Drugs Analgesics ========== 2: Converting from other opioids to oxymorphone Opioid Approximate Equivalent Oral Conversion Oral Dose Ratio Oxymorphone 10 mg 1 Hydrocodone 20 mg 0.5 Oxycodone 20 mg 0.5 Methadone 20 mg 0.5 Morphine 30 mg 0.333 Table 3: Equivalence dosing from oxycodone CR (OXYCONTIN®) to oxymorphone (OPANA ER®) using conversion factor of 0.5 OXYCONTIN® OPANA ER® 10 mg every 12 hours 5 mg every 12 hours 20 mg every 12 hours 10 mg every 12 hours 30 mg every 12 hours 15 mg every 12 hours 40 mg every 12 hours 20 mg every 12 hours 60 mg every 12 hours 30 mg every 12 hours 80 mg every 12 hours 40 mg every 12 hours þ Narcotics vs. Sphincter of Oddi spasm: - Patients with pancreatitis and biliary disease commonly receive meperidine for pancreatic pain, due to the reported decreased pressure on the Sphincter of Oddi with meperidine. Studies have shown that meperidine caused spasm of the sphincter mechanism of the common bile duct and that it also increased rather than relieved natural spasm.1 Clinically, repeated findings provide evidence that equianalgesic doses of meperidine cause similar effects on the Sphincter of Oddi and the biliary tract as morphine, thus refuting one of the major selection criteria for using meperidine preferentially over other opioids.2 Due to the chronic pain and severity associated with pancreatitis, higher doses of meperidine are required for adequate relief, increasing the patient's risk of normeperidine accumulation and toxicity. 1 Latta KS, Ginsberg B, Barkin RL. Meperidine: A Critical Review. American Journal of Therapeutics 2002; 9:53-68 2 Skledar SJ. Meperidine Guidelines for Use OR Pharmacy Services Associations Quarterly Bulletin. 1998 Fall; XIII (II). þ Narcotic Equivalents IV Med PO -------------------------------------------------------------- 60 mg codeine (T3#=30) 100 mg 100 mcg fentanyl N/A N/A hydrocodone (e.g., Vicodin=5+Tylenol) 15 mg 1 mg hydromorphone (e.g., Dilaudid) 4 mg 1 mg levorphanol (e.g., Levo-Dromoran) 2 mg 50 mg meperedine (e.g., Demerol) 150 mg 5 mg methadone 10 mg 5 mg morphine 15 mg N/A oxycodone (e.g., Percocet=5+Tylenol) 10 mg* *but note a recent study, reported at SAEM 2004, found no difference between Vicodin and Percocet in analgesia, so this would mean 10 mg PO = 10 mg PO. see also: þ Oxycontin - Oxycontin-Oral Narcotic Equivalents - Oxycontin-IV/IM/Transdermal Narcotic Equivalents þ Analgesics to Avoid in the Elderly þ See also: - PCA pumps - Local Anaesthetics - MS Contin - Aspirin - Discussion of Ibuprofen and NSAIDs vs. acetaminophen, ASA, narcotics: - Article from Medical Letter: Acetaminophen, NSAIDS and Alcohol. - Narcotic Allergy - Methadone - Demerol (meperidine) þ Fentanyl - ideal for short procedures. - All narcotics, with the exception of fentanyl, produce histamine release. þ Codeine - CNS effects limit effectiveness þ Hydrocodone (Vicodin, Anexsia, Lortabs) - better than codeine [Turturro, Ann Emerg Med, Oct 1991.] þ Darvon, Darvocet (propoxyphene) - OD hard to treat, analgesic effect similar to placebo, very sedating; avoid in elderly. - No better than plain Tylenol [Li Wan Po A, Zhang W Y. Systematic overview of co-proxamol to assess analgesic effects of addition of dextropopoxyphene to paracetamol. BMJ 1997;315:1565-71.] þ Dilaudid - profound analgesia. þ Oxycodone (Percocet, Percodan) - excellent analgesia, much euphoria. þ NSAIDs: General Principles - See also: - For patients with aspirin allergy all the NSAIDS are contraindicated excepting the non-ASA salicylates such as magnesium or choline salisylate. - particularly effective for biliary or ureteral colic. - Fenamic acid derivatives have substantial GI toxicity and offer no obvious advantages. - 550 mg of naproxen was as good for moderate to severe postsurgical pain as 10 mg of MSO4, but lasted longer, though it was a drug company study [Brown CR, Sevelius H, Wild V. A comparison of single doses of naproxen sodium, morphine sulfate, and placebo in patients with postoperative pain. Curr Ther Res 1984;35(4):511-518.] - Toradol (and probably any NSAID) works as well as Demerol for some things: + Biliary Colic: + Renal Colic: + Miscellaneous Pain - NSAIDs don't cut it for truly severe pain; don't even decrease the narcotic requirement. [Wright et. al. Ketrolac for Sickle Cell Vaso-Occlusive Crises Pain in the Emergency Department: Lack of a Narcotic Sparing Effect. Ann Emer Med 1992;21:925-928.] - Doses of ibuprofen 1800 mg/day as effective as 2400 mg/day in soft tissue sports injuries [Hutson. J Int Med Rs 1986;14(3):142.] - Ibuprofen at 1200 mg a day appears to be as effective (for osteoarthirits) as 2400 mg ibuprofen or acetaminophen. [Bradley et al. Comparison of an antiinflammatory dose of ibuprofen... NEJM 1991;325:87.] - It has been said that sulidac (Clinoril) has less renal toxicity than the others and so it might be a logical choice if you are concerned about that. [Ciabattoni et al. Effects of Sulindac and Ibuprofen in Patients with Chronic Glomerular Disease. NEJM 1990;264:41-47.] - All NSAIDS interfere with the action of antihypertensive drugs [Radack et. al. Ibuprofen Interferes with the Efficacy of Antihypertensive drugs. Ann Int Med 1987;107:628-635.] and may preipitate CHF [Guidelines for the Evaluation and Management of Heart Failure. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committe on Evaluation and Management of Heart Failure). Circulation 1995;92:2764-2784.] - ketorolac 60 IM and ibuprofen 800 PO the same for musculoskeletal pain [Turturro MA, Paris PM, Seaberg DC. Ann Emerg Med August 1995; 26:117-120.] - ketorolac 60 IM and Demerol 100 IM almost same for biliary colic [Dula, David J, Geisenger Medical Center, A prospective study of Demerol vs. Toradol in the Treatment of patients with acute biliary colic. Poster presentation at PaACEP 1998 conference.] - Hyperkalemia (often accompanied by a hyperchloremic metabolic acidosis) can be seen with NSAID use, particularly indomethacin. This can be seen even in the face of a normal BUN and creatinine, and probably occurs due to inhibition of prostaglandin-dependent secretion of renin and aldosterone. [Tintinalli 3rd ed. p 626.] Skeletal Muscle Relaxants ------------------------- almost all better than placebo Vistaril/Atarax/Hydroxizine --------------------------- antispasmodic and antiemetic but no real synergistic or analgesic effect Nitrous Oxide ------------- 50/50 oxygen/nitrous mixture no adverse effects in 5000 Pgh prehospital patients avoid with PTX or bowel obstruction (some ? this) or first 2 trimesters of pregnancy or decompression disease; OK in compensated COPD. TENS ---- Stimulates A fibers which inhibits C (pain) fibers. Fast TENS unit for ED; disposable Pediatric Analgesia ------------------- Inadequate analgesia: Selbst Ann Emerg Med 1990;19:1010-13 TAC: best on scalp and face. Approximates lidocaine. Avoid on distal extremities, avoid on lips due to cocaine toxicity; doesn't increase wound infections. DPT: Demerol, Phenergan, Thorazine (2/1/1 per kg.) Versed: Fentanyl: Pgh studying Fentanyl lollipops. Ketamine: Safe in 10,000 children at 4 mg/kg, 1/2 to 2 hour recovery. Migraines: ---------- DHE= dihydroergotamine give 1 mg IV, avoid in those with ischemic disease. Renal Colic ----------- þ Smooth Muscle Relaxants Glucagon, Ca++ blockers: only occasionally effective. þ NSAID's: decrease GFR, decrease edema, decrease smooth muscle tone. Indocin and Voltaren effective in European studies Ketorolac effective in U.S. studies Sickle Crisis ------------- Butorphanol and other agonist/antagonists effective Patient controlled analgesia: use less total medication, less anxious. Closer to a continuous infusion at the optimal rate.