/newsletters\/newsletters\/quick-safety\/quick-safety-48-drug-diversion-and-impaired-health-care-workers\/#.ZDh5THbMI2w\" target=\"_blank\" rel=\"noopener\">https:\/\/www.jointcommission.org\/resources\/news-and-multimedia\/newsletters\/newsletters\/quick-safety\/quick-safety-48-drug-diversion-and-impaired-health-care-workers\/#.ZDh5THbMI2w<\/a>[\/footnote]<\/sup> More information about drug diversion and substance use disorder in health care professionals\u00a0 is discussed in the \"<a href=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/2-3-legal-foundations-and-national-guidelines-for-safe-medication-administration\/\" target=\"_blank\" rel=\"noopener\">Legal Foundations and National Guidelines for Safe Medication Administration<\/a>\" section of the \"Legal\/Ethical\" chapter.\n<h2>Opioid Medication Class<\/h2>\nSee Table 10.4 in the \"<a href=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/10-4-nursing-process-for-analgesics-and-musculoskeletal-medications\/\" target=\"_blank\" rel=\"noopener\">Nursing Process for Analgesics and Musculoskeletal Medications<\/a>\" section of this chapter for a list of common opioid medications used to treat moderate to severe pain. As discussed in that section, 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. Morphine is also commonly used in <strong>[pb_glossary id=\"661\"]patient-controlled analgesia (PCA[\/pb_glossary])<\/strong>; other medications administered via PCA include hydromorphone or fentanyl. To receive the opioid using a PCA device, the patient\u00a0pushes a button, which releases a specific dose but also has a lockout mechanism to prevent an overdose.<sup>[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M., &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 268-270, 324, 332. Elsevier.[\/footnote]<\/sup>\n<h3>Morphine<\/h3>\nMorphine is an example of a potent opioid used to treat severe pain.\n\n<strong>Mechanism of Action: <\/strong>Morphine binds to opioid receptors in the CNS and alters the perception of and response to painful stimuli while producing generalized CNS depression.\n\n<strong>Indications: <\/strong>Morphine is indicated for the relief of moderate to severe acute and chronic pain and for pulmonary edema.\n\n<strong>Nursing Considerations: <\/strong>Morphine is safe for all ages. Use cautiously with clients with liver and renal impairment.\n\n<strong>Side Effects\/Adverse Effects: <\/strong>Adverse effects include respiratory depression, hypotension, light-headedness, dizziness, sedation, constipation, nausea, vomiting, and sweating.\n\n<strong>Health Teaching &amp; Health Promotion: <\/strong>Clients should be advised regarding the risks associated with opioid analgesic use. Please see the outlined \"Special Considerations\" for usage below.<sup>[footnote]uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\">https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote]<\/sup>\n\n<strong>Boxed Warning: <\/strong>The 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. Naloxone is used to reverse opioid overdose. There is also a risk of drug abuse and dependence with morphine.\n\n<strong>Special Considerations<br style=\"clear: both\"><\/strong>\n\n<strong>Respiratory Depression: <\/strong>Respiratory depression is the primary risk of morphine sulfate. Respiratory depression occurs more frequently in elderly or debilitated clients and in those suffering from conditions accompanied by hypoxia, hypercapnia, or upper airway obstruction, for whom even moderate therapeutic doses may significantly decrease pulmonary ventilation.\n\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 preexisting 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 nonopioid analgesics and use morphine sulfate only under careful medical supervision at the lowest effective dose in such clients.\n\n<strong>Misuse, Abuse, and Diversion of Opioids: <\/strong>Morphine sulfate is an opioid agonist and a Schedule II controlled substance. Such drugs are sought by drug abusers and people with addiction disorders. Diversion of Schedule II products is an act subject to criminal penalty.\n\nMorphine can be abused 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 increased risk of misuse, abuse, or diversion. Morphine may be abused by crushing, chewing, snorting, or injecting the product. These practices pose a significant risk to the abuser that could result in overdose and death.\n\n<strong>Interactions With Alcohol and Drugs of Abuse: <\/strong>Morphine has addictive effects when used in conjunction with alcohol, other opioids, or illicit drugs that cause central nervous system depression and respiratory depression, hypotension, profound sedation, coma, or death may result.\n\n<strong>Use in Head Injury and Increased Intracranial Pressure: <\/strong>In 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.\n\n<strong>Hypotensive Effect: <\/strong>Morphine 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.\n\nAdminister morphine sulfate with caution to clients in circulatory shock, as vasodilation produced by the drug may further reduce cardiac output and blood pressure.\n\n<strong>Gastrointestinal Effects: <\/strong>Do 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.\n\nThe administration of morphine sulfate may obscure the diagnosis or clinical course in clients with an acute abdominal condition.\n\n<strong>Use in Pancreatic\/Biliary Tract Disease: <\/strong>Use morphine with caution in clients with biliary tract disease, including acute pancreatitis, as morphine sulfate may cause spasming and diminished biliary and pancreatic secretions.\n\n<strong>Special Risk Groups: <\/strong>Use morphine with caution and in reduced dosages in clients with severe renal or hepatic impairment, Addison\u2019s disease, hypothyroidism, prostatic hypertrophy, 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.\n\nAll opioids may aggravate convulsions in clients with convulsive disorders, and all opioids may induce or aggravate seizures.\n\n<strong>Driving and Operating Machinery: <\/strong>Caution 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.\n\nCaution clients about the potential combined effects of morphine sulfate with other CNS depressants, including other opioids, phenothiazines, sedative\/hypnotics, and alcohol.\n\nNow let\u2019s take a closer look at the medication grid on morphine in Table 10.7a.<sup>[footnote]Frandsen, G., &amp; Pennington, S. (2018). <em>Abrams\u2019 clinical drug: Rationales for nursing practice <\/em>(11th ed.). pp. 305, 310, 952-953, 959-960. Wolters Kluwer.[\/footnote],[footnote]Vallerand, A., &amp; Sanoski, C. A. (2019). <em>Davis\u2019s drug guide for nurses <\/em>(16th ed.). F. A. Davis Company.[\/footnote],[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">DailyMed<\/a>\u00a0by\u00a0<a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the\u00a0<a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">Public Domain<\/a>.<span style=\"font-size: 1em\">[\/footnote]<\/span><\/sup>\n\nTable 10.7a Morphine Medication Grid\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%\" border=\"0\">\n<tbody>\n<tr>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Class\/<\/strong><strong>Subclass<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Prototype\/G<\/strong><strong>eneric<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Nursing <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Side\/Adverse Effects<\/strong><\/th>\n<\/tr>\n<tr>\n<th style=\"width: 20%;vertical-align: top\" scope=\"row\"><strong>Opioid Analgesic<\/strong><\/th>\n<td style=\"width: 20%;vertical-align: top\"><a class=\"arrow\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=680a996c-08a5-4cdb-b7bd-0ada5d8c7adf\" target=\"_blank\" rel=\"noopener noreferrer\">morphine<\/a><\/td>\n<td style=\"width: 20%;vertical-align: top\">Given parenterally and orally\n\nAssess pain prior to and after administration\n\nMonitor respiratory status\n\nMonitor blood pressure\n\nAssess pediatric and geriatric clients frequently\n\nAssess bowel function\n\nUse cautiously with antidepressants and other CNS depressants\n\nNaloxone is used to reverse opioid overdose<\/td>\n<td style=\"width: 20%;vertical-align: top\">Relieves severe pain<\/td>\n<td style=\"width: 20%;vertical-align: top\">Respiratory depression\n\nConfusion\n\nHypotension\n\nLight-headedness\n\nDizziness\n\nSedation\n\nConstipation\n\nNausea and vomiting\n\nSweating<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.7a<img class=\"alignright size-thumbnail wp-image-67\" src=\"https:\/\/pressbooks.ccconline.org\/accdigitalmarketing\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1-150x150.png\" alt=\"Image of a circle containing a speech bubble with a question mark in it.\" width=\"150\" height=\"150\"><\/h2>\n<\/header>\n<div class=\"textbox__content\" style=\"text-align: left\">\n\nOral morphine was administered to a client for rib pain (rated as \u201c6\u201d) from metastatic lung cancer.\n\nWhen should the effectiveness of the medication be evaluated?\n\nNote: Answers to the Critical Thinking activities can be found in the \"<a href=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/chapter-10\/\" target=\"_blank\" rel=\"noopener\">Answer Key<\/a>\" section at the end of the book.\n\n<\/div>\n<\/div>\n<\/div>\n<div class=\"1.7-opioid-analgesics-and-antagonists\">\n<h2>Naloxone (Narcan)<\/h2>\n<strong>Mechanism of Action: <\/strong>Naloxone reverses analgesia and the CNS and respiratory depression caused by opioid agonists. It competes with opioid receptor sites in the brain and, thereby, prevents binding with receptors or displaces opioids already occupying receptor sites.\n\n<strong>Indications: <\/strong>Naloxone is indicated for the complete or partial reversal of opioid depression, including respiratory depression induced by natural and synthetic opioids.\n\n<strong>Nursing Considerations: <\/strong>Naloxone is safe for all ages.\n\n<strong>Side Effects\/Adverse Effects: <\/strong>Adverse effects include tremors, drowsiness, sweating, decreased respirations, hypertension, nausea, and vomiting.\n\n<strong>Health Teaching &amp; Health Promotion: <\/strong>Clients should be advised regarding the risks associated with opioid analgesic use and the need for opioid antagonists. Please see the outlined \"Special Considerations\" for usage below.<sup>[footnote]uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote]<\/sup>\n\n<strong>Special Considerations<\/strong>\n\n<strong>Postoperative: <\/strong>The following adverse events have been associated with the use of naloxone hydrochloride injection in postoperative clients: hypotension, hypertension, ventricular tachycardia and fibrillation, dyspnea, pulmonary edema, and cardiac arrest. Death, coma, and encephalopathy have been reported as results of these events. Excessive doses of naloxone in postoperative clients may result in significant reversal of analgesia and may cause agitation.\n\n<strong>Opioid Depression: <\/strong>Abrupt reversal of opioid depression may result in nausea, vomiting, sweating, tachycardia, increased blood pressure, tremulousness, seizures, ventricular tachycardia and fibrillation, pulmonary edema, and cardiac arrest, which may result in death.\n\n<strong>Opioid Dependence: <\/strong>Abrupt reversal of opioid effects in persons who are physically dependent on opioids may precipitate an acute withdrawal syndrome, which may include, but not limited to, the following signs and symptoms: body aches, fever, sweating, runny nose, sneezing, piloerection, yawning, weakness, shivering or trembling, nervousness, restlessness or irritability, diarrhea, nausea or vomiting, abdominal cramps, increased blood pressure, and tachycardia. In the neonate, opioid withdrawal may also include convulsions, excessive crying, and hyperactive reflexes.\n\nNow let\u2019s take a closer look at the medication grid on naloxone in Table 10.7b.<sup>[footnote]Frandsen, G., &amp; Pennington, S. (2018). <em>Abrams\u2019 clinical drug: Rationales for nursing practice<\/em> (11th ed.). pp. 305, 310, 952-953, 959-960. Wolters Kluwer.[\/footnote],[footnote]This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">DailyMed<\/a>\u00a0by\u00a0<a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the\u00a0<a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">Public Domain<\/a>.[\/footnote]<\/sup>\n\nTable 10.7b Naloxone Medication Grid\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%\" border=\"0\">\n<tbody>\n<tr>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Class\/<\/strong><strong>Subclass<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Prototype\/G<\/strong><strong>eneric<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Nursing <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Side\/Adverse Effects<\/strong><\/th>\n<\/tr>\n<tr>\n<th style=\"width: 20%\" scope=\"row\"><strong>Opioid Antagonist<\/strong><\/th>\n<td style=\"width: 20%\"><a class=\"arrow\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=8535cc84-ad4a-4d67-8480-fb5a2e3406f8\" target=\"_blank\" rel=\"noopener noreferrer\">naloxone<\/a><\/td>\n<td style=\"width: 20%\">Given parenterally and inhaled\n\nAssess for reversal of opioid effect\n\nAssess for hypertension\n\nAssess for return of pain\n\nNaloxone has a shorter duration of action than opioids, and repeated doses are usually necessary<\/td>\n<td style=\"width: 20%\">Blocks the effects of opioid CNS and respiratory depression<\/td>\n<td style=\"width: 20%\">Agitation\n\nTremors\n\nDrowsiness\n\nSweating\n\nDecreased respirations\n\nHypertension\n\nNausea and vomiting<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.7b<img class=\"alignright size-thumbnail wp-image-67\" src=\"https:\/\/pressbooks.ccconline.org\/accdigitalmarketing\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1-150x150.png\" alt=\"Image of a circle containing a speech bubble with a question mark in it.\" width=\"150\" height=\"150\"><\/h2>\n<\/header>\n<div class=\"textbox__content\" style=\"text-align: left\">\n\nA postoperative client just received naloxone for respiratory depression.\n\nWhen should the client\u2019s respiratory status be reassessed?\n\nNote: Answers to the Critical Thinking activities can be found in the \"<a href=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/chapter-10\/\" target=\"_blank\" rel=\"noopener\">Answer Key<\/a>\" section at the end of the book.\n\n<\/div>\n<\/div>\n<\/div>","rendered":"<div class=\"1.7-opioid-analgesics-and-antagonists\">\n<p>Opioid analgesics are prescribed for moderate and severe pain. There are several types of opioids, as listed in Table 10.4 in the previous &#8220;<a href=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/10-4-applying-the-nursing-process-to-pain-management\/\" target=\"_blank\" rel=\"noopener\">Applying the Nursing Process to Pain Management<\/a>&#8221; section. Before discussing morphine, the prototype opioid analgesic, and its antagonist, naloxone, let&#8217;s discuss the opioid epidemic in the United States, efforts to stop this epidemic, and the dangers of drug diversion.<\/p>\n<h2>Understanding the Opioid Epidemic<\/h2>\n<p>The drug overdose epidemic continues to worsen in the United States. Overdose deaths remain a leading cause of injury-related death. In the United States, drug overdoses have claimed over 932,000 lives over the past 21 years. The majority of overdose deaths involve opioids. Deaths involving synthetic opioids (i.e., illicitly made fentanyl)\u00a0 have increased in recent years, especially during the COVID-19 pandemic.<sup><a class=\"footnote\" title=\"Centers for Disease Control and Prevention. (2022). Understanding drug overdoses and deaths. https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html\" id=\"return-footnote-430-1\" href=\"#footnote-430-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><\/sup><\/p>\n<p>The rise in opioid overdose deaths can be outlined in three distinct waves. See Figure 10.7<sup><a class=\"footnote\" title=\"\u201c3 Waves of the Rise of Opioid Overdose Deaths\u201d by National Vital Statistics System, CDC is licensed under\u00a0CC0\" id=\"return-footnote-430-2\" href=\"#footnote-430-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><\/span><\/sup>\u00a0for a graphic representation of the waves of opioid deaths.<\/p>\n<figure style=\"width: 617px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"\" title=\"&quot;3 Waves of the Rise of Opioid Overdose Deaths&quot; by National Vital Statics System, CDC is licensed under CC0\" src=\"https:\/\/pressbooks.ccconline.org\/accdigitalmarketing\/wp-content\/uploads\/sites\/219\/2019\/12\/image10.png\" alt=\"Graph showing three waves of opioid overdose deaths\" width=\"617\" height=\"435\" \/><figcaption class=\"wp-caption-text\">Figure 10.7 Three Waves of Opioid Overdose Deaths<\/figcaption><\/figure>\n<p>The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone). The second wave began in 2010 with rapid increases in overdose deaths involving heroin. The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, especially those involving illicitly manufactured fentanyl.<sup><a class=\"footnote\" title=\"Centers for Disease Control and Prevention. (2018, December 19). Opioid overdose, Understanding the epidemic. https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html\" id=\"return-footnote-430-3\" href=\"#footnote-430-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><\/sup><\/p>\n<h2>CDC&#8217;s Educational Campaigns<\/h2>\n<p>To save lives from drug overdose, the Centers for Disease Control and Prevention (CDC) launched four education campaigns to reach young adults (ages 18-34). The campaigns provide information that can save the lives and highlight actions the public can take to help prevent overdose. Specifically, the campaigns provide critical information about these topics<sup><a class=\"footnote\" title=\"Centers for Disease Control and Prevention. (2022). Understanding drug overdoses and deaths. https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html\" id=\"return-footnote-430-4\" href=\"#footnote-430-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><\/sup>:<\/p>\n<ul>\n<li>Dangers of fentanyl<\/li>\n<li>Risks and consequences of mixing drugs<\/li>\n<li>Life-saving power of naloxone to reverse an opioid overdose<\/li>\n<li>Importance of reducing stigma to support treatment and recovery<\/li>\n<\/ul>\n<div class=\"textbox\">\n<p class=\"arrow\">Read more information about the <a href=\"https:\/\/www.cdc.gov\/drugoverdose\/featured-topics\/overdose-prevention-campaigns.html\" target=\"_blank\" rel=\"noopener\">CDC campaigns to stop overdose deaths<\/a>.<\/p>\n<\/div>\n<h2>CDC Guidelines for Prescribing Opioids for Chronic Pain<\/h2>\n<p>In addition to establishing educational campaigns to prevent opioid deaths, the CDC has also established new clinical practice guidelines regarding the prescription of opioids to ensure clients have access to safer, effective pain treatment while also reducing the number of people who misuse or overdose from these drugs. The CDC&#8217;s <em>Clinical Practice Guidelines for Prescribing Opioids<\/em> &#8211; <em>United States, 2022<\/em> was developed for the prescribing of opioid pain medication for clients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating acute pain (pain lasting less than one month), subacute pain (pain lasting one to three months, and chronic pain (pain lasting longer than three months). This clinical practice guideline is intended to improve communication between clinicians and clients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for clients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.<sup><a class=\"footnote\" title=\"Centers for Disease Control and Prevention. (2022). Clinical practice guidelines for prescribing opioids - United States, 2022. \u00a0https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w\" id=\"return-footnote-430-5\" href=\"#footnote-430-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a><\/sup> Nurses also play an important component in advocating for these outcomes.<\/p>\n<p>Four key areas are covered in the CDC&#8217;s <em>Clinical Practice Guidelines for Prescribing Opioids<sup><a class=\"footnote\" title=\"Centers for Disease Control and Prevention. (2022). Clinical practice guidelines for prescribing opioids - United States, 2022. \u00a0https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w\" id=\"return-footnote-430-6\" href=\"#footnote-430-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/sup><\/em>:<\/p>\n<ol>\n<li>Determining whether or not to initiate opioids for pain<\/li>\n<li>Selecting opioids and determining opioid dosages<\/li>\n<li>Deciding duration of initial opioid prescription and conducting follow-up<\/li>\n<li>Assessing risk and addressing potential harms of opioid use<\/li>\n<\/ol>\n<p>In addition, five guiding principles were identified<sup><a class=\"footnote\" title=\"Centers for Disease Control and Prevention. (2022). Clinical practice guidelines for prescribing opioids - United States, 2022. \u00a0https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w\" id=\"return-footnote-430-7\" href=\"#footnote-430-7\" aria-label=\"Footnote 7\"><sup class=\"footnote\">[7]<\/sup><\/a><\/sup>:<\/p>\n<ol>\n<li>Appropriate treatment of pain<\/li>\n<li>Flexibility to meet the care needs and clinical circumstances of each client<\/li>\n<li>A multimodal and multidisciplinary approach to pain management<\/li>\n<li>Avoiding misapplication of the clinical practice guideline beyond its intended use<\/li>\n<li>Vigilance in attending to health inequities and ensuring access to appropriate, affordable, diversified, coordinated, and effective nonpharmacologic and pharmacologic pain treatment for all persons<\/li>\n<\/ol>\n<p>Improving the way opioids are prescribed through clinical practice guidelines can ensure clients have access to safer, more effective pain treatment while also reducing the risk of opioid use disorder, overdose, and death.<\/p>\n<h2>Drug Diversion and Impaired Health Care Workers<\/h2>\n<p>Drug diversion is a potential threat to patient safety in every health care organization. Drug diversion involves the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for illicit use. The most commonly diverted substances in health care facilities are opioids.<\/p>\n<p>Risks to clients from drug diversion include inadequate pain relief compounded by potentially unsafe care due to the health care worker\u2019s impaired performance.<sup><a class=\"footnote\" title=\"The Joint Commission, Division of Healthcare Improvement. (2019). Drug diversion and impaired health care workers. Quick Safety (48). https:\/\/www.jointcommission.org\/resources\/news-and-multimedia\/newsletters\/newsletters\/quick-safety\/quick-safety-48-drug-diversion-and-impaired-health-care-workers\/#.ZDh5THbMI2w\" id=\"return-footnote-430-8\" href=\"#footnote-430-8\" aria-label=\"Footnote 8\"><sup class=\"footnote\">[8]<\/sup><\/a><\/sup> More information about drug diversion and substance use disorder in health care professionals\u00a0 is discussed in the &#8220;<a href=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/2-3-legal-foundations-and-national-guidelines-for-safe-medication-administration\/\" target=\"_blank\" rel=\"noopener\">Legal Foundations and National Guidelines for Safe Medication Administration<\/a>&#8221; section of the &#8220;Legal\/Ethical&#8221; chapter.<\/p>\n<h2>Opioid Medication Class<\/h2>\n<p>See Table 10.4 in the &#8220;<a href=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/10-4-nursing-process-for-analgesics-and-musculoskeletal-medications\/\" target=\"_blank\" rel=\"noopener\">Nursing Process for Analgesics and Musculoskeletal Medications<\/a>&#8221; section of this chapter for a list of common opioid medications used to treat moderate to severe pain. As discussed in that section, 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. Morphine is also commonly used in <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_430_661\">patient-controlled analgesia (PCA<\/a>)<\/strong>; other medications administered via PCA include hydromorphone or fentanyl. To receive the opioid using a PCA device, the patient\u00a0pushes a button, which releases a specific dose but also has a lockout mechanism to prevent an overdose.<sup><a class=\"footnote\" title=\"McCuistion, L., Vuljoin-DiMaggio, K., Winton, M., &amp; Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 268-270, 324, 332. Elsevier.\" id=\"return-footnote-430-9\" href=\"#footnote-430-9\" aria-label=\"Footnote 9\"><sup class=\"footnote\">[9]<\/sup><\/a><\/sup><\/p>\n<h3>Morphine<\/h3>\n<p>Morphine is an example of a potent opioid used to treat severe pain.<\/p>\n<p><strong>Mechanism of Action: <\/strong>Morphine binds to opioid receptors in the CNS and alters the perception of and response to painful stimuli while producing generalized CNS depression.<\/p>\n<p><strong>Indications: <\/strong>Morphine is indicated for the relief of moderate to severe acute and chronic pain and for pulmonary edema.<\/p>\n<p><strong>Nursing Considerations: <\/strong>Morphine is safe for all ages. Use cautiously with clients with liver and renal impairment.<\/p>\n<p><strong>Side Effects\/Adverse Effects: <\/strong>Adverse effects include respiratory depression, hypotension, light-headedness, dizziness, sedation, constipation, nausea, vomiting, and sweating.<\/p>\n<p><strong>Health Teaching &amp; Health Promotion: <\/strong>Clients should be advised regarding the risks associated with opioid analgesic use. Please see the outlined &#8220;Special Considerations&#8221; for usage below.<sup><a class=\"footnote\" title=\"uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral\" id=\"return-footnote-430-10\" href=\"#footnote-430-10\" aria-label=\"Footnote 10\"><sup class=\"footnote\">[10]<\/sup><\/a><\/sup><\/p>\n<p><strong>Boxed Warning: <\/strong>The 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. Naloxone is used to reverse opioid overdose. There is also a risk of drug abuse and dependence with morphine.<\/p>\n<p><strong>Special Considerations<br style=\"clear: both\" \/><\/strong><\/p>\n<p><strong>Respiratory Depression: <\/strong>Respiratory depression is the primary risk of morphine sulfate. Respiratory depression occurs more frequently in elderly or debilitated clients and in those suffering from conditions accompanied by hypoxia, hypercapnia, or upper airway obstruction, for whom even moderate therapeutic doses may significantly decrease pulmonary ventilation.<\/p>\n<p>Use 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 preexisting 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 nonopioid analgesics and use morphine sulfate only under careful medical supervision at the lowest effective dose in such clients.<\/p>\n<p><strong>Misuse, Abuse, and Diversion of Opioids: <\/strong>Morphine sulfate is an opioid agonist and a Schedule II controlled substance. Such drugs are sought by drug abusers and people with addiction disorders. Diversion of Schedule II products is an act subject to criminal penalty.<\/p>\n<p>Morphine can be abused 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 increased risk of misuse, abuse, or diversion. Morphine may be abused by crushing, chewing, snorting, or injecting the product. These practices pose a significant risk to the abuser that could result in overdose and death.<\/p>\n<p><strong>Interactions With Alcohol and Drugs of Abuse: <\/strong>Morphine has addictive effects when used in conjunction with alcohol, other opioids, or illicit drugs that cause central nervous system depression and respiratory depression, hypotension, profound sedation, coma, or death may result.<\/p>\n<p><strong>Use in Head Injury and Increased Intracranial Pressure: <\/strong>In 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.<\/p>\n<p><strong>Hypotensive Effect: <\/strong>Morphine 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.<\/p>\n<p>Administer morphine sulfate with caution to clients in circulatory shock, as vasodilation produced by the drug may further reduce cardiac output and blood pressure.<\/p>\n<p><strong>Gastrointestinal Effects: <\/strong>Do 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.<\/p>\n<p>The administration of morphine sulfate may obscure the diagnosis or clinical course in clients with an acute abdominal condition.<\/p>\n<p><strong>Use in Pancreatic\/Biliary Tract Disease: <\/strong>Use morphine with caution in clients with biliary tract disease, including acute pancreatitis, as morphine sulfate may cause spasming and diminished biliary and pancreatic secretions.<\/p>\n<p><strong>Special Risk Groups: <\/strong>Use morphine with caution and in reduced dosages in clients with severe renal or hepatic impairment, Addison\u2019s disease, hypothyroidism, prostatic hypertrophy, 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.<\/p>\n<p>All opioids may aggravate convulsions in clients with convulsive disorders, and all opioids may induce or aggravate seizures.<\/p>\n<p><strong>Driving and Operating Machinery: <\/strong>Caution 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.<\/p>\n<p>Caution clients about the potential combined effects of morphine sulfate with other CNS depressants, including other opioids, phenothiazines, sedative\/hypnotics, and alcohol.<\/p>\n<p>Now let\u2019s take a closer look at the medication grid on morphine in Table 10.7a.<sup><a class=\"footnote\" title=\"Frandsen, G., &amp; Pennington, S. (2018). Abrams\u2019 clinical drug: Rationales for nursing practice (11th ed.). pp. 305, 310, 952-953, 959-960. Wolters Kluwer.\" id=\"return-footnote-430-11\" href=\"#footnote-430-11\" aria-label=\"Footnote 11\"><sup class=\"footnote\">[11]<\/sup><\/a>,<a class=\"footnote\" title=\"Vallerand, A., &amp; Sanoski, C. A. (2019). Davis\u2019s drug guide for nurses (16th ed.). F. A. Davis Company.\" id=\"return-footnote-430-12\" href=\"#footnote-430-12\" aria-label=\"Footnote 12\"><sup class=\"footnote\">[12]<\/sup><\/a>,<a class=\"footnote\" title=\"This work is a derivative of DailyMed\u00a0by\u00a0U.S. National Library of Medicine in the\u00a0Public Domain.\" id=\"return-footnote-430-13\" href=\"#footnote-430-13\" aria-label=\"Footnote 13\"><sup class=\"footnote\">[13]<\/sup><\/a><\/span><\/sup><\/p>\n<p>Table 10.7a Morphine Medication Grid<\/p>\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%\">\n<tbody>\n<tr>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Class\/<\/strong><strong>Subclass<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Prototype\/G<\/strong><strong>eneric<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Nursing <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Side\/Adverse Effects<\/strong><\/th>\n<\/tr>\n<tr>\n<th style=\"width: 20%;vertical-align: top\" scope=\"row\"><strong>Opioid Analgesic<\/strong><\/th>\n<td style=\"width: 20%;vertical-align: top\"><a class=\"arrow\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=680a996c-08a5-4cdb-b7bd-0ada5d8c7adf\" target=\"_blank\" rel=\"noopener noreferrer\">morphine<\/a><\/td>\n<td style=\"width: 20%;vertical-align: top\">Given parenterally and orally<\/p>\n<p>Assess pain prior to and after administration<\/p>\n<p>Monitor respiratory status<\/p>\n<p>Monitor blood pressure<\/p>\n<p>Assess pediatric and geriatric clients frequently<\/p>\n<p>Assess bowel function<\/p>\n<p>Use cautiously with antidepressants and other CNS depressants<\/p>\n<p>Naloxone is used to reverse opioid overdose<\/td>\n<td style=\"width: 20%;vertical-align: top\">Relieves severe pain<\/td>\n<td style=\"width: 20%;vertical-align: top\">Respiratory depression<\/p>\n<p>Confusion<\/p>\n<p>Hypotension<\/p>\n<p>Light-headedness<\/p>\n<p>Dizziness<\/p>\n<p>Sedation<\/p>\n<p>Constipation<\/p>\n<p>Nausea and vomiting<\/p>\n<p>Sweating<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.7a<img loading=\"lazy\" decoding=\"async\" class=\"alignright size-thumbnail wp-image-67\" src=\"https:\/\/pressbooks.ccconline.org\/accdigitalmarketing\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1-150x150.png\" alt=\"Image of a circle containing a speech bubble with a question mark in it.\" width=\"150\" height=\"150\" srcset=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1-150x150.png 150w, https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1-65x65.png 65w, https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1-225x225.png 225w, https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1.png 300w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><\/h2>\n<\/header>\n<div class=\"textbox__content\" style=\"text-align: left\">\n<p>Oral morphine was administered to a client for rib pain (rated as \u201c6\u201d) from metastatic lung cancer.<\/p>\n<p>When should the effectiveness of the medication be evaluated?<\/p>\n<p>Note: Answers to the Critical Thinking activities can be found in the &#8220;<a href=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/chapter-10\/\" target=\"_blank\" rel=\"noopener\">Answer Key<\/a>&#8221; section at the end of the book.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"1.7-opioid-analgesics-and-antagonists\">\n<h2>Naloxone (Narcan)<\/h2>\n<p><strong>Mechanism of Action: <\/strong>Naloxone reverses analgesia and the CNS and respiratory depression caused by opioid agonists. It competes with opioid receptor sites in the brain and, thereby, prevents binding with receptors or displaces opioids already occupying receptor sites.<\/p>\n<p><strong>Indications: <\/strong>Naloxone is indicated for the complete or partial reversal of opioid depression, including respiratory depression induced by natural and synthetic opioids.<\/p>\n<p><strong>Nursing Considerations: <\/strong>Naloxone is safe for all ages.<\/p>\n<p><strong>Side Effects\/Adverse Effects: <\/strong>Adverse effects include tremors, drowsiness, sweating, decreased respirations, hypertension, nausea, and vomiting.<\/p>\n<p><strong>Health Teaching &amp; Health Promotion: <\/strong>Clients should be advised regarding the risks associated with opioid analgesic use and the need for opioid antagonists. Please see the outlined &#8220;Special Considerations&#8221; for usage below.<sup><a class=\"footnote\" title=\"uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral\" id=\"return-footnote-430-14\" href=\"#footnote-430-14\" aria-label=\"Footnote 14\"><sup class=\"footnote\">[14]<\/sup><\/a><\/sup><\/p>\n<p><strong>Special Considerations<\/strong><\/p>\n<p><strong>Postoperative: <\/strong>The following adverse events have been associated with the use of naloxone hydrochloride injection in postoperative clients: hypotension, hypertension, ventricular tachycardia and fibrillation, dyspnea, pulmonary edema, and cardiac arrest. Death, coma, and encephalopathy have been reported as results of these events. Excessive doses of naloxone in postoperative clients may result in significant reversal of analgesia and may cause agitation.<\/p>\n<p><strong>Opioid Depression: <\/strong>Abrupt reversal of opioid depression may result in nausea, vomiting, sweating, tachycardia, increased blood pressure, tremulousness, seizures, ventricular tachycardia and fibrillation, pulmonary edema, and cardiac arrest, which may result in death.<\/p>\n<p><strong>Opioid Dependence: <\/strong>Abrupt reversal of opioid effects in persons who are physically dependent on opioids may precipitate an acute withdrawal syndrome, which may include, but not limited to, the following signs and symptoms: body aches, fever, sweating, runny nose, sneezing, piloerection, yawning, weakness, shivering or trembling, nervousness, restlessness or irritability, diarrhea, nausea or vomiting, abdominal cramps, increased blood pressure, and tachycardia. In the neonate, opioid withdrawal may also include convulsions, excessive crying, and hyperactive reflexes.<\/p>\n<p>Now let\u2019s take a closer look at the medication grid on naloxone in Table 10.7b.<sup><a class=\"footnote\" title=\"Frandsen, G., &amp; Pennington, S. (2018). Abrams\u2019 clinical drug: Rationales for nursing practice (11th ed.). pp. 305, 310, 952-953, 959-960. Wolters Kluwer.\" id=\"return-footnote-430-15\" href=\"#footnote-430-15\" aria-label=\"Footnote 15\"><sup class=\"footnote\">[15]<\/sup><\/a>,<a class=\"footnote\" title=\"This work is a derivative of DailyMed\u00a0by\u00a0U.S. National Library of Medicine in the\u00a0Public Domain.\" id=\"return-footnote-430-16\" href=\"#footnote-430-16\" aria-label=\"Footnote 16\"><sup class=\"footnote\">[16]<\/sup><\/a><\/sup><\/p>\n<p>Table 10.7b Naloxone Medication Grid<\/p>\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%\">\n<tbody>\n<tr>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Class\/<\/strong><strong>Subclass<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Prototype\/G<\/strong><strong>eneric<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Nursing <\/strong><strong>Considerations<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Therapeutic Effects<\/strong><\/th>\n<th class=\"shaded\" style=\"width: 20%\" scope=\"col\"><strong>Side\/Adverse Effects<\/strong><\/th>\n<\/tr>\n<tr>\n<th style=\"width: 20%\" scope=\"row\"><strong>Opioid Antagonist<\/strong><\/th>\n<td style=\"width: 20%\"><a class=\"arrow\" href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/drugInfo.cfm?setid=8535cc84-ad4a-4d67-8480-fb5a2e3406f8\" target=\"_blank\" rel=\"noopener noreferrer\">naloxone<\/a><\/td>\n<td style=\"width: 20%\">Given parenterally and inhaled<\/p>\n<p>Assess for reversal of opioid effect<\/p>\n<p>Assess for hypertension<\/p>\n<p>Assess for return of pain<\/p>\n<p>Naloxone has a shorter duration of action than opioids, and repeated doses are usually necessary<\/td>\n<td style=\"width: 20%\">Blocks the effects of opioid CNS and respiratory depression<\/td>\n<td style=\"width: 20%\">Agitation<\/p>\n<p>Tremors<\/p>\n<p>Drowsiness<\/p>\n<p>Sweating<\/p>\n<p>Decreased respirations<\/p>\n<p>Hypertension<\/p>\n<p>Nausea and vomiting<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"__UNKNOWN__\">\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2>Critical Thinking Activity 10.7b<img loading=\"lazy\" decoding=\"async\" class=\"alignright size-thumbnail wp-image-67\" src=\"https:\/\/pressbooks.ccconline.org\/accdigitalmarketing\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1-150x150.png\" alt=\"Image of a circle containing a speech bubble with a question mark in it.\" width=\"150\" height=\"150\" srcset=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1-150x150.png 150w, https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1-65x65.png 65w, https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1-225x225.png 225w, https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-content\/uploads\/sites\/219\/2019\/10\/ORN-Icons_internet-copy_internet-copy-300x300-1.png 300w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><\/h2>\n<\/header>\n<div class=\"textbox__content\" style=\"text-align: left\">\n<p>A postoperative client just received naloxone for respiratory depression.<\/p>\n<p>When should the client\u2019s respiratory status be reassessed?<\/p>\n<p>Note: Answers to the Critical Thinking activities can be found in the &#8220;<a href=\"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/chapter-10\/\" target=\"_blank\" rel=\"noopener\">Answer Key<\/a>&#8221; section at the end of the book.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-430-1\">Centers for Disease Control and Prevention. (2022). <em>Understanding drug overdoses and deaths.<\/em> <a href=\"https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html<\/a> <a href=\"#return-footnote-430-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-430-2\">\u201c<a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/cc0\/\" target=\"_blank\" rel=\"noopener noreferrer\">3 Waves of the Rise of Opioid Overdose Deaths<\/a>\u201d by National Vital Statistics System, CDC is licensed under\u00a0<a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/cc0\/\" target=\"_blank\" rel=\"noopener noreferrer\">CC0<\/a><span style=\"font-size: 12.8px\"> <a href=\"#return-footnote-430-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-430-3\">Centers for Disease Control and Prevention. (2018, December 19). <em>Opioid overdose, Understanding the epidemic.<\/em> <a href=\"https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html<\/a> <a href=\"#return-footnote-430-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-430-4\">Centers for Disease Control and Prevention. (2022). <em>Understanding drug overdoses and deaths.<\/em> <a href=\"https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/drugoverdose\/epidemic\/index.html<\/a> <a href=\"#return-footnote-430-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-430-5\">Centers for Disease Control and Prevention. (2022). <i>Clinical practice guidelines for prescribing opioids - United States, 2022. <\/i>\u00a0<a href=\"https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w<\/a> <a href=\"#return-footnote-430-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-430-6\">Centers for Disease Control and Prevention. (2022). <i>Clinical practice guidelines for prescribing opioids - United States, 2022. <\/i>\u00a0<a href=\"https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w<\/a> <a href=\"#return-footnote-430-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><li id=\"footnote-430-7\">Centers for Disease Control and Prevention. (2022). <i>Clinical practice guidelines for prescribing opioids - United States, 2022. <\/i>\u00a0<a href=\"https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.cdc.gov\/mmwr\/volumes\/71\/rr\/rr7103a1.htm?s_cid=rr7103a1_w<\/a> <a href=\"#return-footnote-430-7\" class=\"return-footnote\" aria-label=\"Return to footnote 7\">&crarr;<\/a><\/li><li id=\"footnote-430-8\">The Joint Commission, Division of Healthcare Improvement. (2019). Drug diversion and impaired health care workers.<em> Quick Safety (48)<\/em>. <a href=\"https:\/\/www.jointcommission.org\/resources\/news-and-multimedia\/newsletters\/newsletters\/quick-safety\/quick-safety-48-drug-diversion-and-impaired-health-care-workers\/#.ZDh5THbMI2w\" target=\"_blank\" rel=\"noopener\">https:\/\/www.jointcommission.org\/resources\/news-and-multimedia\/newsletters\/newsletters\/quick-safety\/quick-safety-48-drug-diversion-and-impaired-health-care-workers\/#.ZDh5THbMI2w<\/a> <a href=\"#return-footnote-430-8\" class=\"return-footnote\" aria-label=\"Return to footnote 8\">&crarr;<\/a><\/li><li id=\"footnote-430-9\">McCuistion, L., Vuljoin-DiMaggio, K., Winton, M., &amp; Yeager, J. (2018). <em>Pharmacology: A patient-centered nursing process approach.<\/em> pp. 268-270, 324, 332. Elsevier. <a href=\"#return-footnote-430-9\" class=\"return-footnote\" aria-label=\"Return to footnote 9\">&crarr;<\/a><\/li><li id=\"footnote-430-10\">uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\">https:\/\/www.unboundmedicine.com\/ucentral<\/a> <a href=\"#return-footnote-430-10\" class=\"return-footnote\" aria-label=\"Return to footnote 10\">&crarr;<\/a><\/li><li id=\"footnote-430-11\">Frandsen, G., &amp; Pennington, S. (2018). <em>Abrams\u2019 clinical drug: Rationales for nursing practice <\/em>(11th ed.). pp. 305, 310, 952-953, 959-960. Wolters Kluwer. <a href=\"#return-footnote-430-11\" class=\"return-footnote\" aria-label=\"Return to footnote 11\">&crarr;<\/a><\/li><li id=\"footnote-430-12\">Vallerand, A., &amp; Sanoski, C. A. (2019). <em>Davis\u2019s drug guide for nurses <\/em>(16th ed.). F. A. Davis Company. <a href=\"#return-footnote-430-12\" class=\"return-footnote\" aria-label=\"Return to footnote 12\">&crarr;<\/a><\/li><li id=\"footnote-430-13\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">DailyMed<\/a>\u00a0by\u00a0<a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the\u00a0<a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">Public Domain<\/a>.<span style=\"font-size: 1em\"> <a href=\"#return-footnote-430-13\" class=\"return-footnote\" aria-label=\"Return to footnote 13\">&crarr;<\/a><\/li><li id=\"footnote-430-14\">uCentral from Unbound Medicine. <a href=\"https:\/\/www.unboundmedicine.com\/ucentral\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/www.unboundmedicine.com\/ucentral<\/a> <a href=\"#return-footnote-430-14\" class=\"return-footnote\" aria-label=\"Return to footnote 14\">&crarr;<\/a><\/li><li id=\"footnote-430-15\">Frandsen, G., &amp; Pennington, S. (2018). <em>Abrams\u2019 clinical drug: Rationales for nursing practice<\/em> (11th ed.). pp. 305, 310, 952-953, 959-960. Wolters Kluwer. <a href=\"#return-footnote-430-15\" class=\"return-footnote\" aria-label=\"Return to footnote 15\">&crarr;<\/a><\/li><li id=\"footnote-430-16\">This work is a derivative of <a href=\"https:\/\/dailymed.nlm.nih.gov\/dailymed\/\" target=\"_blank\" rel=\"noopener noreferrer\">DailyMed<\/a>\u00a0by\u00a0<a href=\"https:\/\/www.nlm.nih.gov\/\" target=\"_blank\" rel=\"noopener noreferrer\">U.S. National Library of Medicine<\/a> in the\u00a0<a href=\"https:\/\/creativecommons.org\/share-your-work\/public-domain\/\" target=\"_blank\" rel=\"noopener noreferrer\">Public Domain<\/a>. <a href=\"#return-footnote-430-16\" class=\"return-footnote\" aria-label=\"Return to footnote 16\">&crarr;<\/a><\/li><\/ol><\/div><div class=\"glossary\"><span class=\"screen-reader-text\" id=\"definition\">definition<\/span><template id=\"term_430_661\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_430_661\"><div tabindex=\"-1\"><p>To receive the opioid, the patient pushes a button on the PCA device, which releases a specific dose but also has a lockout mechanism to prevent an overdose.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><\/div>","protected":false},"author":83,"menu_order":7,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[48],"contributor":[],"license":[],"class_list":["post-430","chapter","type-chapter","status-publish","hentry","chapter-type-numberless"],"part":410,"_links":{"self":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/430","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/wp\/v2\/users\/83"}],"version-history":[{"count":2,"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/430\/revisions"}],"predecessor-version":[{"id":775,"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/430\/revisions\/775"}],"part":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/pressbooks\/v2\/parts\/410"}],"metadata":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/pressbooks\/v2\/chapters\/430\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/wp\/v2\/media?parent=430"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/pressbooks\/v2\/chapter-type?post=430"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/wp\/v2\/contributor?post=430"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/wp-json\/wp\/v2\/license?post=430"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}