Narcotics, also termed opioid drugs, function by interacting with opioid receptors. These receptors are specialized sites in the body that respond to naturally occurring substances such as enkephalins and endorphins. These receptors are distributed throughout:

• Central Nervous System (CNS)

• Peripheral Nerves

• Cells of the Gastrointestinal (GI) Tract

Within the spinal cord, opioid receptors play a role in processing and interpreting signals related to pain. The degree of pain relief and the nature of side effects experienced are influenced by the specific type of opioid receptor that is activated.

Pain

Pain is primarily a subjective and personal experience of discomfort, encompassing both physical sensation and emotional response. Individual reactions to pain vary significantly due to:

• Cultural Factors: Cultural norms can shape the expression and understanding of pain.

• Past Experiences: Previous encounters with pain influence how future pain is perceived.

• Environmental Influences: Current surroundings and stressors can modulate pain perception.

Two main types of sensory nerve fibers transmit pain signals:

• A-delta Fibers: Responsible for transmitting rapid, sharp pain sensations.

• C-Fibers: Responsible for transmitting slower, dull, or persistent pain sensations.

These nerve fibers respond to stimuli by generating electrical signals, which the brain interprets as pain.

Pain Classification

Pain can be categorized in several ways.

Pain Classification by Duration:

1. Acute Pain:

   • Typically arises directly from tissue damage or injury.

   • Acts as a warning signal, prompting the individual to recognize harm and seek appropriate treatment and information for recovery.

2. Chronic Pain:

   • Pain that is ongoing or recurs frequently for an extended period, often beyond the expected healing timeframe.

   • Can significantly disrupt daily life and reduce overall well-being.

Pain Classification by Source:

1. Nociceptive Pain:

   • Results from stimulation of pain receptors (nociceptors) by tissue injury or inflammation.

   • Commonly caused by physical damage like cuts, burns, or fractures.

2. Neuropathic Pain:

   • Originates from damage to or malfunction of the nervous system.

   • Examples include nerve compression, nerve trauma, or conditions like diabetic neuropathy.

3. Psychogenic Pain:

   • Pain where psychological factors, such as emotions, mental state, or behaviors, play a significant role.

   • While the pain is genuinely felt, it may not have a readily identifiable physical cause and is linked to mental or emotional distress.

Types of Opioid Receptors

Several types of opioid receptors exist, each mediating different effects:

1. Mu (μ)-Receptors:

   • Chiefly responsible for blocking pain signals (analgesia).

   • Also involved in side effects like slowed breathing (respiratory depression), intense pleasure (euphoria), and the development of physical dependence.

2. Beta (β)-Receptors:

   • Contribute to regulating pain signal transmission in peripheral tissues outside the CNS.

   • Interact with enkephalins, natural pain-reducing substances produced by the body.

3. Kappa (κ)-Receptors:

   • Associated with pain relief (analgesia), pupil constriction (miosis), drowsiness (sedation), and feelings of displeasure or unease (dysphoria).

4. Sigma (σ)-Receptors:

   • Activation can lead to pupil dilation (mydriasis), hallucinations, and psychotic effects with narcotic use. It is now understood that sigma receptors are not classified as true opioid receptors.

Types of Narcotic Drugs

Narcotics are generally grouped into three main categories based on their action on opioid receptors:

1. Narcotic Agonists:

   • Activate opioid receptors in the CNS.

   • Produce effects such as pain relief (analgesia), drowsiness (sedation), or euphoria.

   • Classified as controlled substances due to their potential to cause physical dependence.

2. Narcotic Agonists-Antagonists:

   • Have a mixed action, stimulating some opioid receptors while blocking others.

   • Can provide pain relief comparable to morphine but often have a lower likelihood of abuse.

   • However, they may be associated with a higher incidence of psychological side effects, like hallucinations or confusion, in some individuals.

3. Narcotic Antagonists:

   • Bind strongly to opioid receptors but do not activate them.

   • Function by counteracting the effects of opioid drugs, effectively reversing opioid overdose.

Narcotic Agonists

These medications work by activating opioid receptors in the CNS, resulting in reduced pain, sedation, and feelings of well-being.

Therapeutic Action

The primary therapeutic action of narcotic agonists is:

• To act as agonists at specific opioid receptors in the CNS. This action results in analgesia (pain relief), euphoria, and sedation.

Indications

Narcotic agonists are prescribed for various medical situations, including:

1. Management of moderate to severe pain, whether it is sudden and short-term (acute) or persistent (chronic).

2. Preoperative medication to reduce anxiety and pain before surgical procedures.

3. As part of a combination approach for managing severe, long-lasting pain.

4. Intraspinal administration to manage severe pain that is resistant to other treatments.

Indication of Narcotic Agonists in Different Age Groups

Children

1. Safety and efficacy are not fully established for many narcotic agonists in children.

2. Narcotic agonists with established pediatric dosing guidelines include:

   • Codeine

   • Fentanyl (except for transdermal patches)

   • Hydrocodone

   • Meperidine

   • Morphine

3. Naloxone is the antidote used to reverse narcotic overdose and effects.

Adults

1. It is important to inform and reassure adults that the risk of addiction when narcotics are used appropriately for acute pain is low.

2. Patients should be educated on the importance of requesting pain medication before pain becomes intense for optimal management.

3. Caution is advised for pregnant and breastfeeding women due to potential risks to the developing fetus or infant.

4. Narcotics sometimes utilized during labor include:

   • Morphine

   • Meperidine

   • Oxymorphone

5. Most narcotic agonists are classified as pregnancy category B, except for oxycodone (category C). Oxycodone may be considered if a narcotic is necessary during pregnancy, but this decision should be made by a healthcare professional.

Older Adults

1. Older adults are more susceptible to adverse drug reactions because of age-related physiological changes and potential pre-existing health conditions.

2. Safety precautions are essential, such as:

   • Ensuring bed side rails are used

   • Keeping call lights within easy reach

   • Providing assistance with ambulation to prevent falls.

Contraindications and Cautions

Situations where narcotic agonists should be avoided or used with caution include:

1. Known allergy to narcotic agonists to prevent allergic reactions.

2. Diarrhea caused by toxins: Narcotics can slow down gastrointestinal activity, potentially worsening the condition by increasing toxin absorption and prolonging exposure.

3. Respiratory dysfunction: Narcotics can depress breathing, which can worsen pre-existing respiratory conditions.

4. Recent GI/GU surgery, acute abdomen, ulcerative colitis: Narcotics’ effects on gastrointestinal motility can complicate these conditions.

5. Head injuries, alcoholism, delirium tremens, cerebrovascular disease: CNS effects of narcotics can exacerbate these conditions.

6. Liver or kidney dysfunction: These conditions can impair the body’s ability to metabolize and eliminate the drug, leading to drug accumulation and potential toxicity.

7. Pregnancy and breastfeeding: Potential risks to the fetus or infant exist.

Adverse Effects

Narcotic agonists can cause a range of side effects:

1. CNS Effects:

   • Light-headedness

   • Dizziness

   • Psychosis

   • Anxiety

   • Fear

   • Hallucinations

   • Pupil constriction (miosis)

   • Impaired cognitive function

2. Gastrointestinal Effects:

   • Nausea

   • Vomiting

   • Constipation

   • Bile duct spasm (biliary spasm)

3. Genitourinary Effects:

   • Ureter spasm (ureteral spasm)

   • Urinary retention

   • Hesitancy in urination

   • Reduced libido

4. Other Effects:

   • Sweating

   • Physical and psychological dependence

5. Narcotic-Induced Respiratory Depression:

   • Narcotics can suppress the respiratory center in the brain, leading to slowed and shallow breathing (respiratory depression), which can progress to cessation of breathing (apnea), cardiac arrest, and shock.

Interactions

Narcotic agonists can interact with other medications:

1. Barbiturates, phenothiazines, MAOIs: Increased risk of:

   • Respiratory depression

   • Low blood pressure (hypotension)

   • Excessive sedation or coma

2. SSRI, MAOI, TCA, St. John’s Wort: Increased risk of serotonin syndrome, a potentially life-threatening condition, if taken with tapentadol, a newer narcotic agonist that also inhibits norepinephrine reuptake.

3. Methylnaltrexone bromide (Relistor): Used to treat opioid-induced constipation in palliative care patients when standard laxatives are not effective.

Drugs Used as Narcotic Agonists

Other Narcotic Agonist Analgesic Drugs:

1. Methadone

2. Oxymorphone

3. Propoxyphene (Note: Propoxyphene is less commonly used and may have been removed from the market in some regions due to safety concerns)

4. Fentanyl

Short Notes about Morphine

Morphine is recognized as the ‘gold standard’ opioid analgesic, serving as the reference point for assessing other opioid pain medications.

When used appropriately for pain management:

• Dependence is infrequent.

• Tolerance is uncommon.

• Significant breathing suppression is usually avoidable.

The appropriate morphine dose is the one that provides effective pain control:

• There is no fixed upper limit to the dose.

• The optimal dose is the lowest amount that manages pain without causing unmanageable side effects.

• Dosage increases should be gradual and tailored to the individual.

Dosage of Morphine

Morphine’s pain-relieving effects do not exhibit a ceiling effect, meaning its analgesic effectiveness continues to increase with higher doses.

There is no standard dosage for chronic pain management in conditions such as cancer and HIV/AIDS. The dose must be individualized and carefully adjusted (titrated) for each patient.

The effective dose is the one that successfully controls pain while keeping side effects to a tolerable level.

Dosage requirements are affected by:

• Pain intensity

• Type of pain

• Individual variations in drug processing (pharmacokinetics)

• Development of tolerance

• Psychological and social factors influencing pain perception

Acute pain, postoperative pain:

• Oral: 5-20mg every 4 hours

• Subcutaneous (SC) or Intramuscular (IM) injection:

  • Adult: 10 mg every 4 hours as needed

  • Newborn: 150mcg/kg every 6 hours

  • Children:

    • 6-12 years: 5-10mg every 4 hours

    • 1-5 years: 2.5-5mg every 4 hours

    • 1 month – 12 months: 200mcg/kg every 6 hours

Chronic pain:

• Oral, SC, or IM:

  • Adult: 10-15mg every 4 hours initially. Dose may be adjusted based on individual response.

  • Children:

    • 2-12 years: Starting at 200-500mcg/kg every 4 hours, adjusted based on response

    • 1-2 years: Starting at 200-400mcg/kg every 4 hours, adjusted based on response

    • 1-12 months: Starting at 80mcg/kg every 4 hours

Myocardial infarction (heart attack):

• Slow Intravenous (IV) injection (2mg/minute): 10mg initially, followed by an additional 5-10mg if needed.

• For elderly or weakened patients: Use half the standard dose.

Acute pulmonary edema (fluid in the lungs):

• Slow IV injection (2mg/minute): 5-10mg

Action of Morphine

Morphine produces its pain-relieving effects by acting on opioid receptors in the brain and spinal cord.

• Pain perception is altered through:

  • Direct effects on the spinal cord, modulating incoming pain signals from the body’s periphery.

  • Activation of descending inhibitory pathways from the brainstem and basal ganglia, which suppress pain signals.

• Morphine also influences the limbic system and higher brain regions, modifying the emotional reaction to pain.

• Systemic effects, including those on the digestive and respiratory systems, are partly controlled centrally via the autonomic nervous system and partly due to direct actions on opioid receptors in peripheral tissues.

Indications

Morphine is indicated for:

1. Management of post-operative pain

2. Pain associated with myocardial infarction

3. Premedication before surgical procedures

4. Management of severe pain of various origins

5. Pain crises related to sickle cell disease

6. Acute pulmonary edema

7. Chronic pain, particularly cancer-related pain

Common Side Effects

Common side effects of morphine include:

1. Constipation: Routine prescription of a laxative is recommended with morphine use (unless diarrhea is present), e.g., Bisacodyl 5mg at night, increasing to 15mg if needed.

2. Nausea and vomiting: If these occur, anti-emetic medications can be administered, e.g., metoclopramide (Plasil) 10mg every 8 hours.

3. Drowsiness: Often experienced in the initial days of morphine therapy. If it persists beyond three days, a dose reduction may be considered.

4. Itching (pruritus): Less common, but if it occurs, a dose adjustment may be warranted.

Contraindication

Morphine should be administered with caution or avoided in patients with:

1. Renal impairment: May affect drug elimination.

2. Severe hepatic dysfunction: May affect drug metabolism.

3. Significant lung disease (including acute or severe bronchial asthma): Due to the risk of respiratory depression.

4. CNS depression from any cause: Can be worsened by morphine’s CNS depressant effects.

5. Elderly and frail patients: Initiate treatment with lower doses due to increased sensitivity to side effects.

Dose Titration and Administration

Titrating Oral Morphine to Other Formulations:

• Adjust the regular oral dose over several days to achieve adequate pain relief.

• Calculate the total daily dose and any breakthrough doses administered in a 24-hour period.

• Increase the 4-hourly dose by adding the breakthrough dose to the regular daily dose and dividing by 6, or increase by 30-50% increments (e.g., 5mg -> 10mg -> 15mg every 4 hours). Increments smaller than 30% may be ineffective.

• If swallowing is difficult, consider alternative routes of administration:

  • Rectal

  • Subcutaneous

  • Buccal (inside the cheek)

  • Intravenous

  • Enteral route via gastrostomy tube (if applicable)

• Conversion ratios:

  • Oral to subcutaneous morphine ratio is approximately 2:1 (e.g., 10mg oral is equivalent to 5mg subcutaneous).

  • Oral to intravenous morphine ratio is approximately 2-3:1 (e.g., 30mg oral is equivalent to 10mg intravenous).

Morphine Formulations:

• Available in immediate-release and slow-release oral forms.

• Once pain is well-managed, transition to slow-release morphine, dividing the total 24-hour dose into two doses given twice daily.

Useful Tips When Using Morphine:

1. Buccal and rectal absorption: Oral morphine can be absorbed through the mucous membranes in the mouth or rectum, allowing administration of small amounts even in patients who are unconscious.

2. Breakthrough pain management: Patients taking regular oral morphine may experience breakthrough pain. An additional dose of oral morphine can be given to manage this. Frequent breakthrough doses may indicate a need to increase the regular 4-hourly dose.

3. Prioritize pain control: Effective pain management is essential before addressing other medical or psychosocial issues. Meaningful discussions about psychosocial concerns are difficult if pain is not adequately controlled.

4. Psychosocial factors in pain: Pain can be caused or exacerbated by psychosocial factors. Addressing these factors is crucial for effective pain control. Analgesia alone may not be sufficient if psychosocial or spiritual problems are contributing to the pain experience.

5. Long-term use for chronic pain: Oral morphine is effective for chronic severe pain and can be used long-term. Doses can be adjusted upwards as needed; some patients may require very high doses for adequate pain control.

6. Dose reduction after pain stimulus removal: If the cause of pain resolves, the morphine dose should be gradually reduced to minimize withdrawal effects.

7. Short-term analgesia without addiction: Opioids can be used for short-term pain relief in conditions like AIDS-related infections (e.g., cryptococcal meningitis), sickle cell crises, burns, and other painful conditions without necessarily causing addiction in these situations.

Narcotic Agonists-Antagonists

These drugs have a mixed effect, stimulating some opioid receptors while blocking others.

Narcotic Agonists-Antagonists

These medications function by both stimulating certain opioid receptors and blocking others.

Therapeutic Action

The intended therapeutic effect of narcotic agonist-antagonists is achieved because they:

• Activate specific opioid receptors while simultaneously blocking other types of opioid receptors.

• Present a lower risk of misuse compared to pure narcotic agonists.

• Can produce pain relief similar to morphine.

Indications

Narcotic agonist-antagonists are prescribed for:

1. Managing moderate to severe pain, including use as pre-anesthetic medication and as a supplement during surgical anesthesia.

2. May be considered for chronic pain management in individuals with a potential for narcotic dependence.

Considerations for Different Age Groups:

Children

• Safety and efficacy in children are not well-defined.

• Buprenorphine is a narcotic agonist-antagonist that can be used in children over 13 years old.

• Naloxone serves as the antidote for narcotic overdose and to reverse narcotic effects.

Adults

• It is crucial to inform and reassure adults that the risk of addiction with prescribed narcotics for acute pain is minimal.

• Patient education should emphasize requesting pain relief before pain becomes severe.

• Caution is advised for pregnant and breastfeeding women due to potential risks to the developing fetus or infant.

Older Adults

• Older adults are more susceptible to adverse drug reactions due to age and potential co-existing health issues.

• Implementation of safety measures is important (e.g., bed rails, accessible call light, assistance with movement).

Contraindications and Cautions

Narcotic agonist-antagonists should be used cautiously or avoided in the following situations:

1. Allergy to narcotic agonist-antagonists to prevent hypersensitivity reactions.

2. Pre-existing physical dependence on narcotics: May trigger withdrawal symptoms.

3. Chronic Obstructive Pulmonary Disease (COPD) or other respiratory issues: Respiratory depression could be worsened.

4. Myocardial Infarction (MI), Coronary Artery Disease (CAD), or hypertension: Cardiac stimulation could exacerbate these conditions.

5. Kidney or liver dysfunction: May affect drug processing and elimination from the body.

6. Pregnancy and breastfeeding: Potential risks to the fetus or infant.

7. Nalbuphine is specifically contraindicated in patients with sulfite allergies due to potential cross-reactivity.

Interactions

Drug-drug interactions to be aware of with narcotic agonist-antagonists:

1. Barbiturates, phenothiazines, MAOIs: Increased likelihood of respiratory depression, low blood pressure (hypotension), and excessive sedation or coma.

2. Tripelennamine: May enhance hallucinogenic and euphoric effects when combined with pentazocine (“Ts and Blues”).

3. Methylnaltrexone bromide (Relistor): Used to manage opioid-induced constipation in palliative care patients when standard laxatives are no longer effective.

Types of Drugs: Narcotic Agonist-Antagonists

Nursing Considerations for Narcotic Agonists and Agonist-Antagonists

Nursing Assessment

Essential nursing assessments include:

1. Assess for contraindications and cautions (e.g., allergies, respiratory issues, heart conditions, liver or kidney problems) to prevent potential complications.

2. Conduct a thorough pain assessment to establish a baseline and monitor the effectiveness of treatment.

3. Perform a comprehensive physical examination (including CNS, vital signs, bowel sounds, urine output) to establish baseline status, evaluate drug efficacy, and detect any adverse effects.

4. Review laboratory results (liver and kidney function tests) to determine if dose adjustments are needed and to identify potential drug toxicity.

Nursing Diagnoses

Potential nursing diagnoses related to narcotic agonists and agonist-antagonists include:

1. Impaired gas exchange related to respiratory depression

2. Disturbed sensory perception related to CNS effects

3. Constipation related to gastrointestinal effects

4. Risk for injury related to CNS effects

Implementation with Rationale

Key nursing interventions and their rationales:

1. Regular pain assessments: To track drug effectiveness and adjust pain management strategies as needed.

2. Availability of narcotic antagonists and ventilation support: Essential when administering IV narcotics to manage severe reactions promptly.

3. Monitor timing of doses: Timely administration can optimize pain relief and promote quicker pain resolution.

4. Employ non-pharmacological pain relief measures: Techniques like breathing exercises, massage, and stress reduction can enhance drug effectiveness and reduce overall pain.

5. Provide comfort measures: Address side effects like GI upset with small meals to improve patient tolerance.

6. Implement safety precautions: Ensure adequate lighting, use bed rails to prevent falls and injuries.

7. Patient education: Educate patients about their medication to enhance understanding and adherence to therapy.

Evaluation

Evaluation of care should include:

1. Monitoring the patient’s response to therapy (pain relief, level of sedation).

2. Monitoring for adverse effects (e.g., GI issues, respiratory depression, heart rhythm problems).

3. Assessing patient’s understanding of their medication by asking them to name the drug, its purpose, and potential side effects.

4. Monitoring patient adherence to the prescribed medication regimen.

Narcotic Antagonists

These agents bind strongly to opioid receptors but do not trigger receptor activation. They effectively block opioid effects, including those resulting from excessive opioid levels in the body.

Therapeutic Action

The desired therapeutic action of narcotic antagonists is:

• To act as receptor blockers by binding strongly to opioid receptors without activating them.

• To reverse the effects of opioids, such as respiratory depression and sedation, by blocking opioid receptors.

Indications

Narcotic antagonists are indicated for:

1. Complete or partial reversal of narcotic-induced respiratory depression.

2. Diagnosis of suspected opioid overdose.

Considerations for Different Age Groups:

Children

1. Safety and efficacy in children are not fully established.

2. Naloxone is the primary antidote used to reverse narcotic overdose and effects.

Adults

1. Patients should be informed and reassured that addiction is not a concern in the context of using narcotics for acute pain under medical supervision. (Note: this point seems less relevant for antagonists which are not used for pain management but for overdose reversal)

2. Education should include the importance of seeking timely pain relief (Note: also less relevant for antagonists).

3. Caution is advised for pregnant and breastfeeding women due to potential effects on the fetus or infant.

Older Adults

1. Older adults are more vulnerable to adverse drug effects due to age and potential underlying health conditions.

2. Safety measures are important (e.g., bed rails, accessible call light, assistance with ambulation).

Contraindications and Cautions

Narcotic antagonists should be used cautiously or avoided in:

1. Allergy to narcotic antagonists to prevent hypersensitivity reactions.

2. Pregnancy and breastfeeding: Potential risks to the fetus and infant.

3. Narcotic addiction: May precipitate opioid withdrawal symptoms.

4. Cardiovascular (CV) disease: Reversal of opioid effects may strain the cardiovascular system.

Adverse Effects

Adverse effects associated with narcotic antagonists may include:

1. CNS Effects:

   • Excitement or agitation

   • Reversal of pain relief (analgesia)

2. Cardiovascular Effects:

   • Rapid heart rate (tachycardia)

   • Changes in blood pressure

   • Irregular heart rhythms (dysrhythmias)

   • Pulmonary edema

3. Acute Narcotic Abstinence Syndrome: In opioid-dependent individuals, this can manifest as:

   • Nausea and vomiting

   • Sweating

   • Rapid heart rate

   • High blood pressure (hypertension)

   • Tremors

   • Anxiety

   • A naloxone challenge may be performed before naltrexone administration to assess withdrawal risk.

Interactions

Generally, there are no significant drug-drug interactions associated with narcotic antagonists

Types of Drugs: Narcotic Antagonists

Nursing Considerations

Nursing Assessment

Essential nursing assessments before and during narcotic antagonist use:

1. Evaluate for contraindications and cautions such as known drug allergies, history of narcotic addiction, or existing myocardial infarction to minimize risks and prevent adverse reactions.

2. Assess pain level to establish a baseline and to evaluate the patient’s response to therapy, though pain assessment is less relevant when antagonists are used for overdose reversal rather than pain management.

3. Conduct a thorough physical assessment, focusing on neurological status (level of consciousness), respiratory rate and rhythm, and vital signs to establish a pre-treatment baseline, monitor drug effectiveness, and identify potential adverse effects.

4. Obtain an electrocardiogram (ECG), if indicated, to assess for pre-existing cardiac conditions and to monitor for any cardiac effects related to drug administration or withdrawal.

Nursing Diagnoses

Potential nursing diagnoses associated with narcotic antagonist use may include:

1. Decreased Cardiac Output related to potential cardiovascular effects of narcotic antagonists or opioid withdrawal.

2. Acute Pain related to opioid withdrawal or the abrupt reversal of analgesia.

3. Risk for Injury related to CNS effects such as agitation or seizures during withdrawal.

Implementation with Rationale

Key nursing interventions for patients receiving narcotic antagonists:

1. Maintain a Patent Airway and Support Ventilation: Rationale: To ensure adequate oxygenation and prevent respiratory compromise, especially in cases of overdose reversal. Be prepared to provide artificial ventilation and cardiac massage if needed.

2. Administer Vasopressors as Prescribed: Rationale: To manage hypotension that may occur due to narcotic overdose or antagonist administration. Vasopressors help to elevate blood pressure and maintain hemodynamic stability.

3. Administer Naloxone Challenge Before Naltrexone: Rationale: To assess the patient’s opioid dependence level and minimize the risk of severe withdrawal. A small dose of naloxone helps determine if naltrexone will precipitate acute withdrawal.

4. Provide Comfort Measures: Rationale: To alleviate symptoms of withdrawal syndrome, such as nausea, vomiting, and anxiety. Comfort measures include a calm environment, antiemetics, and reassurance.

5. Implement Safety Precautions: Rationale: To protect patients from injury due to CNS effects like agitation, confusion, or seizures that can occur during withdrawal. Safety measures include adequate lighting, raised side rails, and close monitoring.

6. Ensure Opioid-Free Period Before Naltrexone: Rationale: To prevent severe withdrawal syndrome. Naltrexone should only be administered after patients have been opioid-free for 7-10 days to reduce the risk of precipitating acute withdrawal.

7. Educate the Client on Drug Therapy: Rationale: To promote understanding of the medication’s purpose, dosage, and potential side effects, enhancing adherence and enabling informed participation in their care.

Evaluation

Aspects of care to evaluate for effectiveness of narcotic antagonist therapy:

1. Monitor Patient Response: Assess for reversal of opioid effects, such as improved respiratory rate and level of consciousness, or in the context of alcohol dependence, monitor progress in treatment.

2. Monitor for Adverse Effects: Evaluate for cardiovascular changes (e.g., arrhythmias, hypertension), and signs of acute withdrawal syndrome.

3. Assess Patient Understanding: Verify patient’s understanding of the medication, its purpose, and potential adverse effects by asking them to reiterate key information.

4. Monitor Patient Compliance: Assess the patient’s adherence to the prescribed medication regimen, particularly in long-term management scenarios like alcohol or opioid dependence treatment.

Opioid Infusion Administration Considerations

Key points for safe and effective opioid infusion administration:

1. Loading Dose: Administer a loading dose at the start of the infusion, unless a recent opioid dose has been given, to rapidly achieve therapeutic plasma levels.
2. Bolus Dosing for Rapid Relief: For quick pain relief or in anticipation of pain, ensure the prescribed bolus dose is administered.
3. Infusion Rate Adjustment: The infusion rate can be adjusted by nursing staff within the prescribed range, based on the patient’s reported pain level.
4. Time to Steady State: It takes approximately four half-lives to reach a stable plasma concentration during continuous infusion (e.g., about 8 hours for morphine/hydromorphone, and around 1.5 hours for fentanyl). If an increase in the infusion rate is needed, a bolus dose should also be given to quickly reach the new therapeutic level.
5. Bolus Frequency as Indicator for Rate Increase: Ideally, the infusion rate should only be increased if the patient requires 3 or more bolus doses within a single hour, suggesting inadequate pain control at the current infusion rate.
6. Hourly Volume and Rate Verification: The infused volume should be checked every hour, and the infusion rate should be verified and documented on the fluid balance chart to ensure accurate administration and monitoring.