• Assess BP, HR, and respiratory rate before and periodically during administration. If respiratory rate <10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Dose may need to be ↓ by 25–50%. Initial drowsiness will diminish with continued use. 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).

  • Assess bowel function routinely. Prevention of constipation should be instituted with ↑ intake of fluids, bulk, and laxatives to minimize constipating effects. Stimulant laxatives should be administered routinely if opioid use >2–3 days, unless contraindicated. Consider drugs for opioid-induced constipation.

• Assess risk for opioid addiction, abuse, or misuse prior to administration.

• Pain: Assess type, location, and intensity of pain before and 1 hr (peak) after administration. When titrating opioid doses, ↑ of 25–50% should be administered until there is either a 50% ↓ in the patient’s pain rating on a numerical 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.
  • An equianalgesic chart (see Equianalgesic Dosing Guidelines) should be used when changing routes or when changing from one opioid to another.
  • Monitor patients for opioid-induced hyperalgesia occurs when an opioid paradoxically causes an ↑ in pain, or an ↑ in sensitivity to pain. Opioid-induced hyperalgesia differs from tolerance, which is the need for ↑ doses of opioids to maintain a defined effect. Symptoms of opioid-induced hyperalgesia include ↑ levels of pain upon opioid dosage ↑, ↓ levels of pain upon opioid dosage ↓, or pain from ordinarily nonpainful stimuli. If opioid-induced hyperalgesia suspected, consider ↓ codeine dose.

  • Prolonged use may lead to physical and psychological dependence and tolerance, which should not prevent patient from receiving adequate analgesia. Most patients who receive codeine for pain do not develop psychological dependence. If progressively higher doses are required, consider conversion to a stronger opioid.

• Cough: Assess cough and lung sounds during antitussive use.

Lab Test Considerations:

• May cause ↑ amylase and lipase concentrations.

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.