What are the nurses responsibilities when administering an opioid analgesic?

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Department: MEDICATION ERRORS: 10 TIPS ON SAFE OPIOID ADMINISTRATION

10 TIPS ON SAFE OPIOID ADMINISTRATION

COHEN, MICHAEL R. RPH, MS, ScD

Author Information

President of the Institute for Safe Medication Practices

The reports described in Medication Errors were received through the USP-ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices [ISMP] at //www.ismp.org or the United States Pharmacopeia [USP] at //www.usp.org. You can also call ISMP at 1-800-FAIL SAFE or send an e-mail message to [email protected]. Michael R. Cohen is a member of the Nursing2007 editorial advisory board.

Nursing 37[5]:p 14, May 2007. | DOI: 10.1097/01.NURSE.0000268748.58433.6a

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In Brief

Matching drug to disease … topical medication given I.V. … 10 tips for safe opioid administration

© 2007 Lippincott Williams & Wilkins, Inc.

Opioids are powerful analgesics that are derived from the opium poppy plant. They are recognised as central in the management of acute pain and cancer pain, but concerns about long-term use have resulted in recommendations that they should be used with caution in the management of chronic pain. Opioids have associated side effects and risks, but these may be exaggerated and some healthcare professionals can be unnecessarily cautious and withhold the use of opioids, even in cases where these medicines may be beneficial. It is important that nurses understand the pharmacology, side effects and risks of opioids, so they can ensure these medicines are administered safely.

Nursing Standard. doi: 10.7748/ns.2020.e11534

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@angelatelford12

Correspondence

Angela.telford1@nhs.net

Conflict of interest

None declared

Telford A [2020] Role of the nurse in supporting the safe use of opioids. Nursing Standard. doi: 10.7748/ns.2020.e11534

On 1 April 2016 the statutory patient safety functions previously delivered by NHS England transferred with the national patient safety team to NHS Improvement

Opioid analgesia is indicated for the treatment of moderate to severe pain. An opioid is a medication that relieves pain by binding to opioid receptors in the central nervous system spinal cord and peripheral nervous system. This guideline does not cover opioid delivery via patient controlled analgesia [PCA] delivery.

Aim

To provide medical and nursing staff at the Royal Children’s Hospital with a clear outline for assessment and management of a patient receiving opioids as an inpatient, including administration and adverse events associated with administration. 

Definition of Terms

• Authorised persons: Nurse or medical staff registered to administer opioids
  
• CPMS: Children’s Pain Management Service [acute pain]
  
• Duration of action: Time the drug action lasts at an effective concentration
• Half-life: Time it takes for the medication to reduce by 50% in the plasma level
  
• IV: Intravenous
  
• Miosis: Excessive constriction of the pupil of the eye
  
• Myoclonus: Spasmodic jerky contraction of groups of muscles
  
• Opioid agonist: A medication with maximal physiological effect at the opioid receptors e.g. morphine
  
• Opioid antagonist: A medication that occupies the opioid receptors but has no physiological action e.g. naloxone 
• SC: Subcutaneous
  
• Tremor: Involuntary contraction or twitching of one or more body parts
  
• VPPCP: Victorian Paediatric Palliative Care Program

Pharmacology

There are three main types of opioid receptors, these receptors have multiple actions:
Mu [m] receptors are primarily responsible for analgesia and side effects of opioids and are associated with analgesia and side effects [Table 1]. Side effects occur regardless of which opioid is used and are generally dose related. Mu receptors subtyped: mu-1 & mu-2.

• mu-1 receptor is primarily responsible for analgesia
  
• mu-2 receptor is primarily responsible for the opioid side effects

Delta [d] receptors are involved with modulation of mu receptors. Primarily responsible for spinal analgesia
Kappa [k] receptors are associated with miosis, spinal analgesia and sedation

Opioids are metabolised in the liver and excreted via the kidneys. Morphine is the most commonly used opioid of choice, and has two main metabolites M3G and M6G. M3G [morphine -3 glucuronide] has no analgesic action, but can cause neurotoxic effects such as tremor and myoclonus. M6G [morphine – 6 – glucuronide] is a powerful analgesic.

Table 1: Side effects of opioids

Neurological

• Sedation
  
• Euphoria
  
• Dysphoria
  
• Agitation
  
• Miosis
  
• Respiratory Depression

Cardiovascular

• Bradycardia
  
• Vasodilation
  
• Hypotension
  
• Pruritus [itch] *

Gastrointestinal/Renal

• Nausea & Vomiting
  
• Constipation
  
• Delayed gastric emptying
  
• Reduced appetite
  
• Urinary retention

Musculoskeletal

• Muscle rigidity** chest wall [rare] Acute effect of IV fentanyl
  

*Fentanyl primarily on the face, Morphine generalised
**Acute effect of IV fentanyl

Table 2: List of opioid medications

 Opioid generic name Medication information Morphine

• Pure mu opioid agonist
  
• Varied formulations and release [oral suspension and tablet [IV/ SC]
  
• Metabolism primarily by the liver and excreted primarily by the kidneys. Metabolites may accumulate in patients receiving infusions or with renal impairment
  
• Onset of action 20 minutes
  
• Duration of action 60-90 minutes
  
• Half-life 2 hours
  

 Fentanyl

• Synthetic mu opioid agonist
  
• Intranasal/transdermal/IV/SC and SL
  
• Lipophilic drug therefore may result in accumulation
  
• Metabolised almost exclusively by liver, less than 10% un-metabolised  excreted by kidneys
  
• Onset of action immediate when given IV
  
• Duration of action 15mins
  
• Half-life 1.5 hours
  

 Hydromorphone

• Synthetic mu opioid
  
• Varied formulations [oral/IV/IM/SC]
  
• Metabolism almost exclusively by liver
  
• Excreted by kidneys
  
• The hydromorphone metabolite H3G may accumulate in patients receiving long-term hydromorphone infusions or patients with renal impairment. H3G can cause CNS disturbances [including confusion, tremor and agitation]
  
• Onset of action 5min
  
• Duration of action 20mins
  
• Half-life 2.5 hours
  

 Oxycodone

• Semisynthetic mu opioid agonist
  
• Oral suspension or tablet /IV/SC
  
• Oral oxycodone will have faster onset of action than that of oral morphine, better bioavailability and longer duration of action. Also has lower rate of adverse effects and fewer concerns about metabolites than morphine
  
• Metabolism by liver, excreted by kidneys
• Onset of action 10-15 minutes
  
• Duration of action 3-6 hours
  
• Half-life 2-4 hours
  

 Tramadol

• Synthetic serotonin and noradrenaline reuptake inhibitor, atypical centrally acting
• 70% active metabolite M1 30% mu opioid agonist effect
• Oral or IV
• Onset of action 30 minutes
• Duration of action 6 hours
• Half-life 5-7 hours

Assessment

Regular observations [Table 3] of patients are indicated during the time a patient receives an opioid infusion to monitor the efficacy of pain management. Pain assessment and measurement as per the clinical nursing guideline, and to recognise and prevent adverse effects such as sedation and respiratory depression. More frequent observations should be undertaken in patients receiving an administration of an opioid bolus

Note that observations for patients on long term opioids can be altered to reflect their tolerance and need for less interruption. This decision can be made by the treating team or CPMS and documented for the required observations

Pain Assessment 

Patients receiving opioid infusions in the high risk category [Table 5] are ideally admitted to a room that supports line of sight by nursing staff [e.g. close to the central desk in each pod]. Patients in Table 5 require continuous pulse oximetry for the duration of their opioid infusion due to their high risk of an adverse event. Effectiveness of the analgesia and any bolus administration should be recorded in the patient clinical observation and progress notes.
Infants 6 months or less who meet the criteria in Table 6 should be monitored following any surgical procedure for the first 24 hours of opioid therapy in intensive care. These patients are at higher risk due to the combination of opioid administration intraoperatively and post operatively, pain and splinting, fluid overload and risk of hypoventilation in the patient’s EMR progress notes

• Sedation nearly always precedes respiratory depression, therefore this is the most important observation as a clinical indicator
  
• Any observations that transgresses the yellow zone VICTOR chart criteria should be reported to the treating team and CPMS [observations that transgress red zone MET criteria should constitute a MET call 22 22]
  
• Pain assessment and score to be documented as per Table 3 and Table 4
  

Table 3: Observations required for documentation for a patient receiving an opioid infusion 

• Sedation score, respiratory rate and heart rate: 
• Pulse oximetry: hourly for duration of opioid infusion
  1 hourly until the opioid infusion is ceased and then observations should be performed in conjunction with the Observation and Continuous Monitoring Guideline
  
• Pain score:
  1 hourly while awake
  
• Vomiting score:
  1 hourly for the first 12hrs, then 4 hourly as indicated
  

Table 4: Observations required for documentation for a patient following administration of a bolus

• Sedation score and Respiratory rate: every 5 minutes for 15 minutes and then return to routine observations.
  
• Pulse oximetry: if indicated and for all infants under 6 months of age
  
• Pain assessment Pain score prior to and following the bolus
  

Table 5: Patients considered at high risk of an adverse event

• Infants 6 months or less
• Ex-premature infants 
• Patients with a history of sleep apnoea or airway obstruction 
• Airway surgery e.g. tonsillectomy and/or adenoidectomy 
• Pre-existing respiratory co-morbidity e.g. recent RSV infection
• Patients with comorbidities including cerebral palsy, craniofacial disorders, muscular dystrophy or neurological conditions including neurosurgery or traumatic brain injury
• Concurrent use of sedatives or mucopolysaccarides 
• Renal impairment
  

Table 6: Criteria for post-operative monitoring in intensive care 

• Significant prematurity e.g.