Monitoring for Opioid-Induced Respiratory Depression

Publication ID: 8572196430
Published on: September 2023
Major Revision: May 24, 2024


Our actionable evidence-based practices were designed by world-renowned patient safety experts to serve as proven step-by-step guidelines on eliminating the top causes of preventable harm. This blueprint has a proven track record of ensuring the best patient care. Please note that our guidelines are continually updated and incorporate the latest safety practices recognized as the gold standard of care.
Frontline staff

This blueprint outlines the steps that frontline staff can follow to monitor for opioid-induced respiratory depression: 

Best Practice Summary

  1. Monitoring after prescribing opioids:
    1. Ensure patients receiving opioids are continuously monitored for SPO2, respiratory rate, and intermittent level of consciousness.
      1. Consider monitoring oxygen reserve index.
    2. Set actionable alarms with clear requirements for the clinician’s and patient’s response.
    3. Reassess pain routinely. Titrate opioid dose as early as possible and consider non-opioid pain management alternatives.
    4. Evaluate new or changed medications that may interact with the opioid medication.
    5. Monitor for signs of deterioration, such as slow respiration and altered mental status.
    6. Include patient signs of deterioration as a discussion point in hand-offs and multidisciplinary rounds.
    7. Use the organization’s escalation criteria to call a rapid response if needed.
    8. Ensure that a reversal agent (Narcan) is located near the patient.
    9. Possibly look into FDA-cleared personal medical devices that reduce opiate withdrawal symptoms.
  2. Discharge:
    1. Plan for home monitoring if the patient is going home with opioids.
      1. Explore the possibility of using a monitoring device with Bluetooth capabilities and pairing it with a mobile device.
    2. Ensure patients and family members understand the importance of monitoring, how to use monitoring equipment, how to appropriately take the opioids, non-opioid pain management strategies, patient-specific risk factors, and when to call for help.
    3. Consider providing reversal agents (Narcan) to patients and family members upon discharge.

Clinical Workflow

  1. Monitoring after prescribing opioids:
    1. Establish the patient’s baseline and risk(s). Have multiple clinicians involved in and contributing to the baseline assessment. Include in assessment what opioid alternatives have worked in the past, if applicable, and what the patient might be willing to try.
    2. Consider moving high-risk patients to an area more visible from the nursing station.
    3. Make sure the patient is continuously monitored and the alarms are appropriately set. Respond to all alarms as quickly as possible.
    4. Use a defined sedation score on a routine basis.
    5. Reassess pain as frequently as defined by the provider. At a minimum, reassess at designated intervals per policy and with a change in patient condition.
      1. If pain persists, order consultation with the care team to discuss pain management strategy.
        • Involve palliative care team members, adjunct therapies, and alternatives. Distinguish the type of pain (acute versus chronic).
      2. If pain decreases, titrate dose for desired effect and consider introducing other pain management strategies.
      3. Reassess the patient’s reaction to the short-term initial dose before advancing treatment.
    6. Reassess vital signs and sedation level as frequently as defined by the provider.
      1. If vital signs indicate potential deterioration, alert provider. Reassess and analyze trends.
      2. If vital signs indicate improvement or no change in condition, alert provider.
      3. If sedation levels are deeper than intended, mobilize a team for rescue by contacting rapid response and the provider.
    7. Raise a concern about any new medications that may adversely influence the current opioid therapy (e.g., benzodiazepines).
    8. Remain sensitive to early indications of deterioration, such as slow respiration, ineffective treatment of pain requiring increased dosages, altered mental status, oxygen saturation, etc.
      1. If an emergency occurs due to respiratory depression, administer Narcan ASAP, check for pulse, and ensure an open airway.
        • If there is a pulse, provide assisted ventilation and oxygenation as needed.
        • If there is no pulse, start CPR.
        • Use naloxone ASAP. If the dose is ineffective, repeat titrated doses every 1-2 minutes.
      2. If a non-emergency occurs but vital signs are indicating a need for increased ventilation support, contact respiratory therapist and/or call rapid response. Start implementing basic changes to prevent further deterioration (e.g., repositioning).
      3. If false alarms are frequent, request that the alarm settings are changed. Reassess positioning of the equipment on the patient.
    9. Include patient’s trends in hand-off report.
  1. Discharge
    1. Plan for at home monitoring if the patient is going home with opioids.
    2. Ensure the patient and family members are well-equipped to use the home monitor and respond appropriately.
    3. Ask about the patient’s expectations for pain and function.
    4. Consider non-opioid pain management methods.
    5. Consider sending patients prescribed opioids home with naloxone, which can be given as either an auto-injector or nasal spray.
      1. Educate family members on the proper use, storage, and administration technique of naloxone.
    6. Educate patients and family members on basic CPR and when to use CPR.
    7. See Education for Patients and Family Members below for information to share with patients and family members.

Education for Patients and Family Members

  1. Within shared decision-making conversations, discuss:
    1. Risks versus benefits
    2. Alternatives to opioids and why opioids are indicated
    3. Side effects of opioids
    4. That the initial benefits of opioid therapy may decrease with prolonged use
    5. The purpose of the monitor and what to watch out for, particularly when the patient is going home with opioids and a monitor. Ensure patients and family members know exactly how to use the monitor and respond appropriately.
    6. How to use naloxone or other reversal agents and the appropriate next steps after administration
    7. How to properly do CPR and when
    8. The policies regarding prescribing, refills, etc., and why those policies exist
    9. How patients will get their medications and afford their medications
    10. The methods for monitoring the patient’s opioid use (e.g., urine drug testing) and why those methods exist
    11. Other members of the care team the patient may encounter and what their roles are in opioid therapy
Unit Managers

This guide outlines the steps that managers can follow to monitor for opioid-induced respiratory depression: 

  1. Pain Management
    1. Develop a multimodal pain management program that is linked with clinical workflows in an easily accessible way.
    2. Standardize workflows to ensure pain is continuously assessed and alternative strategies are considered thoroughly.
  2. Appropriate Monitoring
    1. Set institution-specific criteria that tailors alarms based on individual patient care needs.
    2. Standardize hand-off reports to include information about trends (e.g., end tidal CO2 threshold values). Use this information to adjust alarm thresholds per individual patient.
    3. Create a shared chain of command system between care team members when alarms go off and aren’t addressed.
    4. Standardize debrief expectations and interventions post-rapid response call.
    5. Complete an alarms inventory, display in a grid or other clear visual, and clearly define which disciplines are able to change the alarms and settings and which alarms and settings require interdisciplinary discussion during rounds before changing.
    6. Explore possible personal FDA-approved medical devices dedicated to monitoring or easing withdrawal symptoms.
  3. System-Wide Expectations and Policies for Monitoring
    1. Build the system curriculum around advanced objectives to reinforce concepts and determine where education around opioids can be linked with other related education (e.g., education around sedation).
  4. Measurement and Sustainment
    1. Display performance data visually in a place that everyone can see and in a way that is easily understood. Use this board as a focal point during debrief sessions and update accordingly with actions for improvement.
    2. Ensure organizational committees related to monitoring for opioid-induced respiratory depression are closely linked with other monitoring efforts to increase attention to the issue. Solicit input from members of other committees when determining how a change in monitoring protocols will impact other areas of care.
  5. Performance Improvement Plan
    1. Recommended monitoring for opioid-induced respiratory depression improvement team members:
      1. Admitting and registration staff
      2. Quality and safety specialists
      3. Pain management specialists
      4. Palliative care specialists
      5. Nurses
      6. Physicians
      7. Pharmacists
      8. Anesthesia providers (e.g., anesthesiologists, CRNAs, etc.)
      9. Mental health professionals (e.g., psychologists, psychiatrists, addiction specialists, etc.)
      10. Occupational, physical, and respiratory therapists
      11. Chiropractors
      12. Care coordination and social workers
    2. Understand what is currently happening and why. Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data (and validating the sources), but the most important action here is to go to the point of care and observe. Even if team members work in the area daily, examining existing processes from every angle is generally an eye-opening experience. The team should ask questions of the frontline during the observations that allow them to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.
    3. Prioritize the gaps and potential solutions. Identify root causes of the gaps identified. Conduct a prioritization exercise to understand the organizational impact and effort of identified solutions, as many of the gaps may be addressed with the same solution. Determine which are priorities of focus for the organization.
  1. Metrics to Consider Assessing
    1. Process metrics
      1. Frequency of pain assessment
      2. Patient assessment with changes in treatments
      3. Use of organizationally standardized tools for risk factor assessment
      4. Justification of reasons documented for alarm adjustments
      5. Patient’s understanding during conversations around shared decision making, review of treatment agreements, and risks and benefits
      6. Number of patients prescribed opioids who were also referred to non-pharmacologic therapy
      7. Concurrent opioid and benzodiazepine treatments
      8. False alarm rate
      9. Alarm overrides
      10. The frequency that aggregated monitoring data is reviewed to determine whether there is a need to adjust alert threshold
      11. Number of reversal agents utilized or frequency of naloxone administration
      12. Post-discharge follow-up visit frequency
      13. Patient and Family Advisory Council (PFAC) involvement in monitoring-related decision making
    2. Structural metrics
      1. Whether a protocol exists that includes standard monitoring for opioid-induced respiratory depression processes and what to do upon an alarm
      2. Whether a rapid response team exists
      3. Whether the organization has a clear protocol for pain assessment
      4. Whether the organization has a standardized pain assessment tool
      5. Whether the organization has a mechanism to follow-up with patients discharged with opioids
    3. Outcome metrics
      1. Mortality
      2. Length of stay
      3. Codes due to opioid-induced respiratory depression
      4. Rapid responses due to opioid-induced respiratory depression
      5. Rate of patients with postoperative respiratory failure per 1,000 elective surgical discharges for patients 18 years and older
  1. Pain Management Assessment Tools to Standardize (e.g., sedation assessment tools)
    1. Develop a multimodal pain management program that is linked with clinical workflows in an easily accessible way.
    2. Standardize workflows to ensure pain is continuously assessed and alternative strategies are considered thoroughly.
Hospital Executives

This protocol outlines the steps that executives can follow to prevent opioid-induced respiratory depression: 

Opioid-induced respiratory depression is the biggest killer of adolescents in the US. Over 100,000 young adults died last year from an opioid overdose. Many were taking illicit opioids or other medications that had been laced with fentanyl. Therefore, extreme care of prescribed opioids must be taken, and nasal Narcan should be kept close by. Remote monitoring for respiratory depression is strongly advised. Explore FDA-approved personal medical devices that support patients through opiate withdrawal.

  1. Clinical and Financial Implications

It has been shown that most adverse drug events are a result of drug-drug interactions, with up to 16% involving opioids. Over 80% of patients receive opioids even after low-risk surgeries, and the subsequent incidence of respiratory depression among postoperative patients is approximately 0.5%. Of the opioid-related adverse drug events reported, it has been estimated that nearly one third of deaths were due to inappropriate monitoring of patients on opioids. As many as 1 in 4 patients receiving prescription opioids report struggling with addiction.

The following are solutions to reduce postoperative opioid-induced respiratory depression:

    1. Properly monitor and identify patients at risk for “failure to rescue.”
    2. Create systems to notify staff of important changes in patient condition.
    3. Ensure proper pain management and opioid dosing.
    4. Use automated decision support to ensure staff use the right therapy at the right time.
  1. The Problem
    1. Over 50% of patients in the hospital receive opioids at some point in their care, and of those patients, up to 4.2% will experience an adverse event between hospitalization and post-discharge, contributing to a 55% longer length of stay, 47% higher costs, 36% increased risk of readmission after 30 days, and 3.4 times greater likelihood of mortality. It is estimated that 97% of opioid-induced respiratory depression events within 24 hours of surgery could be prevented with better patient monitoring.
  2. The Cost
    1. It is not uncommon for legal settlements for death or severe brain injury to range from $650,000 to $7.7 million. Postoperative overdoses in the hospital and in the home/community doubled between 2002 to 2011, indicating that, despite national attention from governing bodies, opioid-related adverse events were on the rise during the first decade of this century.
  3. The Solution
    1. Many healthcare organizations have successfully implemented and sustained improvements and reduced death from opioid-induced respiratory depression. The related checklists for managers and frontline staff outline the actionable steps organizations should take to successfully improve monitoring for opioid-induced respiratory depression-related harm and summarize the available evidence-based practice protocols.

What We Know About Monitoring for Opioid-Induced Respiratory Depression

Opioids are commonly administered to patients to relieve acute pain and rank among the drugs most frequently associated with adverse events. While the administration of opioids is pivotal for the well-being and treatment of many hospitalized patients, there are a significant number of adverse effects from opioid administration. Among the plethora of adverse effects, sudden death due to decreased respiration and addiction are among the most significant.

Clinical and Financial Implications

The cost associated with respiratory failure after surgery alone in the US healthcare system is an estimated $2 billion.

While opioid use is safe for many patients, opioid analgesics are associated with adverse effects, including respiratory depression, in many post-surgical patients.

Adverse effects associated with opioids not only include respiratory depression but also hyperalgesia, early development of tolerance, ileus (inability of the intestine to move food or waste), constipation, sedation, nausea and vomiting, and delayed recovery. In addition, patients receiving opioids in the hospital have almost twice the incidence of cardiac arrest compared to other patients. If these adverse events lead to death or serious harm to a patient, they are labeled as “failure to rescue.”

Administration of supplemental oxygen complicates the monitoring issue, as it can delay detection of depressed ventilation and further impair hypoxic respiratory drive.

The Institute of Medicine (IOM) described failure to rescue as a key issue in healthcare quality in 2001.

Recommendations to Address Opioid-Induced Respiratory Depression

In 2011, the Anesthesia Patient Safety Foundation recommended continuous monitoring for all patients receiving parenteral opioids and using a system to notify caregivers when alarming conditions occur or are anticipated.

In August 2012, the Joint Commission issued a Sentinel Event alert (a change in policy based on death or serious harm to a patient), urging all healthcare systems to introduce measures to improve safety for patients receiving opioids, including systematic protocols to assess pain and proper opioid dosing, as well as continuous monitoring of oxygenation and ventilation.

In 2014, the Center for Medicare and Medicaid Services (CMS) clarified the surgical services Condition of Participation (CoP) for hospitals to have adequate provisions for immediate postoperative care and to emphasize the need for monitoring after surgery for patients receiving parenteral opioid medications, regardless of where they are in the hospital.

Research has studied the development of early warning systems, and these systems have been validated in Europe and Australia.

One study demonstrated that clinicians using continuous pulse oximetry, measured through motion and low perfusion pulse oximetry, and a robust clinician notification system identified patient distress earlier, which decreased rapid response team activations by 65% and ICU transfers by 48%, thereby reducing ICU days by 135 days annually.

Patient & Families

The following guide outlines the steps that patients and patient families can follow to prevent opioid-induced respiratory depression:

Opioid-induced respiratory depression is a serious and potentially life-threatening side effect of opioid medications. It occurs when opioids depress the brainstem’s respiratory centers, leading to decreased sensitivity to carbon dioxide and reduced drive to breathe.

  1. Take opioids exactly as prescribed.
  2. Always let your doctor know of any side effects immediately.
  3. Do not combine with alcohol or other medications without talking to your doctor first.
  4. Do not share your prescription at all.
  5. Store your prescriptions in a secure place, out of reach of others (including children, family, friends, and visitors).
  6. If you have unused prescription opioids at the end of your treatment, find your community drug take-back program or your pharmacy mail-back program to dispose of them safely. Do not flush the opioids down the toilet.
  7. Ask your physician for the possibility of a personal FDA-approved medical device that reduces withdrawal symptoms, and/or measures oxygen levels.

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Fazio, S., et al. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. Patient Safety Network. (2020)

Hah, Jennifer M et al. “Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic.” Anesthesia and analgesia vol. 125,5. (2017)

Joint Commission. Safe Use of Opioids. (2012)

Joint Commission. 2023 Annual Updates Safe Use of Opioids—Concurrent Prescribing (CMS506). (2023)

Jungquist C, et al. Identifying Patients Experiencing Opioid-Induced Respiratory Depression During Recovery From Anesthesia: The Application of Electronic Monitoring Devices. (2019)

Khanna A, et al. Opioid-induced respiratory depression increases hospital costs and length of stay in patients recovering on the general care floor. (2021)

Khanna A, et al. Prediction of Opioid-Induced Respiratory Depression on Inpatient Wards Using Continuous Capnography and Oximetry: An International Prospective, Observational Trial. (2020)

Kozub E, et al. Preventing Postoperative Opioid-Induced Respiratory Depression Through Implementation of an Enhanced Monitoring Program. (2022)

Urman R, et al. Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial. (2021)

Wright, Adam et al. “Preventability of adverse drug events involving multiple drugs using publicly available clinical decision support tools.” American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists vol. 69,3. (2012)