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7.5 High-Alert Medications: Opioids

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NCLEX-RN Registered Nurse

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1 Introduction

About the NCLEX-RN Exam Next Generation NCLEX (NGN) Clinical Judgment Measurement Model (NCJMM) How to Use This Course

2 Chapter 2: Management of Care

2.1 Legal Rights and Responsibilities 2.2 Advance Directives and Self-Determination 2.3 Informed Consent Protocols 2.4 Client Advocacy and Rights (HIPAA) 2.5 Assignment, Delegation, and Supervision 2.6 Five Rights of Delegation 2.7 Scope of Practice (RN vs LPN vs UAP) 2.8 Ethical Practice Principles

3 Chapter 3: Safety and Infection Prevention and Control

3.1 Standard Precautions and Hand Hygiene 3.2 Transmission-Based Precautions (Contact, Droplet, Airborne) 3.3 PPE Donning and Doffing Sequences 3.4 Fall Prevention and Restraints 3.5 Fire Safety (RACE/PASS) 3.6 Disaster Triage and Emergency Response

4 Chapter 4: Health Promotion and Maintenance

4.1 Growth and Development (Erikson/Piaget) 4.2 Developmental Stages: Infancy through Older Adult 4.3 Maternal and Newborn Care (Antepartum) 4.4 Intrapartum Care and Fetal Monitoring 4.5 Postpartum Care (BUBBLE-HE) 4.6 Health Screening Guidelines 4.7 Immunization Schedules

5 Chapter 5: Psychosocial Integrity

5.1 Therapeutic Communication Techniques 5.2 Non-Therapeutic Communication (What to Avoid) 5.3 Anxiety Disorders and Mental Health Concepts 5.4 Schizophrenia: Hallucinations and Delusions 5.5 Depression and Suicide Assessment 5.6 Substance Misuse and Withdrawal 5.7 Grief and End-of-Life Care

6 Chapter 6: Basic Care and Comfort

6.1 Mobility and Hazards of Immobility 6.2 Assistive Devices (Crutches, Canes, Walkers) 6.3 Nutrition and Diet Therapy 6.4 Enteral Nutrition (Tube Feeding) 6.5 Bowel Elimination and Ostomy Care 6.6 Urinary Elimination and Catheter Care

7 Chapter 7: Pharmacological and Parenteral Therapies

7.1 Medication Administration Rights 7.2 Medication Calculations 7.3 High-Alert Medications: Insulins 7.4 High-Alert Medications: Anticoagulants 7.5 High-Alert Medications: Opioids 7.6 High-Alert Medications: Digoxin and Electrolytes 7.7 IV Therapy and Complications 7.8 Blood Product Administration 7.9 Total Parenteral Nutrition (TPN)

8 Chapter 8: Reduction of Risk Potential

8.1 Laboratory Values: Hematology (CBC) 8.2 Laboratory Values: Metabolic Panel (BMP) 8.3 Laboratory Values: Coagulation Studies 8.4 Vital Signs and Trend Recognition 8.5 Perioperative Care (Pre-Op and Post-Op) 8.6 Nasogastric Tubes and Therapeutic Procedures

9 Chapter 9: Physiological Adaptation

9.1 Fluid Imbalances (Hypovolemia and Hypervolemia) 9.2 Arterial Blood Gases (ABGs) and Acid-Base Balance 9.3 Medical Emergencies: Stroke (CVA) 9.4 Medical Emergencies: Myocardial Infarction (MONA) 9.5 Diabetic Emergencies (Hypoglycemia and DKA) 9.6 Respiratory Conditions (COPD, Pneumonia) 9.7 Cardiac Conditions (Heart Failure) 9.8 Neurological Conditions (Seizures)

7.5 High-Alert Medications: Opioids

Key Takeaways Explain This Topic AI

Respiratory depression is the most serious opioid adverse effect - assess respiratory rate before EVERY dose; hold if RR < 12/min

Naloxone (Narcan) is the antidote for opioid overdose - it has a shorter half-life than most opioids, so re-sedation can occur

Opioid-naive patients are at highest risk for respiratory depression - start low and titrate slowly

Constipation is an expected side effect that does NOT develop tolerance - prophylactic bowel regimen is essential

  • Assess pain using validated scales; do not rely solely on vital signs or patient appearance
  • Last updated: October 2026

Opioid analgesics are essential for pain management but carry significant risks. The NCLEX tests your ability to safely administer opioids, recognize adverse effects, and respond to emergencies.

Common Opioid Analgesics

  • Drug Route Relative Potency Duration
  • Morphine PO, IV, IM, SubQ Standard (1x) 4-5 hours
  • Hydromorphone (Dilaudid) PO, IV 5-7x morphine 4-5 hours
  • Fentanyl IV, Transdermal, Transmucosal 80-100x morphine IV: 30-60 min; Patch: 72 hr
  • Oxycodone PO 1.5x morphine 4-6 hours
  • Hydrocodone PO ~1x morphine 4-6 hours
  • Codeine PO 0.1x morphine 4-6 hours
  • Meperidine (Demerol) PO, IM 0.1x morphine 2-3 hours

Clinical Note: Meperidine is rarely used due to neurotoxic metabolite (normeperidine) that can cause seizures.

Before Administration: The Opioid Assessment

ALWAYS assess before each dose:

  • Respiratory Rate - Hold if < 12 breaths/min
  • Level of Consciousness - Excessive sedation = hold and assess
  • Pain Score - Document current pain level
  • Last Dose Time - Verify minimum interval has passed
  • Allergies - True allergy vs. expected side effect
  • Other CNS Depressants - Benzodiazepines, alcohol increase risk
  • Respiratory Depression: The Priority Concern

Signs of Opioid-Induced Respiratory Depression:

  • Respiratory rate < 12/min
  • Shallow respirations
  • Oxygen saturation declining
  • Excessive sedation (difficult to arouse)
  • Snoring or obstructed breathing

Sedation Scale (Pasero Opioid-Induced Sedation Scale):

  • Level Description Action
  • S = Sleep Normal sleep, easily aroused None
  • 1 Awake and alert None
  • 2 Slightly drowsy, easily aroused Acceptable
  • 3 Frequently drowsy, arousable Decrease dose; monitor closely
  • 4 Somnolent, minimal response Stop opioid; call provider; consider Naloxone
  • Naloxone (Narcan): Opioid Reversal

Indications:

  • Respiratory depression (RR < 8-10/min)
  • Unresponsive to stimulation
  • Oxygen saturation falling despite supplemental O2

Administration:

  • IV: 0.4-2 mg every 2-3 minutes until response
  • IM, SubQ, or Intranasal if no IV access
  • Titrate to respiratory improvement, NOT complete reversal

Critical Concept: Naloxone has a shorter half-life (30-90 min) than most opioids (4-5 hours). Re-sedation can occur. Monitor for at least 2 hours after administration; may need repeat doses.

Side Effects of Rapid Reversal:

  • Severe pain return
  • Hypertension, tachycardia
  • Pulmonary edema
  • Withdrawal symptoms in opioid-dependent patients
  • Managing Opioid Side Effects
  • Side Effect Management
  • Constipation Prophylactic scheduled stimulant laxative such as senna (does NOT develop tolerance)
  • Nausea/Vomiting Antiemetics; usually improves after 2-3 days
  • Pruritus (itching) Antihistamines; not a true allergy
  • Urinary retention Bladder assessment; may need catheterization
  • Hypotension Slow position changes; assess fluid status
  • Sedation Expected initially; assess for excessive sedation
  • Opioid-Naive vs. Opioid-Tolerant
  • Opioid-Naive Opioid-Tolerant
  • No recent opioid use Regular opioid use > 1 week
  • Higher risk of respiratory depression May need higher doses for effect
  • Start with lower doses Cross-tolerance to other opioids
  • Titrate slowly Still at risk if doses increased
  • Equianalgesic Dosing

When converting between opioids, use equianalgesic charts:

  • Opioid Oral Dose IV Dose
  • Morphine 30 mg 10 mg
  • Hydromorphone 6 mg 1.5 mg
  • Oxycodone 20 mg N/A

Remember: These are approximations. Incomplete cross-tolerance means starting 25-50% below calculated dose.

Patient-Controlled Analgesia (PCA)

Safety Features:

  • Lockout interval prevents overdose
  • Basal rate (if ordered) provides continuous relief
  • Patient activates demand doses
  • Only the PATIENT should push the button (not family)

Nursing Responsibilities:

  • Verify pump settings with two nurses
  • Assess pain and sedation regularly
  • Document usage and pain scores
  • Teach patient proper use
  • Special Populations

Elderly:

  • Start at 25-50% of usual adult dose
  • Longer duration of action (slower metabolism)
  • Higher risk of falls, confusion

Renal Impairment:

  • Morphine metabolites accumulate - consider alternatives
  • Hydromorphone or fentanyl often preferred

Hepatic Impairment:

  • Reduced metabolism - lower doses needed
  • Extended duration of action
  • On the Exam
  • Respiratory assessment before every opioid dose
  • Know when to hold medication (RR < 12)
  • Recognize need for Naloxone
  • Understand that constipation requires prophylaxis
  • PCA - only patient pushes button