Patient Counseling: Most Important Opioid Warnings

JANUARY 30, 2017
I believe it is our duty as pharmacists to educate patients about their medications.  Furthermore, according to the Omnibus Budget Reconciliation Act of 1990 (OBRA ’90), among other items, pharmacists must counsel patients on the proper use, warnings, and common side effects of their medications.
Yes, outpatient pharmacies are busy and regularly we are pressured into meeting pharmacy metrics, which may limit time at the pharmacy counter. We constantly weigh the importance of discussing medication with patients at the counseling counter against completing our ever increasing workload before our shift is complete.
To fit it all in, we need to have a clear understanding of the salient counseling points for the top 300 medications ready to go at a moment’s notice. When called to the counseling counter, following a brief introduction, we quickly review the patient’s prescriptions and any notes we have made, and then launch into our session.
Of course, we all have our own way and order of addressing the prescription counseling points as well as our personal way of engaging with our patients. Among other items, of course, we will never let a patient leave the counter without at least a brief discussion of the important black box warnings associated with each specific prescription dispensed.
These are the most important warnings as designated by the FDA. When a medication is listed as having a black box warning it means that an adverse reaction or inappropriate use may lead to serious injury or death. Discussing with a patient the cautions about these warnings may save theirs or a family member’s life.
Long-acting opioid medications, such as oxymorphone er, oxycodone er, and morphine er, have between 7 or 8 black box warnings associated with them. Before you review the list below, take a moment and see if you can list them.
  1. Extended release opiates are only for moderate to severe pain when around-the-clock pain control is needed and other pain medications are not working. 
  2. If these medications are used on a patient not used to taking narcotics, they may stop breathing.  Serious or fatal cases have happened even with the regular dose. Swallow the tablet whole, do not crush or chew the tablet.
  3. These medications have an increased risk of abuse, addiction and theft. Tell your doctor know if you or anyone in your family has a history of substance abuse. Store these medications in a safe place to prevent theft.
  4.  If a child accidently takes even one tablet, they may stop breathing and die.
  5.  Do not consume alcohol while taking these medications. Combining alcohol and extended release opioids may be fatal.
  6.  When pregnant mothers use these medications, the unborn child is at risk.  The newborn may need prolonged withdrawal treatment.
  7.  These medications may interact with other specific medications and cause serious side effects including death.  Tell your doctor and pharmacist all of your other medications before starting extended release opiates.
  8.  Be aware, combining these medications with anxiety medications, such as diazepam or alprazolam, may cause extreme sleepiness, significant breathing difficulties, and death.
Keep these warnings in mind the next time you approach the counter to talk with a patient about their long acting opioid pain medication. 

Steve Leuck, PharmD
Steve Leuck, PharmD
Steve Leuck, PharmD, has been practicing both hospital and community pharmacy for over 30 years. He founded AudibleRx, in 2011, which provides Consumer Medication Information which is both Useful and Accessible. Content designed to meet health literacy guidelines. Format designed to "read along" with the audio presentation in a simple to use web application. More information at