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Pharmacologic class: Opioid agonist-antagonist
Therapeutic class: Opioid analgesic
Controlled substance schedule IV Pregnancy risk category C
Alters perception of and emotional response to pain by binding with opioid receptors in brain, causing CNS depression. Also exerts antagonistic activity at opioid receptors, which reduces risk of toxicity, drug dependence, and respiratory depression.
Injection: 1 mg/ml, 2 mg/ml
Nasal spray: 10 mg/ml
Indications and dosages
➣ Moderate to severe pain
Adults: 1 to 4 mg I.M. q 3 to 4 hours as needed, not to exceed 4 mg/dose. Or 0.5 to 2 mg I.V. q 3 to 4 hours as needed. With nasal spray, 1 mg (one spray in one nostril) q 3 to 4 hours, repeated in 60 to 90 minutes if needed.
➣ Labor pains
Adults: 1 to 2 mg I.V. or I.M., repeated after 4 hours as needed
➣ Preoperative anesthesia
Adults: 2 mg I.M. 60 to 90 minutes before surgery
➣ Balanced anesthesia
Adults: 2 mg I.V. shortly before anesthesia induction, or 0.5 to 1 mg I.V. in increments during anesthesia
• Renal or hepatic impairment
• Elderly patients
• Symptomatic relief of ureteral colic
• Hypersensitivity to drug
Use cautiously in:
• head injury, ventricular dysfunction, coronary insufficiency, respiratory disease, renal or hepatic dysfunction
• history of drug abuse.
• Make sure solution is clear and free of particulates before giving.
• When using nasal spray, insert tip of the sprayer about ¼″ into nostril, point tip backwards, and administer one spray.
• Be aware that I.V. route is preferred for severe pain.
☞ Know that drug may cause infant respiratory distress in neonate of pregnant patient, especially if given within 2 hours of delivery.
CNS: drowsiness, sedation, dizziness, tremor, irritability, syncope, stimulation
CV: hypertension, hypotension, palpitations, bradycardia, tachycardia, extrasystole, arrhythmias
EENT: blurred vision, nasal congestion or dryness, dry or sore throat
GI: nausea, vomiting, constipation, epigastric distress, dry mouth, GI obstruction
GU: urinary retention or hesitancy, dysuria, early menses, decreased libido, erectile dysfunction
Hematologic: hemolytic anemia, hypoplastic anemia, thrombocytopenia, agranulocytosis, leukopenia, pancytopenia
Respiratory: thickened bronchial secretions, chest tightness, wheezing
Skin: urticaria, rash, diaphoresis
Other: increased or decreased appetite, weight gain, local stinging, anaphylactic shock, hypersensitivity reaction (with I.V. use)
Drug-drug. CNS depressants: additive CNS effects
Drugs-herbs. Kava, St. John's wort, valerian: increased CNS depression
Drug-behaviors. Alcohol use: additive CNS effects
• Monitor respiratory status closely, especially after I.V. administration.
• Watch for signs and symptoms of withdrawal in long-term use and in opioid-dependent patients.
• Assess elderly patient closely for sensitivity to drug.
• Teach patient how to use nasal spray properly.
• Emphasize importance of using drug exactly as prescribed.
• Caution patient that drug may be habit-forming.
• Advise patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and behaviors mentioned above.
ClassificationTherapeutic: opioid analgesics
Pharmacologic: opioid agonists antagonists
Time/action profile (analgesia)
|IM||within 15 min||30–60 min||3–4 hr|
|IV||within mins||4–5 min||2–4 hr|
|Intranasal||within 15 min||1–2 hr||4–5 hr|
Adverse Reactions/Side Effects
Central nervous system
- confusion (most frequent)
- dysphoria (most frequent)
- hallucinations (most frequent)
- sedation (most frequent)
- floating feeling
- unusual dreams
Ear, Eye, Nose, Throat
- blurred vision
- miosis (high doses)
- respiratory depression
- nausea (most frequent)
- dry mouth
- urinary retention
- sweating (most frequent)
- clammy feeling
- physical dependence
- psychological dependence
Drug-Drug interactionUse with extreme caution in patients receiving MAO inhibitors (may produce severe, potentially fatal reactions—reduce initial dose of butorphanol to 25% of usual dose).Additive CNS depression with alcohol, antidepressants, antihistamines, and sedative/hypnotics.May precipitate withdrawal in patients who are physically dependent on opioids and have not been detoxified.May ↓ effects of concurrently administered opioids.Concomitant use of kava-kava, valerian, chamomile, or hops can ↑ CNS depression.
Availability (generic available)
- Assess type, location, and intensity of pain before and 30–60 min after IM, 5 min after IV, and 60–90 min after intranasal administration. When titrating opioid doses, increases of 25–50% should be administered until there is either a 50% reduction 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. Patients requiring doses higher than 4 mg should be converted to an opioid agonist. Butorphanol is not recommended for prolonged use or as first-line therapy for acute or cancer pain.
- An equianalgesic chart (see ) should be used when changing routes or when changing from one opioid to another.
- Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Dose may need to be decreased by 25–50%. Respiratory depression does not increase in severity, only in duration, with increased dosage.
- Assess previous analgesic history. Antagonistic properties may induce withdrawal symptoms (vomiting, restlessness, abdominal cramps, increased BP and temperature) in patients who are physically dependent on opioid agonists.
- Butorphanol has a lower potential for dependence than other opioids; however, prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent the patient from receiving adequate analgesia. Most patients receiving butorphanol for pain do not develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve pain.
- Lab Test Considerations: May cause ↑ serum amylase and lipase levels. If an opioid antagonist is required to reverse respiratory depression or coma, naloxone (Narcan) 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 direct 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 1–2 min. Titrate dose to avoid withdrawal, seizures, and severe pain.
Potential Nursing DiagnosesAcute pain (Indications)
Risk for injury (Side Effects)
Disturbed sensory perception(visual, auditory) (Side Effects)
- high alert: Accidental overdosage of opioid analgesics has resulted in fatalities. Before administering, clarify all ambiguous orders; have second practitioner independently check original order, dose calculations, route of administration, and infusion pump programming.
- Explain therapeutic value of medication before administration to enhance the analgesic effect.
- Regularly administered doses may be more effective than prn administration. Analgesic is more effective if given before pain becomes severe.
- Coadministration with nonopioid analgesics may have additive analgesic effects and permit lower opioid doses.
- Intramuscular: Administer IM injections deep into well-developed muscle. Rotate sites of injections.
- pH: 3.0–5.5.
- Diluent: May give IV undiluted.
- Concentration: 1–2 mg/mL.
- Rate: Administer over 3–5 min. high alert: Rapid administration may cause respiratory depression, hypotension, and cardiac arrest.
- Y-Site Compatibility: acyclovir, alemtuzumab, allopurinol, amifostine, amikacin, aminocaproic acid, aminophylline, amphotericin B lipid complex, amphotericin B liposome, anidulafungin, argatroban, ascorbic acid, atracurium, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, calcium chloride, calcium gluconate, carboplatin, carmustine, caspofungin, cefazolin, cefepime, cefoperazone, cefotaxime, cefotetan, ceftazidime, ceftriaxone, cefuroxime, chlorpromazine, cisatracurium, cladribine, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doxacurium, doxorubicin hydrochloride, doxorubicin liposome, doxycycline, enalaprilat, ephedrine, epinephrine, epirubicin, epotein alfa, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, filgrastim, fluconazole, fludarabine, fluorouracil, gemcitabine, gentamicin, glycopyrrolate, granisetron, heparin, hydrocortisone, idarubicin, ifosfamide, imipenem/cilastatin, irinotecan, isoproterenol, ketorolac, labetalol, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, melphalan, meperidine, metaraminol, methotrexate, methoxamine, methyldopate, methylprednisolone, metoclorpramide, metoprolol, metronidazole, milrinone, mitoxantrone, morphine, multivitamins, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancruonium, papaverine, pemetrexed, penicillin G, pentazocine, phenobarbital, phentolamine, phenylephrine, phytonadione, piperacillin/tazobactam, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, protamine, pyridoxime, quinupristin/dalfopristin, ranitidine, remifentanil, rituximab, rocuronium, sargramostim, sodium acetate, streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, trastuzumab, trimethphan, vancomycin, vasopressin, vecuronium, verapamil, vincristine, vinorelbine, voriconazole, zoledronic acid
- Y-Site Incompatibility: amphotericin B cholesteryl, amphotericin B colloidal, azathioprine, chloramphenicol, dantrolene, diazepam, diazoxide, furosemide, genciclovir, indomethacin, insulin, pantoprazole, pentamidine, pentobarbital, phenytoin, sodium bicarbonate, trimethoprim/sulfamethoxazole
- Intranasal: Administer 1 spray in 1 nostril.
- Instruct patient on how and when to ask for pain medication.
- Medication may cause drowsiness or dizziness. Advise patient to call for assistance when ambulating and to avoid driving or other activities requiring alertness until response to the medication is known.
- Encourage patients on bedrest to turn, cough, and deep-breathe every 2 hr to prevent atelectasis.
- Instruct patient to change positions slowly to minimize orthostatic hypotension.
- Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication.
- Advise patient that good oral hygiene, frequent mouth rinses, and sugarless gum or candy may decrease dry mouth.
- Intranasal: Instruct patient on proper use of nasal spray. See package insert for detailed instructions. Instruct patient to replace protective clip and clear cover after use and to store the unit in the child resistant container. Caution patient that medication should not be used by anyone other than the person for whom it was prescribed. Excess medication should be disposed of as soon as it is no longer needed. To dispose of, unscrew cap, rinse bottle and pump with water, and dispose of in waste can.
- If 2-mg dose is prescribed, administer additional spray in other nostril. May cause dizziness and dysphoria. Patient should remain recumbent after administration of 2-mg dose until response to medication is known.
- Decrease in severity of pain without a significant alteration in level of consciousness or respiratory status.