Ward Storage

• All narcotics, with the exception of refrigerated narcotic infusion bags, must be stored in a double-locked compartment or an automated dispensing system.

• Keys for these locked storage areas must be managed by designated nursing unit staff, typically the ward in-charge. Keys should be:

  • Carried by authorized personnel at all times during their shift.

  • Alternatively, stored in an approved, secure lockbox.

  • A spare key should be held by the pharmacy for emergency access.

• In areas utilizing multiple narcotic keys, a key reconciliation process is mandatory at the end of each nursing shift. This reconciliation and its documentation must be recorded in Narcotic Drug (NCD) administration records.

• Ampoules must be clearly labeled and physically separated to prevent medication errors.

• In the event of lost or compromised keys, immediate lock and key replacement must be arranged through physical plant services to maintain security.

• A dedicated register book is required to track both narcotic stock поступления (in) and расход (out) on the ward.

• Empty ampoules must be carefully retained as a record of drug administration and potentially for inventory reconciliation purposes as per hospital policy.

• Strict adherence to the FEFO system is required for ward stock, and records must be maintained for two years, mirroring pharmacy practices.

• All narcotics received by and dispensed from nursing units must be meticulously documented. This documentation must be in the NCD administration record book or an equivalent automated dispensing system record, and include:

  • Patient’s full name.

  • Prescribing physician’s name.

  • Administered dose.

• Any narcotic wastage must be witnessed by a second authorized staff member. Both individuals must sign documentation confirming observed wastage directly into a designated sharps container on the unit.

• Narcotic counts are mandatory and must be performed at least once per nursing shift by two registered nurses. Any discrepancies that are not resolved before the end of the shift necessitate the completion of an incident report.

• A minor count variance of less than 5% specifically for oral narcotic solutions may be rectified through procedural correction without the immediate requirement of an incident report, as per facility policy. The Patient Services Manager is ultimately responsible for ensuring all discrepancies are resolved, all required signatures are obtained in the NCD administration book, and the completed book is returned to the pharmacy within two weeks of completion.

Key Considerations in Narcotic Storage

The primary responsibility for narcotic storage is typically divided: Pharmacy staff are responsible for central storage, while nursing staff assume responsibility for secure ward-level storage. Both groups are crucial in maintaining a controlled environment and limiting access to authorized personnel only. Nurses, in particular, must possess a thorough understanding of the regulations and guidelines governing narcotic storage and handling. Strict adherence to protocols is essential to uphold drug safety and efficacy. By implementing these best practices, healthcare professionals contribute to preventing drug diversion, misuse, and abuse, ensuring narcotics are used solely for their intended therapeutic purposes.

1. Secure Containment: Narcotics must be stored within a robust, locked cabinet or safe. Access should be strictly limited to authorized personnel. The storage location itself should be:

   • Secure and well-illuminated.

   • Located away from public areas to prevent unauthorized access.

   • Ideally situated near the nursing station on wards to facilitate closer monitoring and control.

2. Proper Identification: All narcotic medications must be clearly and accurately labeled. Labels must include:

   • Generic drug name.

   • Strength of the medication.

   • Total quantity in the container.

   • Lot number for traceability.

   • Expiration date to ensure use before expiry.

   • Labels must be legible and firmly affixed. Damaged or outdated labels must be promptly replaced.

3. Accurate Inventory Management: A precise and current inventory of all narcotics must be maintained at all times. This involves:

   • Regular inventory checks to physically verify stock levels.

   • Reconciliation of physical stock against recorded inventory to identify discrepancies.

   • Documentation of any discrepancies, losses, or incidents related to narcotic use or storage by nursing staff, as per policy.

4. Temperature and Humidity Control: Certain narcotics, such as fentanyl and hydromorphone, are especially sensitive to environmental conditions. They require storage in a cool, dry environment to prevent:

   • Degradation of the drug.

   • Loss of potency.

   • The storage area must be routinely monitored for temperature and humidity levels. Any deviations from recommended ranges must be reported and addressed immediately.

5. Restricted Access Protocols: Access to narcotic storage areas must be rigorously controlled and restricted. Authorization should be granted only to personnel who are:

   • Trained in proper narcotic handling procedures.

   • Officially approved to handle and administer these controlled substances.

   • Nursing staff must adhere to strict protocols for accessing and dispensing narcotics, including:

     • Verification of patient identity before administration.

     • Confirmation of prescription validity and dosage accuracy.

     • Thorough documentation of each narcotic administration event.

6. Proper Disposal Procedures: Narcotics that are expired, damaged, or no longer required for patient care must be disposed of in a manner that strictly adheres to:

   • Government regulations regarding controlled substance disposal.

   • Prescribed facility procedures for narcotic waste management.

Expired, Rejected, or Returned Class A Drugs

1. Unused, non-expired drugs should be returned to the original prescriber or dispensing pharmacy.

2. Drugs that are expired or rejected for any reason must be returned to the pharmacy in-charge. The pharmacist will then initiate contact with the Drug Inspector, as required by regulation.

3. Expired drugs must be destroyed under the direct supervision of the pharmacy in-charge, and this destruction must be witnessed by the Drug Inspector, ensuring compliance and accountability.

4. The destruction process must follow established WHO guidelines for pharmaceutical waste disposal, ensuring environmental and safety standards are met.

5. Detailed records of the destruction event must be meticulously recorded in the Class A drug register. This record must include:

   • Quantity of each drug destroyed.

   • Specific reason for destruction (e.g., expiry, rejection).

Importation of Class A Drugs

1. Manufacturing and wholesale of Class A drugs necessitate securing an annual import license from the relevant regulatory body.

2. Currently, the National Drug Authority (NDA) in this jurisdiction typically limits import licenses for narcotics to:

   • National Medical Stores (Government) – the primary government pharmaceutical procurement and distribution agency.

   • Joint Medical Stores (NGO) – a major non-governmental organization involved in healthcare supply chains.

3. Private retail pharmacies and hospitals generally access narcotics through these authorized importer agencies, rather than directly importing themselves.

Prescription Practices of Narcotics

This section outlines the process for legally ordering narcotics, typically involving a written order from a prescriber to a dispensing entity.

Ordering Narcotics from Pharmacy to Wards

• Within the pharmacy setting, the designated responsible individual is tasked with obtaining narcotic drugs from registered and authorized suppliers, complying with all ordering regulations.

• The pharmacist is responsible for maintaining comprehensive records of all narcotic drug entries (stock received) into the pharmacy, ensuring inventory control and accountability.

• Dispensing of narcotics is legally restricted to being performed only by a registered pharmacist or a licensed medical practitioner, ensuring professional oversight.

Ordering Narcotics on the Ward

• Given the high potential for misuse and abuse, the prescription of narcotics is legally restricted to registered medical practitioners (doctors).

• Physicians should only prescribe narcotics after a thorough evaluation has determined that non-opioid analgesics (NSAIDS) are insufficient to manage the patient’s pain, particularly in cases of severe pain following:

  • Surgery.

  • Cancer treatment.

  • Or other conditions causing intractable pain.

• The prescribing physician must generate a prescription in duplicate:

  • One copy is retained by the dispensing entity (pharmacy or ward stock).

  • The second copy is placed in the patient’s medical file for record-keeping.

• The prescription itself must be legibly written and contain all legally required information, including:

  • Full name and signature of the prescribing physician.

  • Name of the narcotic drug.

  • Patient’s full name for identification.

  • Route of administration (e.g., oral, IV, IM).

  • Duration of therapy, if applicable.

• Evidence of drug administration must be clearly documented. Typically, this is achieved by retaining empty ampoules in a designated manner as per hospital policy, providing physical confirmation of drug use.

• If a ward in-charge is authorized to place narcotic orders from ward stock, they must personally sign the order documentation, assuming accountability for the drug request.

• Upon collection of narcotics, ward staff must meticulously check the medication received against the order to ensure accuracy in drug, dose, and quantity.

• After verification, the nurse receiving the narcotics must sign the relevant documentation, formally acknowledging receipt and assuming responsibility for the controlled substances.

Prescription Authority

Legal authority to prescribe Class A drugs (narcotics) is typically limited to:

1. Registered medical doctors (physicians).

2. Registered dentists.

3. Registered veterinary surgeons (within their scope of practice).

4. In some jurisdictions, specially trained palliative care nurses or clinical officers may be granted limited prescribing authority, often within a structured palliative care program.

Prescription Form Requirements

Narcotic prescription forms are considered legal documents and must contain comprehensive details. Prescriptions are typically:

• Valid for a limited duration, often 14 days from the date of issue.

• Supply quantity is restricted, generally not to exceed a one-month supply based on prescribed dosage.

• Must be issued in duplicate to maintain records for both prescriber and dispenser.

Mandatory Prescription Information

Narcotic prescriptions must include the following key details:

1. Patient Demographics:

   • Full name.

   • Age.

   • Sex.

   • Complete address.

2. Total Dose Prescribed:

   • Must be clearly stated in both words and numerical figures to prevent ambiguity and potential errors.

3. Pharmaceutical Form:

   • Specify the required drug formulation, e.g., tablets, oral solution, injection.

4. Strength Specification:

   • Where applicable and to avoid confusion, clearly state the drug strength, e.g., “5mg per 5mL” or “50mg per 5mL” for oral morphine solutions.

Penalties for Unlawful Narcotic Possession

Under the relevant legislation, any individual found to be in unlawful possession of classified narcotic drugs is subject to significant penalties:

1. Financial Fine: A fine not exceeding a substantial amount, for example, 2 million Ugandan shillings (or equivalent in local currency).

2. Imprisonment: A term of imprisonment for a period not exceeding a specified duration, such as 2 years.

3. Combined Penalties: The court has the discretion to impose both a fine and imprisonment.

Important Legal Notes

1. Ongoing Legislative Review: Be aware that the National Drug Authority (NDA) statute and related drug control legislation may be under periodic review and amendment. It is important to stay updated on the current legal framework.

2. Pharmacists’ Council Establishment: The establishment of a Pharmacists’ Council (or equivalent professional regulatory body) often signifies increased professional oversight and regulatory enforcement within the pharmaceutical sector.

3. Narcotic Handling Guidelines: Specific guidelines for handling Class A drugs (narcotics) were established in 2001 (or relevant year of implementation in your jurisdiction). These guidelines provide detailed operational procedures for storage, dispensing, administration, and record-keeping, and must be adhered to by healthcare professionals.

Legal Implications of Narcotics: The Narcotic Drugs and Psychotropic Substances (Control) Act

The Narcotic Drugs and Psychotropic Substances (Control) Act, No. 3 of 2016 (or relevant legislation in your jurisdiction), carries significant legal implications for narcotics control.

• Criminalization of Drug-Related Offenses: The Act explicitly criminalizes various activities related to narcotics, including:

  • Possession of illicit narcotics.

  • Sale of narcotics outside legal frameworks.

  • Manufacture of illegal narcotics.

  • Trafficking of narcotics.

  • This criminalization applies to substances typically classified as narcotics, such as cocaine, heroin, and marijuana (to the extent they are legally defined as narcotics in your jurisdiction).

  • Individuals found guilty of these offenses are subject to severe legal penalties, which may include substantial imprisonment terms and significant financial fines.

• Establishment of the National Drug Authority (NDA): The Act formally establishes the National Drug Authority (NDA) (or equivalent regulatory agency). The NDA is vested with broad regulatory powers, primarily focused on controlled substances. Its responsibilities encompass:

  • Regulating the importation of controlled substances into the country.

  • Regulating the exportation of controlled substances.

  • Overseeing the distribution of controlled substances within the jurisdiction.

  • The NDA is empowered to issue licenses and permits that are legally required for:

    • Manufacturing narcotics.

    • Distributing narcotics.

    • Selling narcotics.

  • To ensure compliance with the Act and related regulations, the NDA has the authority to conduct inspections of facilities and operations involved in handling controlled substances.

• Legal Framework for Treatment and Rehabilitation: Recognizing the public health aspects of drug abuse, the Act establishes a legal framework to support:

  • Treatment programs for individuals struggling with substance use disorders.

  • Rehabilitation services aimed at helping individuals recover from addiction.

  • The Act mandates the development of a National Drug Policy, which outlines the government’s strategic approach to drug control and demand reduction.

  • It also establishes a National Drug Abuse Prevention and Control Program. The objectives of this program are to:

    • Prevent drug abuse through public health initiatives.

    • Promote public awareness regarding the dangers and harms associated with narcotic drug use.

• Specific Penalties for Offenses: The Act specifies stringent penalties to deter narcotic-related crimes. For example:

  • Possession of narcotic drugs can result in imprisonment for up to 10 years, a fine reaching up to 10 million Ugandan shillings (or equivalent), or both imprisonment and a fine.

  • Trafficking of narcotics, considered a more serious offense, carries even harsher penalties, potentially including life imprisonment, a very substantial fine (e.g., up to 20 billion Ugandan shillings), or both life imprisonment and a large fine.

In summary, the Narcotic Drugs and Psychotropic Substances (Control) Act, No. 3 of 2016 in Uganda is a comprehensive piece of legislation designed to:

• Combat drug abuse and illicit trafficking through strict criminal penalties and regulatory controls.

• Provide for the treatment and rehabilitation of individuals struggling with addiction, recognizing substance abuse as a public health issue.

It is imperative for all individuals within Uganda to understand the legal implications of narcotics as defined by this Act and to comply fully with its provisions to avoid facing severe legal repercussions.

Administration of Narcotics on the Ward

• Prescription Requirement: A valid doctor’s prescription is mandatory before any narcotic medication can be administered to a patient.

• Qualified Personnel for Administration: Narcotics must be administered by:

  • Qualified nursing staff (registered nurses, licensed practical nurses, etc.).

  • In training settings, 3rd-year nursing students may administer narcotics, but only under the direct supervision of a qualified staff member.

• Dual Signatory Documentation: Following administration, both the administering nurse and the supervising staff member (if applicable) must sign the narcotic register. This dual signature serves as a verification and accountability measure.

• Adherence to the 5 Rights of Medication Administration: Strict adherence to the “5 Rights” is paramount in narcotic administration to prevent medication errors:

  • Right Patient: Verify patient identity before administration.

  • Right Drug: Confirm the correct narcotic medication is selected.

  • Right Dose: Ensure the prescribed dose is accurate.

  • Right Route: Administer via the prescribed route (e.g., oral, IV, IM).

  • Right Time: Administer at the correct time interval as prescribed.

• Empty Ampoule Management: Empty ampoules from injectable narcotics must be collected and returned to the ward in-charge. This practice aids in inventory control and reconciliation.

• Management of Remnants: In the event of any remaining narcotic solution after dose preparation, it must be returned to the pharmacy for appropriate disposal and documentation, according to facility policy.

• Wastage Documentation: Any narcotic drug wastage (e.g., due to spillage, partial dose discarded) must be meticulously recorded in the narcotic register, and this wastage record must be signed by the nurse who performed the waste and a witness, as per protocol.

Precautions Regarding Narcotics

• Dispensing Restrictions: Narcotics must be dispensed only by a registered pharmacist or a licensed medical practitioner, reflecting their controlled status.

• Prohibition of Personal Use: Medical practitioners are strictly prohibited from obtaining or using narcotic drugs for personal use, ensuring ethical and legal compliance.

• Antidote Availability: It is essential to keep a readily available antidote for narcotic overdose, such as naloxone, in locations where narcotics are stored and administered, to manage potential adverse events.

• Prescription Requirement for Orders: All narcotic orders must originate from a doctor or authorized medical practitioner and must be issued using a prescribed, legally compliant prescription form.

• Legal Transportation: Transportation of narcotics must be conducted legally, adhering to all regulations regarding secure transport and documentation.

• Compliance with NDA Rules: All handling and management of narcotics must be in strict compliance with the rules and regulations set forth by the National Drug Authority (NDA) or the relevant regulatory body.

• Health Inspector Access: Health inspectors from regulatory bodies must be granted access to check narcotic records and to obtain drug samples for quality control and compliance monitoring.

• Import/Export Restrictions: Unauthorized export or import of narcotics is strictly prohibited. Legal trade in narcotics is restricted to licensed pharmacists and authorized drug shops operating within the legal framework.

NARCOTIC DRUG ABUSE

Narcotics, while highly effective for pain management, also possess properties that can lead to abuse, including euphoria, narcosis (drowsiness), tolerance, and dependence.

• Drug Abuse Defined: Drug abuse is characterized as the use of drugs for non-medical purposes or for personal gratification without a valid physician’s prescription, often leading to harmful consequences.

• Narcotic Abuse Specifically: Narcotic abuse refers to the misuse of narcotic drugs specifically to seek feelings of well-being or euphoria rather than for legitimate pain relief or other medically indicated purposes.

• Drug Dependence: Drug dependence is a complex state arising from the interaction between an individual and a drug. It is characterized by:

  • A compulsion or overwhelming drive to continue taking the drug.

  • Desire to experience pleasurable psychological effects associated with the drug.

  • In some cases, the motivation to use the drug is to avoid the onset of uncomfortable withdrawal symptoms.

• Drug Tolerance: Drug tolerance develops when repeated drug use leads to a reduced response to the drug over time. As tolerance increases, the individual requires higher doses of the drug to achieve the same initial effect. Tolerance is commonly associated with drugs that can cause dependence.

REASONS FOR NARCOTIC DRUG ABUSE AND DEPENDENCE

Factors contributing to narcotic drug abuse and dependence are multifaceted:

• Non-Medical Use for Social or Emotional Reasons: Intermittent use of drugs motivated by social factors or emotional coping mechanisms rather than medical necessity. Examples include using alcohol to relieve stress or escape from personal problems (escapism).

• Prolonged Continuous Use: Continuous, long-term use of a drug can gradually lead to dependence, even if initially used for legitimate reasons.

• Curiosity and Peer Influence: Curiosity about the drug’s effects and the desire for social acceptance within peer groups that engage in drug use can be significant factors. Individuals may be driven by a desire to experience the drug’s effects firsthand or to fit in with a particular social circle.

• Genetic Predisposition: Genetic factors can play a role in substance use disorders. Some individuals may have a family history of addiction or a genetic vulnerability that increases their susceptibility to drug dependence.

• Drug Availability and Accessibility: Easy access to drugs within a community or environment can significantly increase the likelihood of abuse. Increased availability reduces barriers to initiation and continued use.

• Work-Related Stress: High levels of work pressure and stress can be a contributing factor for some individuals, who may turn to narcotics or other substances as a maladaptive coping mechanism to manage job-related stress.

• Weak Legal Enforcement: Looser or poorly enforced drug laws can contribute to increased drug availability and reduced deterrence against drug use and trafficking.

• Irrational Drug Use Patterns: Irrational or inappropriate patterns of drug use, including self-medication without proper medical guidance, can increase the risk of abuse and dependence.

• Socioeconomic Factors: Poverty and chronic stress related to socioeconomic hardship can increase vulnerability to substance abuse as a means of coping with difficult life circumstances.

• Recreational Drug Seeking: Use of narcotics purely for recreational purposes, seeking euphoria or altered states of consciousness, is a direct pathway to potential abuse and dependence.

• Attention Deficit Hyperactivity Disorder (ADHD) in Children: While paradoxical, in some cases, individuals with untreated ADHD may be at a slightly increased risk of substance abuse later in life as they may self-medicate to manage symptoms. However, this is complex and requires careful interpretation.

• Peer Pressure: Strong peer pressure to engage in drug use, particularly during adolescence and young adulthood, can be a significant influence.

• Occupation-Related Factors: Certain occupations that involve high stress, long hours, or exposure to substance use subcultures may carry a higher risk of substance abuse.

Effects of Narcotics

The effects of narcotics, particularly when abused, are wide-ranging and can be detrimental:

• Addiction and Dependence: This is a complex cluster of behaviors associated with drug misuse, typically developing gradually with prolonged use and escalating dosages. Addiction has both:

  • Physical Dependence: Occurs when the body adapts to the presence of the narcotic. If drug use is abruptly stopped, withdrawal symptoms will manifest due to the body’s physiological readjustment.

  • Psychological Dependence: Characterized by a strong emotional or mental craving for the drug, driven by the desire for its subjective effects, even when the individual is aware of the associated risks.

• Tolerance: As described earlier, tolerance is a decreased responsiveness to the drug over time. This necessitates increasing the dosage to achieve the desired effect, escalating the risk of adverse consequences.

Specific Effects of Narcotic Abuse Include:

• Accidents: Impaired judgment, sedation, and slowed reaction times increase the risk of various accidents, including traffic accidents, falls, and workplace incidents.

• Cognitive Impairment: Chronic narcotic abuse can lead to cognitive deficits, affecting memory, attention, decision-making, and overall mental function.

• Seizures and Coma: In cases of severe overdose or toxicity, narcotics can induce seizures and progress to coma due to central nervous system depression.

• Opioid-Induced Hyperalgesia (OIH): Paradoxically, chronic opioid use can sometimes lead to increased sensitivity to pain, a condition known as OIH. This can complicate pain management efforts.

• Infection at Injection Sites: For individuals who inject narcotics, there is a significant risk of local infections at the injection site, ranging from minor skin infections to serious conditions like cellulitis or abscesses.

• Transmission of Bloodborne Infections: Sharing needles and injection equipment is a major route for the transmission of bloodborne infections such as HIV (Human Immunodeficiency Virus) and Hepatitis B and C (HBV, HCV) among injecting drug users.

• Constipation: Narcotics commonly cause gastrointestinal side effects, with constipation being a frequent and often persistent problem.

• Pneumonia: Respiratory depression associated with narcotic abuse can increase the risk of aspiration pneumonia, especially if consciousness is impaired.

SIGNS OF NARCOTIC DEPENDENCE

Observable signs that may indicate narcotic dependence:

• High Drug Consumption/Tolerance: Regularly ingesting large amounts of narcotics or demonstrating tolerance, needing increasing doses to achieve the same effect.

• Craving: Experiencing intense cravings or urges for the drug, indicating psychological dependence.

• Withdrawal Symptoms: Exhibiting withdrawal symptoms when drug use is reduced or stopped, confirming physical dependence.

• Physical Signs:

  • Shallow breathing (respiratory depression).

  • Constipation (chronic GI effect).

  • Nausea and vomiting (can be both a sign of use and withdrawal).

  • Small pupils (miosis), pinpoint pupils.

  • Slurred speech (intoxication effect).

• Behavioral Changes:

  • Reduced participation in recreational activities or hobbies, as drug seeking and use become prioritized.

  • Seeking analgesia even for minor discomfort (drug-seeking behavior).

  • Exhibiting sedation or euphoria inconsistent with their situation.

SIGNS OF WITHDRAWAL

Signs and symptoms of narcotic withdrawal, reflecting the body’s readjustment to the absence of the drug:

• Psychological/Emotional:

  • Anxiety and agitation or conversely, immobility and lethargy.

  • Intense craving for the narcotic.

• Respiratory: Tachypnea (rapid breathing).

• Gastrointestinal:

  • Diarrhea.

  • Abdominal cramps.

  • Yawning.

  • Runny nose (rhinorrhea).

  • Excessive salivation.

• Musculoskeletal: Muscle aches and pains.

  • Tremors (shaking).

• Autonomic:

  • Sweating (diaphoresis).

  • Dilated pupils (mydriasis), wide pupils.

• Appetite: Lack of appetite.

Intoxication Effects

Signs and symptoms of narcotic intoxication (acute drug effects):

• Mental Status Effects:

  • Euphoria (feeling of intense well-being).

  • Sedation and drowsiness.

  • Decreased anxiety.

  • Sense of tranquility and calmness.

  • Indifference to pain, particularly from mild to moderate stimuli, during mild-to-moderate intoxication.

  • Severe intoxication can lead to delirium (confusion, disorientation) and coma (unconsciousness).

• Physiological Effects:

  • Respiratory depression: Slowed and shallow breathing, which can occur even while the patient appears conscious and alert.

  • Alterations in temperature regulation: Disruption of the body’s ability to maintain normal temperature.

  • Hypovolemia: Can be both true hypovolemia (reduced blood volume) and relative hypovolemia (altered blood distribution), leading to hypotension (low blood pressure).

  • Miosis: Pupil constriction, resulting in pinpoint pupils.

  • Needle marks or soft tissue infections: In individuals who inject narcotics, evidence of injection use and potential injection-site complications.

  • Increased sphincter tone: Can lead to urinary retention due to tightening of the urinary sphincter muscle.

TREATMENT OF NARCOTIC OVERDOSE

• Emergency Presentation: A patient with narcotic overdose may present to the emergency department in an unconscious state, often exhibiting signs like constricted pupils and severely depressed respiration.

• Diagnostic Clues:

  • Collateral history from accompanying individuals can provide crucial information about potential drug use.

  • Urine drug testing can help confirm the presence of narcotics in the system.

• Naloxone Administration: The primary treatment for narcotic overdose is the administration of naloxone (Narcan), a narcotic antagonist.

  • Intravenous (IV) administration is the preferred route for rapid onset of action.

  • Naloxone reverses the effects of narcotics by competitively binding to opioid receptors and blocking opioid action.

  • Reversal typically occurs rapidly, within 1-5 minutes of IV naloxone administration.

  • In some cases of opioid dependence treatment, methadone may be used as a longer-acting opioid agonist for substitution therapy, but naloxone is the immediate reversal agent for overdose.

TREATMENT OF WITHDRAWAL SYMPTOMS

• Clonidine: Clonidine, an alpha-adrenergic agonist, is often used to alleviate certain withdrawal symptoms, particularly autonomic symptoms such as:

  • Excessive salivation.

  • Runny nose.

  • Sweating.

  • Muscle aches.

• Combined Clonidine and Naloxone for Detoxification: In some detoxification protocols, clonidine can be used in conjunction with naloxone.

  • Naloxone, in this context, is used as a long-acting narcotic antagonist to facilitate rapid opioid detoxification.

  • The combination aims to manage withdrawal symptoms while accelerating the process of opioid removal from the body.

• Narcotics Anonymous (NA) and Counseling: Narcotic abuse support groups like Narcotics Anonymous and individual or group counseling are crucial components of long-term recovery. These provide:

  • Peer support and shared experiences.

  • Coping strategies for managing cravings and triggers.

  • Psychological and emotional support throughout the recovery process.

PREVENTIVE MEASURES

Strategies to prevent narcotic drug abuse and dependence:

• Health Education for Patients: Educate patients about the risks associated with narcotics, including addiction, tolerance, and dependence. Emphasize the importance of using narcotics only as prescribed and under medical supervision.

• Strict Lock and Key Security: Maintain secure storage of narcotics, utilizing lock and key systems and restricted access to prevent diversion and unauthorized use.

• Patient Expression and Counseling: Encourage patients to openly express their feelings about pain and medication. Provide appropriate counseling and support to address underlying emotional or psychological factors that might contribute to drug-seeking behavior.

• Avoid Long-Term Narcotic Therapy: Whenever clinically feasible, avoid prescribing long-term narcotic therapy for chronic pain conditions. Explore alternative non-opioid pain management strategies to minimize the risk of dependence.

• Strict Patient Monitoring: Implement rigorous monitoring of patients who are prescribed narcotics, especially those at higher risk of abuse. Closely track prescription refills, assess for signs of drug-seeking behavior, and monitor for adverse effects or misuse.

Nursing Responsibilities During Narcotic Administration

Nurses play a critical role in the safe and responsible administration of narcotics:

• Legal and Regulatory Compliance: Recognize that narcotics are federally regulated substances. Nurses must adhere to all legal and institutional protocols for narcotic handling and documentation.

• Accurate Record-Keeping: Meticulously record all narcotic administration details in a dedicated narcotic inventory sheet or electronic system. This documentation must include:

  • Date and time of administration.

  • Client’s full name.

  • Specific type of narcotic drug administered.

  • Exact amount (dose) of drug used.

  • Nurse’s signature as accountability.

• Witnessed Wastage Documentation: If a narcotic dose requires wastage after being signed out (e.g., partial dose, spillage), the wastage procedure must be witnessed by a second authorized staff member. Both the administering nurse and the witness must sign the narcotic inventory sheet to document the wastage event.

• Availability of Narcotic Antagonists: Ensure that narcotic antagonists, such as naloxone, are readily available in areas where narcotics are administered. Naloxone is crucial for emergency management of respiratory depression.

• Allergy and Adverse Reaction Assessment: Assess patients for known allergies to narcotics and for any history of adverse reactions to narcotics experienced previously.

• Respiratory Disease Assessment: Assess for pre-existing respiratory diseases, such as asthma, which may increase the patient’s risk of respiratory depression from narcotics.

• Pain Assessment: Thoroughly assess the characteristics of the patient’s pain (location, intensity, type, etc.) and evaluate the effectiveness of pain medications that have been used previously.

• Baseline Vital Signs: Obtain and document baseline vital signs (respiratory rate, heart rate, blood pressure, oxygen saturation) before administering any narcotic medication.

• Adherence to Administration Guidelines: Administer narcotics strictly according to established guidelines, including correct dose, route, timing, and patient identification protocols.

• Ongoing Monitoring: Continuously monitor patients after narcotic administration, paying close attention to:

  • Vital signs.

  • Level of consciousness (LOC).

  • Pupillary response (pupil size and reaction to light).

  • Nausea and vomiting.

  • Bowel function (monitor for constipation).

  • Urinary function (monitor for urinary retention).

  • Effectiveness of pain management – is the narcotic providing adequate pain relief?

• Patient Education on Non-Pharmacological Pain Management: Teach patients non-invasive pain management techniques (e.g., relaxation exercises, heat/cold therapy, positioning) for use in conjunction with narcotic analgesics. This strategy aims to reduce reliance on narcotics and prevent overuse.

Client and Family Teaching

Provide essential education to patients and their families regarding narcotic use:

• Addiction Risk in Pain Management: Reassure patients that using narcotics to treat severe pain, as prescribed, is unlikely to cause addiction when used appropriately and under medical supervision.

• Avoid Alcohol Consumption: Emphasize the importance of avoiding alcohol while taking narcotics, as alcohol can potentiate the sedative and respiratory depressant effects of narcotics.

• Caution with Over-the-Counter Medications: Instruct patients to avoid taking any over-the-counter (OTC) medications unless specifically approved by their healthcare provider, as some OTC drugs can interact with narcotics.

• Increase Fluid and Fiber Intake: Advise patients to increase their intake of fluids and dietary fiber to prevent or manage constipation, a common side effect of narcotics.

• Potential for Dizziness, Drowsiness, Impaired Thinking: Warn patients that narcotics can cause dizziness, drowsiness, and impaired thinking. Advise caution when driving or making important decisions until they understand how the medication affects them.

• Report Decreasing Effectiveness or Side Effects: Instruct patients to report any decreasing effectiveness of the narcotic in pain relief or the appearance of any concerning side effects to their physician promptly.

Treatment is a Multistage Process for Narcotic Abuse/Dependence

Treatment for narcotic abuse and dependence is typically a comprehensive, multistage process:

1. Assessment: Thoroughly assess the patient’s substance use using standardized screening tools. The WHO’s CAGE questionnaire (Cut down, Annoyed, Guilty, Eye-opener) is a common screening tool for substance use disorders.

2. Detoxification: The primary goal of detoxification is to safely manage withdrawal symptoms and remove the narcotic from the body.

   • Patient Motivation: Patient motivation and willingness to engage in treatment are crucial for successful detoxification. Help patients understand and appreciate the disadvantages of ongoing substance use.

   • Medications for Detoxification: Medications may be used to manage withdrawal symptoms. Examples include:

     • Chlordiazepoxide (a benzodiazepine) at a starting dose of 25mg three times a day or alternatives like diazepam or haloperidol (in appropriate dosages).

     • Carbamazepine (an anticonvulsant) may be used to help prevent seizures or convulsions during withdrawal, typically at a dose of 200-400mg twice daily (b.d.).

     • Vitamin supplementation: Vitamin B complex or multivitamins are often administered to address nutritional deficiencies common in substance abusers.

3. Motivational Counseling: Motivational interviewing and counseling are essential to:

   • Increase patient awareness that they have a substance use problem.

   • Collaboratively identify the underlying causes of the substance use problem with the patient.

   • Work to eliminate or address these underlying causes if possible.

   • Help the person develop effective problem-solving skills to cope with triggers and challenges without resorting to substance use.

4. Relapse Prevention: Strategies to prevent relapse are crucial for long-term recovery:

   • Monitor for behavioral changes: Be vigilant for any changes in behavior that might indicate a potential relapse.

   • Recognize craving signs: Be alert to any signs of craving for the substance, which may precede relapse.

   • Restrict substance access: Ensure the client does not have access to the substance during treatment and early recovery.

5. Rehabilitation: Focus on restoring overall health and function:

   • Treat any medical complications that have arisen as a result of substance abuse.

   • Provide proper nutrition, with an emphasis on protein-rich foods, to aid in repairing damaged tissues and restoring nutritional balance.

6. Social Reintegration: Facilitate the patient’s return to a healthy social life:

   • Encourage community or social support: Emphasize the importance of support from friends, family, and community networks in recovery.

   • Alcoholics Anonymous (AA) or Supportive Groups: Encourage the client to join support groups like Alcoholics Anonymous or Narcotics Anonymous, or other relevant peer support groups.

7. Group Therapy and Counseling: Utilize group settings for therapeutic benefit:

   • Manage Difficult Emotions: Help clients learn to manage challenging feelings and difficult situations without resorting to substance use.

   • Assertiveness Training: Encourage the client to develop assertiveness skills to effectively communicate needs and boundaries.

   • Relaxation and Leisure Techniques: Identify and teach relaxation techniques and strategies for healthy use of leisure time as alternatives to substance use.

   • Substance Abuse Education: Present educational materials that clearly explain the negative consequences of substance abuse and its harmful effects on the body and mind.

8. Vocational Rehabilitation: Assist with occupational aspects of recovery:

   • Vocational Training: Train the client in simple, practical activities that can help them stay busy, develop skills, and potentially earn income, promoting self-sufficiency and structure.

9. Health Education: Ongoing health education is vital for sustained recovery:

   • Create Awareness of Dangers: Raise awareness about the dangers of substance abuse and its long-term consequences.

   • Encourage Effective Coping Mechanisms: Promote the development of healthy and effective coping mechanisms for stress and emotional challenges, instead of relying on substance use.

   • Medication Adherence: Emphasize the importance of taking medications as prescribed for any co-occurring mental health conditions or medical issues.

   • Open Communication: Encourage the client to share their feelings and problems with supportive individuals rather than isolating themselves or resorting to substance use as a coping strategy.