Name of the Narcotic Drugs
- Opium
- morphine
- Codeine
1.Opium
| Opium |
| Availability oral liquid: Schedule II 118mL/bottle Each mL contains 10 mg of anhydrous morphine |
| Indications and dosages Diarrhoea 6 mg (0.6 mL) PO q6hr; not to exceed 6 mL/day |
Mechanism of Action
Opium, because of its morphine content, inhibits GI motility and propulsion, diminishes digestive secretion; increases GI muscle tone
Pharmacokinetics
- Absorption: Well, absorbed from the gastrointestinal tract
- Metabolism: Extensively metabolized in liver, undergoes conjugation with glucuronic acid
- Excretion: Urine (~75% [unchanged])
Contraindications
Hypersensitivity
Respiratory disease/depression, diarrhea due to poison (until toxic material eliminated from the GI tract), pseudomembranous colitis
2.Morphine
| Morphine |
| Availability morphine hydrochloride Rectal suppositories: 20 mg, 30 mg Syrup: 1 mg/ml, 5 mg/ml, 10 mg/ml, 20 mg/ml, 50 mg/ml Tablets: 10 mg, 20 mg, 40 mg, 60 mg morphine sulfate Capsules: 15 mg, 30 mg Capsules (extended release): 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 90 mg, 100 mg, 120 mg, 200 mg Capsules (sustained release): 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 100 mg Oral solution: 2 mg/ml, 4 mg/ml, 20 mg/ml (concentrate), 10 mg/5 ml, 20 mg/5 ml, 100 mg/5 ml Rectal suppositories: 5 mg, 10 mg, 20 mg, 30 mg Solution for epidural injection (extended-release, liposomal): 10 mg/ml, 15 mg/1.5 ml, 20 mg/2-ml vials Solution for epidural or intrathecal use (preservative free, for continuous micro infusion device): 10 mg/ml and 25 mg/ml in 20-ml vials Solution for epidural or I.V. injection (preservative-free): 0.5 mg/ml, 1 mg/ml Solution for I.M., I.V., or subcutaneous injection: 1 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml, 10 mg/ml, 15 mg/ ml, 25 mg/ml, 50 mg/ml Solution for I.V. injection (for patient-controlled analgesia [PCA] device): 1 mg/ml, 2 mg/ml, 3 mg/ml, 5 mg/ml Tablets: 15 mg, 30 mg Tablets (controlled-release, sustained release): 15 mg, 30 mg, 60 mg, 100 mg, 200 mg Tablets (soluble): 10 mg, 15 mg, 30 mg |
| Indications and dosages ➣ Severe to moderate pain Oral use— Adults: 5 to 30 mg P.O. (immediate release) q 4 hours p.r.n. Or 20 mg P.O. (controlled-release, Kadian) once or twice daily p.r.n. Or 200 mg P.O. (MS Contin) in opioid-tolerant patients who require daily morphine equivalent dosages above 400 mg. I.M. or subcutaneous use— Adults: 5 to 20 mg/70 kg I.M. or subcutaneously q 4 hours p.r.n. |
| I.V. use— Adults: 2 to 10 mg/70 kg I.V. p.r.n. given slowly over 4 to 5 minutes. As a continuous I.V. infusion, 0.1 to 1 mg/ ml in dextrose 5% in water delivered by controlled-infusion device. Rectal use— Adults: 10 to 30 mg P.R. q 4 hours p.r.n. |
| Epidural use— Adults: Initially 5 mg (Astramorph PF, Duramorph) injected in lumbar region (may relieve pain up to 24 hours). If response isn’t adequate within 1 hour, carefully give incremental doses of 1 to 2 mg p.r.n., up to 10 mg/24 hours. For continuous epidural infusion, 2 to 4 mg/24 hours. For epidural injection (DepoDur) before orthopedic leg surgery, recommended dosage is 15 mg; before lower abdominal or pelvic surgery, 10 to 15 mg. For cesarean section after umbilical cord clamping, recommended dosage is 10 mg |
| Intrathecal use— Adults: Usual intrathecal dosage is one-tenth of epidural dosage; 0.2 to 1 mg as a single injection in lumbar area may relieve pain up to 24 hours. |
Mechanism of Action
Binds with and activates opioid receptors (mainly mu receptors) in brain and spinal cord to produce analgesia and euphoria.
Pharmacokinetics
- Peak plasma time: PO, <60 min; PR, 20-60 min; SC, 50-90 min; IM, 30-60 min; IV, 20 min
- Protein bound: IV, 36%
- Metabolized in liver via conjugation with glucuronic acid
- Half-life: 2-4 hr (immediate release); 11-13 hr (Kadian)
- Excretion: Urine (2-12%), feces (7-10%)
Administration
- For best response, give at pain onset.
- Give oral form with food or milk to minimize GI upset.
- If desired, crush immediate-release form and mix with food or fluids.
- Don’t crush or break extendedrelease form; remind patient to swallow it whole.
- If desired, open sustained-release capsules (Kadian) and sprinkle entire contents onto small amount of food (such as applesauce). Have patient consume mixture immediately without chewing, crushing, or dissolving pellets.
- When giving by direct I.V., dilute in at least 5 ml of sterile water for injection or normal saline solution. Give 2.5 to 10 mg over 4 to 5 minutes.
- For continuous I.V. infusion, use infusion pump or PCA pump. Titrate dosage to provide adequate pain relief.
- Don’t use parenteral form if it’s cloudy or contains visible particulates.
Contraindications
- Hypersensitivity to drug, tartrazine, bisulfites, or alcohol
- Acute bronchial asthma
- Upper airway obstruction
- Respiratory depression
- GI obstruction, paralytic ileus
Precautions:
- Head trauma; increased intracranial pressure; severe renal, hepatic, or pulmonary disease; hypothyroidism; adrenal insufficiency; prostatic hypertrophy
- Elderly or debilitated patients
- Pregnant or breastfeeding patients.
Adverse reactions
- CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, nightmares
- CV: hypotension, bradycardia
- EENT: blurred vision, diplopia, miosis
- GI: nausea, vomiting, constipation, dry mouth
- GU: urinary retention
- Respiratory: apnea, respiratory depression, respiratory arrest
- Skin: flushing, itching, sweating
- Other: physical or psychological drug dependence, drug tolerance
Patient monitoring
- Monitor vital signs. Contact prescriber if respiratory rate is 10 breaths/ minute or less.
- Assess pain character, location, and intensity.
- Monitor fluid intake and output. Stay alert for urinary retention.
- Monitor bowel elimination pattern. If constipation occurs, intervene as appropriate.
- Assess neurologic status. Implement safety measures as needed to prevent injury.
- Evaluate patient for signs and symptoms of physical or psychological dependence. Be watchful for drug hoarding
Patient teaching
- Tell patient he may crush immediaterelease form and mix with food or fluids.
- Advise patient not to crush or break extended-release form. Instruct him to swallow it whole.
- Tell patient he may open sustained release capsule (Kadian), sprinkle entire contents of capsule onto a small amount of food (such as applesauce), and consume immediately. Stress importance of not chewing, crushing, or dissolving pellets.
- Advise patient to take drug at the first sign of pain, because continuous dosing is more effective than p.r.n. dosing
- Tell patient and caregiver that drug may cause respiratory depression. Instruct them to immediately report respiratory rate of 10 breaths/minute or less.
- Inform patient that drug may cause constipation or urinary retention. Encourage high-fiber diet and high fluid intake
- Stress importance of taking drug only as prescribed. Point out that drug may cause psychological or physical dependence.
- Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, vision, and alertness.
- Teach patient and caregiver about appropriate safety measures to prevent injury.
- Caution patient to avoid alcohol and other CNS depressants during and for 24 hours after therapy.
- Advise patient to avoid herbs, which may worsen adverse CNS effects.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above
Nursing Considerations
- Use cautiously in patients about to undergo surgery of the biliary tract and patients with acute pancreatitis secondary to biliary tract disease because morphine may cause spasm of the sphincter of Oddi.
- Store morphine at room temperature.
- Before giving morphine, make sure opioid antagonist and equipment for oxygen delivery and respiration are available.
- Before therapy, assess patient’s drug use, including all prescription and OTC drugs.
- Expect prescriber to start patient who has never received opioids on immediate release form and then switch to E.R. form if therapy must last longer than a few days
- Keep in mind that when morphine is given by epidural route, dosage must be individualized according to patient’s age, body mass, physical status, previous experience with opioids, risk factors for respiratory depression, and drugs to be coadministered before or during surgery.
- Give oral form with food or milk to minimize adverse GI reactions, if needed. Solution can be mixed with fruit juice to improve taste.
- If needed, open E.R. capsules and sprinkle contents on applesauce (at room temperature or cooler) just before giving to patient. Make sure patient doesn’t chew or crush capsules or dissolve capsule’s pellets in his mouth.
- Be aware that E.R. forms of morphine aren’t interchangeable.
- Discard injection solution that is discolored or darker than pale yellow or that contains precipitates that don’t dissolve with shaking
- For direct I.V. injection, dilute appropriate dose with 4 to 5 ml of sterile water for injection. Inject 2.5 to 15 mg directly into tubing of free-flowing I.V. solution over 4 to 5 minutes. Rapid I.V. injection may increase adverse reactions.
- For continuous I.V. infusion, dilute drug in D5W and administer with infusioncontrol device. Adjust dose and rate based on patient response, as prescribed.
- Avoid I.M. route for long-term therapy because of injection site irritation.
- During subcutaneous injection, take care to avoid injecting drug intradermally.
- For intrathecal injection, expect prescriber to give no more than 2 ml of 0.5-mg/ml solution or 1 ml of 1-mg/ml solution. Expect intrathecal dosage to be about onetenth of epidural dosage.
- If rectal suppository is too soft to insert, refrigerate for 30 minutes or run wrapped suppository under cold tap water
- Monitor patient with seizure disorder for increased seizure activity because morphine may worsen the disorder.
- Monitor patient for excessive or persistent sedation; dosage may need to be adjusted.
- If patient is receiving a continuous morphine infusion, watch for and notify prescriber about new neurologic signs or symptoms. Inflammatory masses (such as granulomas) have caused serious neurologic reactions, including paralysis.
- Expect morphine to cause physical and psychological dependence; watch for drug tolerance and withdrawal, such as body aches, diaphoresis, diarrhea, fever, piloerection, rhinorrhea, sneezing, and yawning.
- If tolerance to morphine develops, expect prescriber to increase dosage.
- Morphine may have a prolonged duration and cumulative effect in patients with impaired hepatic or renal function. It also may prolong labor by reducing strength, duration, and frequency of uterine contractions.
- When discontinuing morphine in patients receiving more than 30 mg daily, expect prescriber to reduce daily dose by about one-half for 2 days and then by 25% every 2 days thereafter until total dose reaches initial amount recommended for patients who haven’t received opioids (15 to 30 mg daily). This regimen minimizes the risk of withdrawal symptoms.
3.Codeine
| Codeine |
| Availability Tablets: 15 mg, 30 mg, 60 mg |
| Indications and dosages ➣ Mild to moderately severe pain Adults: 15 to 60 mg P.O. q 4 hours as needed. Doses above 60 mg may fail to give commensurate pain relief, and may be associated with an increased incidence of undesirable adverse effects |
Mechanism of Action
May produce analgesia through partial metabolism to morphine. Drug binds with mu, delta, and kappa receptors in the spinal cord and with mu1 and kappa3 receptors higher in the CNS, decreasing intracellular cAMP, which inhibits adenylate cyclase activity and prevents release of pain neurotransmitters, such as substance P and dopamine, and altering perception of and emotional response to pain. Drug also suppresses cough by acting on opiate receptors in the cough center.
Pharmacokinetics
- Peak plasma time: 0.5-1 hr
- Protein bound: 25%
- Prodrug metabolized to morphine by CYP2D6; demethylated/conjugated in liver (undergoes O-demethylation, N-demethylation, and partial conjugation with glucuronic acid)
- Half-life: 3-4 hr
- Excretion: Urine, feces
Administration
- If GI upset occurs, give with food.
- Titrate dosage for appropriate analgesic effect.
- If overdose occurs, give naloxone I.V. as prescribed. Repeat administration as needed (up to manufacturer’s recommended maximum dosage) to reverse toxic effects.
Contraindications
- Hypersensitivity to drug, its components, or other opioids
- Respiratory depression, severe bronchial asthma, hypercarbia
- Paralytic ileus or suspected paralytic ileus
Precautions:
- Severe renal, hepatic, or pulmonary disease
- Adrenal insufficiency, circulatory shock, hypotension, pancreatic or biliary tract disease, urethral stricture, seizures, head trauma, hypothyroidism, increased intracranial pressure, prostatic hypertrophy, undiagnosed abdominal pain, alcoholism
- Concomitant use of alcohol, other opioids, illicit drugs
- Elderly or debilitated patients
- Pregnant or breastfeeding patients
- Labor and delivery patients
- Children younger than age 18 (safety and efficacy not established).
Adverse reactions
- CNS: confusion, sedation, malaise, agitation, euphoria, floating feeling, headache, hallucinations, unusual dreams, apathy, mood changes
- CV: hypotension, bradycardia, peripheral vasodilation, reduced peripheral resistance
- EENT: blurred or double vision, miosis, reddened sclera GI: nausea, vomiting, constipation, decreased gastric motility
- GU: urinary retention, urinary tract spasms, urinary urgency
- Respiratory: suppressed cough reflex, respiratory depression
- Skin: flushing, sweating
- Other: physical or psychological drug dependence, drug tolerance
Patient monitoring
- Monitor vital signs and CNS status.
- Assess pain level and efficacy of pain relief.
- Evaluate patient for adverse reactions.
- Stay alert for overdose signs and symptoms, such as CNS and respiratory depression, GI cramping, and constipation.
- Assess other drugs in patient’s drug regimen for those that could cause additive or adverse interactions.
- Monitor patient for signs and symptoms of drug dependence or tolerance.
Patient teaching
- Teach patient to minimize adverse GI effects by taking doses with food or milk.
- Tell patient to notify prescriber promptly if he experiences shortness of breath or difficulty breathing or if nausea, vomiting, or constipation become pronounced.
- Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, alertness, vision, coordination, and physical dexterity.
- Instruct patient to move slowly when sitting up or standing, to avoid dizziness or light-headedness from sudden blood pressure decrease.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, herbs, and behaviors mentioned above.
Nursing Considerations
- Evaluate patient for therapeutic response, including decreased pain, cough, and facial grimacing.
- Take safety precautions, if needed.
- Monitor respiratory depth, effort, and rate. Notify prescriber immediately if respiratory rate drops below 10 breaths/min.
- Rotate sites for subcutaneous delivery. Repeated injection in same site may cause tissue irritation, pain, and induration.
REFERENCES
- Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
- McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
- April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
- Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
- Nursebro.com, Search – Nursebro
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