Opioid Analgesics: Safe Use, Naloxone, Secure Storage, and Overdose Recognition

Who needs this teaching

Clients discharged with an opioid analgesic for acute pain, such as oxycodone or hydrocodone with acetaminophen, and the family. Opioids bind mu receptors in the central nervous system. Respiratory depression is the most serious adverse effect, and sedation precedes it. Risk increases with higher doses, other CNS depressants, sleep apnea, older age, and renal or hepatic impairment.

The priority teaching points

1. Prescribed use. Take the lowest effective dose for the shortest time, exactly as prescribed. Never take extra doses or take doses closer together. Use prescribed nonopioid analgesics, ice, and elevation. Count the acetaminophen in combination products; total acetaminophen stays at or below 4,000 mg daily for adults, or the lower limit the provider sets. Do not crush or chew extended-release tablets.
2. CNS depressants. Never combine opioids with alcohol, benzodiazepines, sleep medications, or other sedatives. The combination causes profound sedation, respiratory depression, coma, and death (FDA boxed warning). Ask before antihistamines such as diphenhydramine, muscle relaxants, or gabapentin.
3. Driving and falls. Do not drive or operate machinery until the client knows how the opioid affects alertness. Rise slowly and use fall precautions.
4. Constipation. Opioids cause constipation, and tolerance to this effect does not develop. Drink fluids, eat fiber, and walk as able. Take the prescribed stool softener and stimulant laxative starting with the first opioid dose. Report no bowel movement for 3 days.
5. Naloxone. Keep naloxone nasal spray in the home and teach the family to use it. For an unresponsive person with slow, shallow, or absent breathing: shout and rub the sternum, lay the person on the back, spray 1 dose into one nostril, and call 911. If there is no response in 2 to 3 minutes, give a second dose in the other nostril with a new device. Place the person in the recovery position and stay until help arrives. Naloxone has a shorter duration than most opioids, so respiratory depression returns.
6. Storage and disposal. Store opioids locked and out of reach of children, pets, and visitors. Count the tablets. Never share or sell them. When pain resolves, take leftover tablets to a drug take-back site or pharmacy disposal kiosk. With no take-back option, follow the disposal instructions in the Medication Guide.
7. Overdose signs. Signs are extreme sleepiness or inability to wake, slow or absent breathing, pinpoint pupils, blue or gray lips and nails, and choking or snoring sounds. Give naloxone and call 911.

Red flags the client reports

Teach-back questions

• "Which drinks and medicines will you avoid while you take this opioid?"
• "Show me how you would give the naloxone spray."
• "What will you do if the person does not respond after 3 minutes?"
• "Where will you store your tablets?"
• "What will you do with leftover tablets?"

Teaching tips

• Teach the family member who would give naloxone, and observe a return demonstration with a trainer device.
• Start the bowel regimen with the first dose.
• Write the nearest take-back location on the handout.

Read more on NCLEXPace

• Pain Management and Naloxone: Relieve Pain, Protect Breathing
• Antidotes and Reversal Agents: The Only List You Need
• High-Alert Medications: The Four That Hurt People Most

Sources

• Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95.
• Naloxone Hydrochloride Nasal Spray 4 mg (nonprescription): FDA Drug Facts labeling (DailyMed).
• Oxycodone and Acetaminophen Tablets: FDA prescribing information, including boxed warning, and Medication Guide (DailyMed).
• Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Pain.