PHAR13672:

Pharmacology for Nurses

Module 7 – Unit 8: Opioids and

Opioid Use Disorder
Learning Outcomes
By the end of the class students will:
1. Understand the factors that influence opioid misuse
2. Summarize the opioids used in pain management and
their side effects
3. Explain the medications used to treat opioid misuse
disorder
Who is at risk of an
opioid poisoning?
 Apparent opioid related
deaths in Canada
3,023 deaths
2016

2017 4,120 deaths

2018 4,588 deaths

2019 3,823 deaths

12

More than 15,393 apparent

opioid-related deaths occurred between
January 2016 and December 2019.

Government of Canada, 2020

Government of Canada, 2020
 • Heroin

• Fentanyl

• Oxycodone
Commonly Misused
• Morphine
Opioids
• Hydrocodone

• Hydromorphone

• Codeine phosphate

• Meperidine hydrochloride
 Framework for
problematic
prescription dru
Prescription
use drug Diversio
- Theft
n
Diversio - Double-
- Selling
n: doctoring
- Sharin - For eries
Therapeutic g Recreational
Use Use

Benefit Side Benefi ts

s• Improvement • ects
Eff Physical dependence • Hi
in function • Overdose/poisonin h/euphoria
• Addiction (substance use
disorder)

1
0
 Opioid
○ Brain
Eff ects
○ Euphoria
○ Pain relief
○ Respiratory depression
○ Cough suppressant
○ Stimulate areas to cause feelin s of
nausea and vomiting
○ Gastrointestinal tract
○ Various effects (e. ., less secretions,
inhibition of peristalsis) leading to
constipation
 Opioid Intoxication

Recent use of an opioid

▪ Clinically significant problematic behavioral or psychological changes (e.g., initial euphoria
followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment) that
developed during, or shortly after, opioid use
▪ Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or
more) of the following signs and symptoms developing during, or shortly after, opioid use:
□ Drowsiness or coma
□ Slurred speech
□ Impairment in attention or memory
▪ Signs and symptoms are not attributable to another medical condition and are not better
explained by another mental disorder, including intoxication with another substance
 Opioid Classification
1. Full agonists interact with a receptor to produce a maximal response
from that receptor (analgesia following morphine administration is an
example)

2. Partial agonists bind to receptors but elicit only a partial functional

response no matter the amount of drug administered (buprenorphine)

3. Antagonists bind to receptors but produce no functional response,

while at the same time preventing an agonist from binding to that
receptor (naloxone)
WHO Pain Ladder
Overview of
opioids
Varying levels of response
depending on the type of opioid

Example

Full agonist Oxycodone, hydromorphone,

fentanyl, morphine, methadone

Partial agonist Buprenorphine

Antagonist Naloxone, naltrexone

6
 Drug Profile: Opioid Agonists
Classification Indications Contraindications
Therapeutic Classification: opioid Management of mild to moderate pain Known drug allergy
analgesic, antitussives Acute or severe asthma
Pharmacologic Classification: Antitussive (in smaller doses)- cough Children under the age of 18
syrups.
codeine sulphate/phosphate- mild to
moderate.
Schedule I Controlled Substance

PO
MOA ADRs Nursing Considerations
Binds to opiate receptors in the CNS. CNS: • High Alert: Accidental overdosage of opioid analgesics has resulted in fatalities.
Alters the perception of and response • Confusion Before administering, clarify all ambiguous orders.
to painful stimuli while producing • Sedation • Drug subject to Controlled Drugs and Substances Act
generalized CNS depression • Dizziness • Codeine may impair mental and physical abilities
Decreases cough reflex GI: • Codeine may cause drug dependence and tolerance
Decreases GI motility • Constipation • Assess type, location, and intensity of pain before and one hour (peak) after
• Nausea administration Assess bowel function routinely. Advise patient to increase fluids and
Therapeutic Effect(s): • GI upset bulk with possible laxative
Decreased pain CV:
• Hypotension
Resp:
• Respiratory depression
• Asthma exacerbation
Misc:
• Physical/Psychological dependence
• Tolerance
 Drug Profile: Opioid Agonists
Classification Indications Contraindications
Therapeutic Classification: opioid Severe pain Known drug allergy
analgesic Acute or severe asthma
Pharmacologic Classification: opioid
agonists

morphine sulphate
Schedule I Controlled Substance

PO/IM/IV/SQ/PR/XR
MOA ADRs Nursing Considerations
Binds to opiate receptors in the CNS. CNS: • High Alert: Do not confuse MS Contin (morphine sulphate) with Oxycontin (oxycodone).
Alters the perception of and response to • Sedation • High Alert: Do not confuse morphine with hydromorphone – errors have resulted in death.
painful stimuli while producing generalized • Disorientation • Drugs subject to Controlled Drugs and Substances Act
CNS depression • Euphoria • Morphine may impair mental and physical abilities
• Lightheadedness • Morphine may cause drug dependence and tolerance
Therapeutic Effect(s): • Dysphoria • Assess type, location, and intensity of pain before and one hour (peak) after administration
Decrease in severity of pain • Lowered seizure threshold Assess bowel function routinely. Advise patient to increase fluids and bulk with possible
GI: laxative
• Constipation
• Nausea
• Vomiting
CV:
• Hypotension
• Palpitations
Resp:
• Respiratory depression
• Asthma exacerbation
GU:
• Urinary retention
Misc:
• Physical/Psychological dependence
• Tolerance
 Drug Profile: Opioid Agonists
Classification Indications Contraindications
Therapeutic Classification: Opioid Opioid Use Disorder (OUD) Known drug allergy
analgesic Severe liver disease
Pharmacologic Classification: Ddetoxification treatment of opioid History of QT prolongation
Methadone- for opioid use disorders. addiction (heroin or other morphine-like Caution in CNS-related pathologies such as
drugs), and for maintenance substitution trauma, increased intracranial pressure,
treatment for opioid dependence in adults dementia, delirium

PO

MOA ADRs Nursing Considerations

Long-acting opioid agonist with a half-life • Restlessness • Women who are pregnant or breastfeeding
of 12 to 24 hours. Prevents withdrawal • Nausea or vomiting can take methadone
symptoms for 24-36 hours following dosing • Slow breathing • Babies born to someone on methadone can
to ultimately reduce cravings and drug- • Itchy skin experience Neonatal Abstinence Syndrome
seeking behaviours • Heavy sweating (NAS)
• Constipation • Patients on prolonged therapy should be
Therapeutic Effect(s): • Sexual problems tapered gradually from the drug
Reduces the craving for opioids, • Take with or without food
suppresses euphoria, and prevents
withdrawal symptoms
Opioid
withdrawal
Early, subjective withdrawal symptoms
Other early withdrawal
● Anxiety symptoms “Chronic”
● ● Dysphoric mood
Restlessness symptoms
● ● Nausea/vomiting
“Achy feelin ” in the ● Anxiety
● Lacrimation/
back and legs
● rhinorrhea ● Dysphori
Irritability
● ● Pupillary dilation, a
Increased sensitivity
to pain piloerection, ● Anhedoni
increased sweating a
● Diarrhea
● Yawning
● Insomnia
● Fever
● Insomnia
 Drug Profile: Opioid
Classification Agonists/Antagonist
Indications Contraindications
Therapeutic Classification: Opioid Use Disorder (OUD) Known drug allergy
Buprenorphine hydrochloride and Severe liver disease
Naloxone Ddetoxification treatment of opioid
addiction (heroin, fentanyl, oxycontin), and
Pharmacologic Classification: for maintenance substitution treatment for
Suboxone opioid dependence in adults

Sublingual tablet or film

Transdermal
MOA ADRs Nursing Considerations
Long-acting opioid agonist with a half-life • Flu-like symptoms • Women who are pregnant or breastfeeding
of 12 to 24 hours • Vomiting can take suboxone
• Sweating • Babies born to someone on methadone can
• Stomach pain experience Neonatal Abstinence Syndrome
Therapeutic Effect(s): • Low energy (NAS)
Blocks the opioid receptors in the brain that • Headache • Action of onset is 30-60 mins and lasts 24
helps to reduce significant withdrawal • Tooth Decay hours
symptoms from opioid detox and can help • Tremors
reduce a person’s urges for Opioids • Difficulty breathing
• Pain, including nerve pain
 Drug Profile: Opioid Antagonist
Classification Indications Contraindications
Therapeutic Classification: Reversal of CNS and Known drug allergy
opioid reversal agent respiratory depression because
Pharmacologic of suspected opioid overdose
Classification: opioid
antagonists
Use for opioid toxicity.
naloxone hydrochloride
(Narcan®)

IV/Nasal Spray
MOA ADRs Nursing Considerations
Competitively blocks the GI: • Monitor vital signs and level of consciousness frequently for 3-4
effects of opioids, including • N/V hours after the expected peak of blood concentrations.
CNS and respiratory CV: • Assess level of pain after administration when used to treat
depression, without producing • Ventricular arrhythmias postoperative respiratory depression.
any agonist (opioid-like) • Indicated in cases of suspected acute opioid overdose
effects. • Failure of the drug to significantly reverse the effects of the
presumed opioid overdose indicates that the condition may not be
Therapeutic Effect(s): related to opioid overdose.
Reversal of signs of opioid
excess.
Harm Reduction •Provides people who use substances a choice of how
they will minimize harms through non-judgemental and
non-coercive strategies

•Acknowledges that many individuals coping with

addiction and problematic substance use may not be
able to remain abstinent

•Goal is to prevent the negative consequences of

substance use and to improve health

•Examples include:
• using a nicotine patch instead of smoking
• using substances in a safe environment
• needle exchange programs

(CMHA )
1
3 Health Quality Ontario, 2019
https://www.hqontario.ca/portals/0/documents/evidence/quality-standards/qs-opioid-use-disorder-clinician- uide-en.pdf
 Key recommendations
from national clinical
practice
uideline
● Injectable opioid agonist treatment can
be considered for individuals with
severe, treatment refractory opioid use
disorder

● Hydromorphone is an acceptable
treatment option
2
7

● Evidence for use in treating severe

opioid use disorder for people who use
opioids intravenously
View the video directly via: https://www.youtube.com/watch?v=-QX Qdm
uK0&ab_channel=HealthyCanadians
 • Constipation is a common
adverse effect and
may be prevented with
Opioid adequate fluid and
Analgesics fibre intake.
• Instruct patients to follow
: directions for administration
carefully and to keep a record
Nursing of their pain experience and
Implicatio response to treatments.
• Patients should be instructed
ns to change positions slowly to
prevent possible orthostatic
hypotension.

(Sealock et al., 2021).

 Monitor for therapeutic
effects.
Opioid Decreased perception of
Analgesics pain
Decreased severity of pain
: Increased periods of
Nursing comfort
Improved activities of daily
Implicatio living, appetite, and sense
ns of well-being
Decreased fever
(acetaminophen)

(Sealock et al., 2021).

Knowledge Check
Your 82-year-old postoperative client is hard to rouse 30
minutes after you administered IV morphine. Their BP
is 102/72, respirations are 8 and shallow and SpO2 is
88% on room air. Which of the following (with health
care provider orders) are priority nursing actions? Select
all that apply.

a) Administer oxygen
b) Administer naloxone
c) Insert a foley catheter
d) Increase IV fluid rate
e) Raise the head of the bed
References

• Lewis, L. S., Bucher, L., Heitkemper, M. M., Harding, M. M., Barry, A. M.,
Lok, J., Tyerman, J., Goldsworthy, S., Kwong, J., & Roberts, D. (2019).
Medical-Surgical Nursing in Canada, 4th edition. Elsevier.
• Nursing Education Consultants, Inc. (2017). Nursing Education
Consultants, Inc: The Testing Experts. Retrieved from
http://www.nursinged.com/index.html
• Snyder, K., Seneviratne, C., Lilley, L. L., Collins, R. S., & Snyder, S. J.
(2021). Lilley's Pharmacology for Canadian Health Care Practice, 4th
edition. Elsevier.