Safe Administration of Opioids

1. Safe Administration of Opioids

2. Opioids Natural and synthetic drugs whose effects are mediated by specific receptors in the nervous system Binds to specific sites in the CNS Used for moderate to severe pain Nonopioids Nonopioids acts on peripheral nerve endings at injured site and usually have analgesic, antipyretic, and antinflammatory properties Examples: Tylenol, Aspirin, Ibuprofen Classification of Pain Medications

3. Do not have a ceiling (the more medication you administer, the more pain relief the patient will receive) Side effects usually include respiratory depression, vasodilation, lowered blood pressure, euphoria, sedation, n/v, constipation, biliary tract spasm Opioids

4. HIGH ALERT MED: Those that bear a heightened risk of causing significant harm when they are used in error Indicated for short term, acute pain Eliminated by the kidneys, should not be used for patients with decreased renal function Renal excretion of this drug is often delayed in the elderly causing a build up of the toxic metabolite normeperidine Rapid IV administration increases the possibility of hypotension and respiratory depression Check if patient on anticonvulsant before medicating Initial optimum dose is 25-50 mg; the elderly especially need the lowest dose range to start (remember start low and go slow unless opioid dependent, such as cancer patient). Some larger younger patients even need 100 mg but these doses quickly exceed the 600 mg/24 hour max dose These doses also produce numerous side effects including irritability, tremors, muscle twitching, agitation, and seizures Metabolized to an active, toxic metabolite (normeperidine) in the liver; its extended half-life may lead to cumulative effects. Do not use in renal failure or dialysis patients! Demerol (Meperidine Hydrochloride)

5. HIGH ALERT MED Multiple routes/brand names used for moderate to severe pain Usual starting dose for opioid naïve adult patients is 2-5 mg IV; for elderly patients starting doses of 1mg-2mg may be sufficient Side effects include resp depression, hypotension, bradycardia, constipation, confusion, sedation Assess VS, level of sedation and LOC regularly in these patients Morphine

6. HIGH ALERT MED Usual starting dose is 1-2 mg every 4-6 hours in younger opiate tolerant patients Use lower initial doses in opiate-naïve patients and elderly patients Doses appropriate for the general population may cause serious respiratory depression in vulnerable patients Available in more than one concentration (10mg/ml); usually reserved for compounding in pharmacy May be given undiluted; further dilution with 5 ml sterile water or NS is appropriate Rapid IV administration increases the possibility of hypotension and resp. depression Inject 2 mg or fraction over a minimum of 2-3 minutes Six times more potent than Morphine milligram per milligram Dilaudid (Hydromorphone)

7. Careful use especially with: Younger patients Debilitated Renal/liver/pulm/cardiac disease Elderly (go low and slow and titrate up for elderly) Naïve (patients who do not take these medications regularly) Sleep apnea/snoring Morbid obesity Post-surgery esp. thoracic or other surgeries that impair breathing Higher doses of opioids Also receiving other sedating drugs Smoker Longer time receiving anesthesia Precautions with Opioids

8. Monitor for side effects especially when initiating and changing dosages Use equianalgesic dosing: When changing route and dosing, modify amount based on drug and patient O2 saturation reflects oxygenation and not necessarily ventilation. Patient may be in respiratory distress even with adequate O2 sat. Before administering pain medication, assess respiratory effort and rate, HR, blood pressure, LOC Dilute pain medication per direction Administer per manufacturer’s direction Assessment & Administration

9. Mild pain considered to be rated 1-3 on a 1-10 scale Non-opioids with adjuvants Non-opioids (Tylenol, Motrin, Naproxen) Adjuvants (added to reduce side effects and contribute to pain relief - corticosterioids, benzos, etc.) Moderate pain considered to be 4-6 on a 1-10 scale Give opioids in low doses Use combination drugs such as Lortab/Percocet Non-opioids and adjuvants may continue For patients with cancer diagnoses, may introduce oxycodone and Morphine in small doses WHO Ladder

10. Severe pain is considered to be 7-10 on a 1-10 scale Add higher doses of opioids Begin using strong opioids such as Morphine, Oxycodone, Dilaudid, Methadone Continue to use non-opioids and adjuvants WHO Ladder

11. Schedule II opioid agonists, including hydromorphone, morphine, oxycodone, fentanyl, and methadone, have the highest potential for abuse and risk of producing respiratory depression. Alcohol, CNS depressants, and other opioids potentiate the respiratory depressant effects of Dilaudid, increasing the risk for respiratory depression that might result in death

12. All patients receiving opioids via PCA pump must also have continuous pulse oximetry Pulse oximetry may be interrupted for ambulation or physical activities where monitoring would be disruptive Emphasize to the patient and family that if someone other than the patient operates the pump, they may harm the patient RR, O2 sat, pain and sedation level per RASS (Richmond Agitation Sedation Scale) every 2 hours Document sedation level through CPSI (PCA, input, assessment options, sedation status) Full VS with O2 sat, pain level, sedation level per RASS every 4 hours Call physician for resp. <12, resp. distress, SBP <90, O2 sat < 90%, HR <50 or >120, RASS score -2 or less, mental status change, uncontrolled pain, uncontrolled nausea, uncontrolled itching PCA Pumps

13. +4: Combative: Violent, immediate danger to staff +3: Very agitated: Pulls or removes tubes or catheters +2: Agitated: Frequent, non-purposeful movement +1: Restless: Anxious but movements not aggressive or vigorous 0: Alert & calm: -1: Drowsy: Not fully alert but sustained awakening to voice (> or = 10 seconds) -2: Light sedation: Briefly awakens with eye contact to voice (< 10 seconds) -3: Moderate sedation: Movement or eye opening to voice (but no eye contact) -4: Deep sedation: No response to voice, but movement or eye opening to physical stimulation -5: Unarousable: No response to voice or physical stimulation Procedure for RASS Assessment: Observe patient Patient is alert, restless, or agitated (0 to +4) If not alert, state patient’s name and say to open eyes and look at speaker Patient awakens with sustained eye opening and eye contact (Score -1) Patient awakens with eye opening and eye contact, but not sustained (Score -2) Patient has any movement in response to voice but no eye contact (Score -3) When no response to verbal stimulation, physically stimulate the patient by shaking shoulder and/or rubbing sternum Patient has any movement to physical stimulation (Score -4) Patient has no response to any stimulation (Score -5) Richmond Agitation Sedation Scale (RASS)

14. All opioids/controlled substances should be wasted in the medication room with a witness Used Fentanyl patches should be removed with gloves, folded in half, and placed in redsharps container in med room Red sharpscontainer: ALL narcotics in all dosage forms with or without sharps. All non-hazardous sharps. Green container: Non-narcotic, non-hazardous, non-flammable drugs in all dosage forms without sharps Controlled substance waste must not be able to be recovered Wasting Opioids