• Joseph H Crane and Katie J Suda.
• College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN 38163, USA. jcrane2@uthsc.edu
• Int J Clin Pharm. 2011 Oct 1; 33 (5): 733-6.

CaseOpioids are commonly prescribed for pain, and are often connected to mental status adverse events. Delirium is a side effect associated with narcotic analgesics, with a higher incidence in the elderly. This report describes an elderly male that received a total knee arthroplasty and received morphine post-operatively. On post-operative day 2, morphine was discontinued due to mental status changes and switched to oxycodone/acetaminophen. Twenty-four hours after administering oxycodone, the patient's mental status declined. After the patient returned to baseline he was transferred to rehabilitation and re-challenged with oxycodone/acetaminophen. The re-challenge was inadvertent due to inadequate documentation of the adverse event and lack of understanding by the health care team of delirium associated with opioids. A similar rapid decline in mental status occurred.ConclusionClinicians should be cognizant of narcotic analgesics inducing mental status changes, even with an alternative. Detailed documentation of adverse events should occur to avoid accidental re-challenges.

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