• Accidental overdose of opioid analgesics has resulted in fatalities. Before administering, clarify all ambiguous orders; have second practitioner independently check original order, dose calculations, and infusion pump settings. Medication errors with opioid analgesics are common in the pediatric population and include misinterpretation or miscalculation of doses and use of inappropriate measuring devices.

• Explain therapeutic value of medication prior to administration to enhance the analgesic effect.
  • Regularly administered doses may be more effective than as needed administration. Analgesic is more effective if given before pain becomes severe.
  • Coadministration with nonopioid analgesics may have additive analgesic effects and permit lower doses.
  • Oral dose is <50% as effective as parenteral dose. When changing to oral administration, dose may need to be ↑ (see Equianalgesic Dosing Guidelines).
  • Medication should be discontinued gradually after long-term use to prevent withdrawal symptoms. For patients who are physically opioid dependent, initiate the taper by a small enough increment (no greater than 25–50% of total daily dose) to avoid withdrawal symptoms, and proceed with dose-lowering at an interval of every 2–4 days. Patients who have been taking opioids for briefer periods of time may tolerate a more rapid taper. Monitor frequently to manage pain and withdrawal symptoms (restlessness; lacrimation; rhinorrhea; yawning; perspiration; chills; myalgia; mydriasis; irritability; anxiety; backache; joint pain; weakness; abdominal cramps; insomnia; nausea; anorexia; vomiting; diarrhea; or ↑ BP, respiratory rate, or HR). If withdrawal symptoms occur, pause the taper for a period of time or ↑ dose of opioid analgesic to previous dose, and then proceed with a slower taper. Also, monitor patients for changes in mood, emergence of suicidal thoughts, or use of other substances. A multimodal approach to pain management may optimize the treatment of chronic pain and assist with the successful tapering of the opioid analgesic.
  • May be administered via PCA pump.
• PO: Doses may be administered with food or milk to minimize GI irritation. Dilute syrup in half-full glass of water.
• IM: Patient should be lying down when administered; IM is the preferred route for repeated doses. SUBQ administration may cause tissue irritation.

• FDA strongly encourages health care professionals to complete a REMS-compliant education program that includes all the elements of the FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain, available at www.fda.gov/OpioidAnalgesicREMSBlueprint. Information on programs can be found at 1-800-503-0784 or www.opioidanalgesicrems.com.

• Discuss availability of naloxone for emergency treatment of opioid overdose with the patient and caregiver and assess the potential need for access to naloxone, both when initiating and renewing therapy, especially if patient has household members (including children) or other close contacts at risk for accidental exposure or overdose. Consider prescribing naloxone, based on the patient’s risk factors for overdose, such as concomitant use of CNS depressants, a history of opioid use disorder, or prior opioid overdose. However, the presence of risk factors for overdose should not prevent the proper management of pain in any patient.

IV Administration:

• Administer undiluted.

• Rate:

  Administer slowly over at least 5 min. Rapid administration may lead to ↑ respiratory depression, hypotension, and circulatory collapse.

• Intermittent Infusion: Diluent: Dilute with D5W, D10W, dextrose/saline combinations, dextrose/Ringer’s or LR injection combinations, 0.45% NaCl, 0.9% NaCl, or LR. Administer via infusion pump.Concentration: 1 mg/mL.