What should be prescribed to a patient taking lorazepam (Ativan) and oxycodone for a rib fracture, given the risk of opioid-induced respiratory depression?

Naloxone Should Be Prescribed for Patients Taking Lorazepam and Oxycodone

The patient should be prescribed naloxone (Option A) due to the high risk of respiratory depression from the combination of lorazepam and oxycodone.

Rationale for Naloxone Prescription

• The concomitant use of benzodiazepines (lorazepam) and opioids (oxycodone) significantly increases the risk of respiratory depression, sedation, coma, and death compared to using opioids alone 1
• The FDA black box warning for lorazepam specifically warns about the dangers of combined use with opioids due to the risk of profound sedation, respiratory depression, coma, and death 1
• When benzodiazepines and opioids are combined, there is increased potential for benzodiazepines to significantly worsen opioid-related respiratory depression 1
• The American Heart Association recommends naloxone as the specific antidote for opioid-induced respiratory depression 2

Administration of Naloxone

• Initial adult dosing of naloxone is 0.4 mg IV, which can be repeated every 2-3 minutes as needed, with alternative routes including intramuscular and intranasal administration 2
• For patients with therapeutic opioid use, lower initial doses (0.04-0.2 mg) may be considered to avoid complete reversal of analgesia 2
• Naloxone should be titrated to reversal of respiratory depression and restoration of protective airway reflexes 3

Risk Factors in This Patient

• The patient is taking lorazepam 0.5 mg TID PRN (a benzodiazepine) and will be discharged on oxycodone (an opioid) 1
• This combination significantly increases the risk of respiratory depression as both medications cause CNS depression through different mechanisms 1
• Benzodiazepines interact at GABAA sites while opioids interact primarily at mu receptors, creating a synergistic depressant effect on respiration 1
• Rib fractures may further compromise respiratory function, increasing the risk of respiratory depression 3

Monitoring and Follow-up

• The patient should be monitored for signs of respiratory depression, including decreased respiratory rate, oxygen saturation, and level of consciousness 2
• The duration of action of naloxone (30-60 minutes) is shorter than many opioids, so patients should be observed for at least 2 hours after the last dose of naloxone 2
• If respiratory depression recurs, additional doses of naloxone or a continuous infusion may be required 3

Why Not Other Options

• Percocet (Option B) contains oxycodone plus acetaminophen, which would be redundant since the patient is already prescribed both Tylenol (acetaminophen) and oxycodone 3
• Vicodin (Option C) contains hydrocodone plus acetaminophen, which would be redundant with the Tylenol already prescribed and would add another opioid to the regimen, increasing risk 3
• Ketamine (Option D) is not indicated for take-home use in this scenario and would add another CNS depressant to the regimen 3

Patient Education

• Advise both the patient and caregivers about the risks of respiratory depression and sedation when lorazepam is used with opioids 1
• Instruct the patient not to drive or operate heavy machinery until the effects of concomitant use with the opioid have been determined 1
• Educate the patient and caregivers on the proper use of naloxone in case of respiratory depression 2

Pitfalls to Avoid

• Failing to recognize the significant risk of respiratory depression with combined benzodiazepine and opioid use 1
• Not providing naloxone for a patient at high risk for respiratory depression 3
• Assuming that standard doses of opioids are safe in patients taking benzodiazepines 1
• Not educating patients and caregivers about the signs of respiratory depression and proper use of naloxone 2