• Assess type, location, and intensity of pain before and 1 hr after IM or 30 min (peak) after IV administration. When titrating opioid doses, increases of 25–50% should be administered until there is either a 50% ↓ in the patient’s pain rating on a numeric or visual analogue scale or the patient reports satisfactory pain relief. A repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal. Patients requiring doses higher than 20 mg should be converted to an opioid agonist. Nalbuphine is not recommended for prolonged use or as first-line therapy for acute or cancer pain.
• An equianalgesic chart (see Equianalgesic Dosing Guidelines) should be used when changing routes or when changing from one opioid to another.
• Assess BP, HR, and respiratory rate before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Dose may need to be ↓ by 25–50%. Monitor for respiratory depression, especially during initiation or following dose ↑; serious, life-threatening, or fatal respiratory depression may occur. May cause sleep-related breathing disorders (central sleep apnea, sleep-related hypoxemia). Nalbuphine produces respiratory depression, but this does not markedly ↑ with increased doses.
• Monitor for severe hypotension, including orthostatic hypotension and syncope, in ambulatory patients, especially in patients with compromised ability to maintain BP.
• Assess bowel function routinely. Institute prevention of constipation with ↑ intake of fluids and bulk and with laxatives to minimize constipating effects. Administer stimulant laxatives routinely if opioid use exceeds 2–3 days, unless contraindicated. Consider drugs for opioid-induced constipation.
• Assess previous analgesic history. Antagonistic properties may induce withdrawal symptoms (vomiting, restlessness, abdominal cramps, ↑ BP and temperature) in patients physically dependent on opioids.
• Although this drug has a low potential for dependence, prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent patient from receiving adequate analgesia. Most patients who receive nalbuphine for pain do not develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve pain.
• Assess risk for opioid addiction, abuse, or misuse prior to administration.

Lab Test Considerations:

• May cause ↑ serum amylase and lipase.

Toxicity and Overdose:

• If an opioid antagonist is required to reverse respiratory depression or coma, naloxone is the antidote. Dilute the 0.4-mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by IV push every 2 min. For children and patients weighing <40 kg, dilute 0.1 mg of naloxone in 10 mL of 0.9% NaCl for a concentration of 10 mcg/mL and administer 0.5 mcg/kg every 2 min. Titrate dose to avoid withdrawal, seizures, and severe pain.