A nurse is assessing a client after administering phenytoin IV bolus for a seizure
General High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error. **REMS Drug** Pronunciation: Trade Name(s) Ther. Class. opioid analgesics Pharm. Class. opioid agonists Controlled Substance Schedule: II Action Binds to opiate receptors in the
CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. Therapeutic Effect(s): Decrease in severity of pain. Absorption: Variably absorbed (about 30%) following oral administration. More reliably absorbed from rectal, subcut, and IM sites. Following epidural administration, systemic absorption and absorption into the intrathecal space via
the meninges occurs. Distribution: Widely distributed. Crosses the placenta; enters breast milk in small amounts. Protein Binding: Premature infants: <20%; Adults: 35%. Metabolism and Excretion: Mostly metabolized by the liver. Active metabolites excreted renally. Half-life: Premature neonates: 10–20 hr; Neonates: 7.6 hr; Infants 1–3 mo: 6.2 hr; Children 6 mo–2.5 yr: 2.9 hr; Children 3–6 yr: 1–2 hr; Children 6–19 yr with sickle cell disease:
1.3 hr; Adults: 2–4 hr. TIME/ACTION PROFILE (analgesia)
Contraindication/PrecautionsContraindicated in:
Use Cautiously in:
Adverse Reactions/Side EffectsCV: hypotension, bradycardia Derm: flushing, itching, sweating EENT: blurred vision, diplopia, miosis Endo: adrenal insufficiency GI: constipation, nausea, vomiting GU: urinary retention Neuro: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams Resp: RESPIRATORY DEPRESSION (including central sleep apnea and sleep-related hypoxemia) Misc: physical dependence, psychological dependence, tolerance * CAPITALS indicate life-threatening. InteractionsDrug-Drug
Drug-Natural Products: Concomitant use of kava-kava, valerian, or chamomile can ↑ CNS depression. Route/DosageLarger doses may be required during chronic therapy PO Rect: (Adults ≥50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients– 30 mg every 3–4 hr initially or once 24-hr opioid requirement is determined, convert to extended-release morphine by administering total daily oral morphine dose every 24 hr (as ER capsules), 50% of the total daily oral morphine dose every 12 hr (as MS Contin ), or 33% of the total daily oral morphine dose every 8 hr (as MS Contin ). See equianalgesic chart, equianalgesic dosing guidelines. Dose of ER capsules should not exceed 1600 mg/day because of fumaric acid in formulation. PO Rect: (Adults and Children <50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients– 0.3 mg/kg every 3–4 hr initially. PO (Children >1 mo): Prompt-release tablets and solution– 0.2–0.5 mg/kg every 4–6 hr as needed. Controlled-release tablet– 0.3–0.6 mg/kg every 12 hr. IM IV Subcut (Adults ≥50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients– 4–10 mg every 3–4 hr. MI– 8–15 mg, for very severe pain additional smaller doses may be given every 3–4 hr. IM IV Subcut (Adults and Children <50 kg): Usual starting dose for moderate to severe pain in opioid-naive patients– 0.05–0.2 mg/kg every 3–4 hr, maximum: 15 mg/dose. IM IV Subcut (Neonates): 0.05 mg/kg every 4–8 hr, maximum dose: 0.1 mg/kg. Use preservative-free formulation. IV Subcut (Adults): Continuous infusion– 0.8–10 mg/hr; may be preceded by a bolus of 15 mg (infusion rates vary greatly; up to 80 mg/hr have been used). IV Subcut (Children >1 mo): Continuous infusion, postoperative pain– 0.01–0.04 mg/kg/hr. Continuous infusion, sickle cell or cancer pain– 0.02–2.6 mg/kg/hr. IV (Neonates): Continuous infusion– 0.01–0.03 mg/kg/hr. Epidural: (Adults): Intermittent injection– 5 mg/day (initially); if relief is not obtained at 60 min, 1–2 mg increments may be made (total dose not to exceed 10 mg/day). Continuous infusion– 2–4 mg/24 hr; may ↑ by 1–2 mg/day (up to 30 mg/day). Epidural: (Children >1 mo): 0.03–0.05 mg/kg, maximum dose: 0.1 mg/kg or 5 mg/24 hr. Use preservative-free formulation. IT (Adults): 0.2–1 mg. Use preservative-free formulation. Availability (generic available)Immediate-release tablets: 15 mg, 30 mg Cost: Generic: 15 mg $22.17/100, 30 mg $37.77/100 Extended-release tablets (MS Contin): 15 mg, 30 mg, 60 mg, 100 mg, 200 mg Cost: Generic: 15 mg $167.57/100, 30 mg $317.19/100, 60 mg $532.39/100, 100 mg $763.63/100, 200 mg $1,838.19/100 Extended-release capsules: 10 mg, 20 mg, 30 mg, 45 mg, 50 mg, 60 mg, 75 mg, 80 mg, 90 mg, 100 mg, 120 mg Cost: 10 mg $609.60/100, 20 mg $673.20/100, 30 mg $606.31/100, 45 mg $898.99/100, 50 mg $1,224.00/100, 60 mg $1,465.20/100, 75 mg $1,498.31/100, 80 mg $1,951.20/100, 90 mg $1,770.29/100, 100 mg $2,407.20/100, 120 mg $2,088.66/100 Oral solution: 1 mg/mL , 10 mg/5 mL, 20 mg/5 mL, 5 mg/mL , 100 mg/5 mL Cost: Generic: 4 mg/mL $17.51/100 mL, 20 mg/mL $25.20/30 mL Rectal suppositories: 5 mg, 10 mg, 20 mg, 30 mg Cost: Generic: 5 mg $60.00/12, 10 mg $75.00/12, 20 mg $90.00/12, 30 mg $112.50/12 Solution for epidural, IV injection (preservative-free): 0.5 mg/mL, 1 mg/mL Solution for epidural or IT use (continuous microinfusion device; preservative-free): 10 mg/mL, 25 mg/mL Solution for IM, subcut, IV injection: 1 mg/mL, 2 mg/mL, 4 mg/mL, 5 mg/mL, 8 mg/mL, 10 mg/mL, 25 mg/mL, 50 mg/mL Solution for IV injection (PCA device): 1 mg/mL, 2 mg/mL, 3 mg/mL, 5 mg/mL Assessment
Lab Test Considerations: May ↑ plasma amylase and lipase levels. Toxicity and Overdose: If an opioid antagonist is required to reverse respiratory depression or coma, naloxone is the antidote. Dilute the 0.4-mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by IV push every 2 min. For children and adults weighing <40 kg, dilute 0.1 mg of naloxone in 10 mL of 0.9% NaCl for a concentration of 10 mcg/mL and administer 0.5 mcg/kg every 2 min. Titrate dose to avoid withdrawal, seizures, and severe pain. Implementation
IV Administration
Patient/Family Teaching
Evaluation/Desired Outcomes
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