{"id":458,"date":"2019-12-01T20:17:11","date_gmt":"2019-12-01T20:17:11","guid":{"rendered":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/chapter\/10-7-opioid-analgesics-and-antagonists\/"},"modified":"2021-12-07T11:31:05","modified_gmt":"2021-12-07T11:31:05","slug":"10-7-opioid-analgesics-and-antagonists","status":"publish","type":"chapter","link":"https:\/\/pressbooks.publishdot.com\/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":"
\n\nOpioid analgesics are prescribed for moderate and severe pain. See Figure 10.8 in the \"Nursing Process\" section for a list of common opioid medications used to treat moderation pain 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 [pb_glossary id=\"2513\"]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 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]<\/sup>\n

Morphine<\/h2>\nMorphine is an example of an opioid used to treat moderate to severe pain.\n\nMechanism of Action<\/strong>\n\nMorphine binds to opioid receptors in the CNS and alters the perception of and response to painful stimuli while producing generalized CNS depression.\n\nIndications for Use<\/strong>\n\nMorphine is indicated for the relief of moderate to severe acute and chronic pain and for pulmonary edema.\n\nNursing Considerations Across the Lifespan<\/strong>\n\nMorphine is safe for all ages. Use cautiously with patients with liver and renal impairment.\n\nAdverse\/Side Effects<\/strong>\n\nAdverse effects include respiratory depression, hypotension, light-headedness, dizziness, sedation, constipation, nausea, vomiting, and sweating.\n\nPatient Teaching & Education<\/strong>\n\nPatients should be advised regarding the risks associated with opioid analgesic use.\u00a0 Please see the outlined \"Special Considerations\" for usage below.[footnote]uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral[\/footnote]<\/sup>\n\nBlack Box Warning <\/strong>\n\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. Naloxone is used to reverse opioid overdose. There is also a risk of drug abuse and dependence with morphine.\n\nSpecial Considerations
<\/strong>\n\nRespiratory Depression<\/strong>\n\nRespiratory depression is the primary risk of morphine sulfate. Respiratory depression occurs more frequently in elderly or debilitated patients 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 patients with chronic obstructive pulmonary disease or cor pulmonale and in patients having a substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression. In such patients, 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.\n\nMisuse, Abuse, and Diversion of Opioids<\/strong>\n\nMorphine 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\nInteractions with Alcohol and Drugs of Abuse<\/strong>\n\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.\n\nUse In Head Injury and Increased Intracranial Pressure<\/strong>\n\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 patients with head injuries.\n\nHypotensive Effect<\/strong>\n\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.\n\nAdminister morphine sulfate with caution to patients in circulatory shock, as vasodilation produced by the drug may further reduce cardiac output and blood pressure.\n\nGastrointestinal Effects<\/strong>\n\nDo not administer morphine to patients 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 patients with an acute abdominal condition.\n\nUse in Pancreatic\/Biliary Tract Disease<\/strong>\n\nUse morphine with caution in patients with biliary tract disease, including acute pancreatitis, as morphine sulfate may cause spasming and diminished biliary and pancreatic secretions.\n\nSpecial Risk Groups<\/strong>\n\nUse morphine with caution and in reduced dosages in patients with severe renal or hepatic impairment, Addison\u2019s disease, hypothyroidism, prostatic hypertrophy, or urethral stricture, and in elderly or debilitated patients. Exercise caution in the administration of morphine sulfate to patients with CNS depression, toxic psychosis, acute alcoholism, and delirium tremens.\n\nAll opioids may aggravate convulsions in patients with convulsive disorders, and all opioids may induce or aggravate seizures.\n\nDriving and Operating Machinery<\/strong>\n\nCaution patients 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 patients 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.[footnote]Frandsen, G., Pennington, S. (2018).\u00a0Abrams\u2019 clinical drug: Rationales for nursing practice (11th ed.)<\/em>. (pg. 305, 310, 952-953, 959-960). Wolters Kluwer.[\/footnote],[footnote]Vallerand, A. & Sanoski, C. A. (2019). Davis\u2019s Drug Guide for Nurses,\u00a0<\/em>(16th ed.). F.A. Davis Company.[\/footnote],[footnote]This work is a derivative of\u00a0Daily Med<\/a>\u00a0by\u00a0U.S. National Library of Medicine<\/a>\u00a0in the\u00a0public domain<\/a>.\u00a0\u00a0[\/footnote]<\/span><\/sup>\n\nTable 10.7a Morphine Medication Grid\n\n\n\n\n\n
Class\/<\/strong>\n\nSubclass<\/strong><\/th>\nPrototype-<\/strong>\n\ngeneric<\/strong><\/th>\nAdministration <\/strong>Considerations<\/strong><\/th>\nTherapeutic Effects<\/strong><\/th>\nAdverse\/Side Effects<\/strong><\/th>\n<\/tr>\n
Opioid analgesic<\/th>\nmorphine<\/a><\/td>\nGiven parenterally and orally\n\nAssess pain prior to and after administration\n\nMonitor respiratory status\n\nMonitor blood pressure\n\nAssess pediatric and geriatric patients frequently\n\nAssess bowel function\n\nUse cautiously with antidepressants and other CNS depressants\n\nNaloxone is used to reverse opioid overdose<\/td>\nRelieves moderate to severe pain<\/td>\nRespiratory depression\n\nConfusion\n\nHypotension\n\nLight-headedness\n\nDizziness\n\nSedation\n\nConstipation\n\nNausea and vomiting\n\nSweating<\/td>\n<\/tr>\n
<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n \n
\n\n \n\n<\/div>\n
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Critical Thinking Activity 10.7a\n\"Image<\/h2>\n<\/header>\n
\n\nOral morphine was administered to a patient 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 \"Answer Key\" sections at the end of the book.\n\n<\/div>\n<\/div>\n<\/div>\n
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Concerns Related to Opioid Use<\/h2>\n

CDC Guidelines for Prescribing Opioids for Chronic Pain<\/h3>\nImproving the prescription of opioids through clinical practice guidelines can ensure patients have access to safer, effective pain treatment while also reducing the number of people who misuse or overdose from these drugs.\n\nThe CDC developed and published the CDC Guideline for Prescribing Opioids for Chronic Pain <\/em>to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care.[footnote]Centers for Disease Control and Prevention. (2019, August 28). Opioid overdose, CDC guideline for prescribing opioids for chronic pain. https:\/\/www.cdc.gov\/drugoverdose\/prescribing\/guideline.html<\/a>\u00a0[\/footnote]<\/sup>\n

The Need<\/h3>\nImproving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the risk of opioid use disorder, overdose, and death.\n