Opioids

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Used for somatic (body) pain. Pain is described as achey. There are sustained release (long acting) and immediate release (short acting) forms.

• Long-acting opioids are used for prevention of baseline pain by maintaining a constant level of drug for 8-72 hrs.
• Short-acting forms are used for breakthrough pain (or spikes of pain).
• Dose is limited by relief of pain and/or side effects of medications.
• Side effects: sedation, decreased mental status, loss of short term memory, hallucinations, confusion, nausea, constipation, dizziness, swelling, respiratory depression (decreased breathing drive)

Strong Opioids

Morphine

Morphine extended release (MS Contin, Oramorph, Kadian, Avinza)

• Generic available in 8-12 hour formulation
• MS Contin and Oramorph are designed to be taken every 8-12 hours. The morphine peaks at one hour and then declines.
• MS Contin and Oramorph are slow release tablets. They may not be crushed or broken without destruction of the delivery system. Crushing or breaking the tablets may result in overdose.
• Kadian is designed to be taken every 12-24 hours. The morphine peaks at 8 hours and declines.
• Avinza is designed to be taken every 24 hours. It releases 10% of the medication in the first hour and has several smaller bursts of medication over the next 23 hours.
• The advantage of Kadian and Avinza lies in their delivery system. The capsule contains medication pellets which may be taken apart. The pellets may be sprinkled in apple sauce or other soft food if you have difficulty swallowing a pill.

Morphine immediate release

• Available in tablets or elixir
• Generic formulation
• Tablets are available in 15-30mg
• Elixir is available in many concentrations from 5mg per teaspoon to 100mg per milliliter(one teaspoon is equivalent to 5 milliliters)
• This medication may be taken hourly to relieve acute pain
• Pain relief usually occurs within 30 minutes after ingestion

Oxycodone

Oxycodone extended release (Oxycontin)

• No generic available
• Oxycontin peaks at one hour and again at 5-6 hours
• It is designed to be taken every 12 hours. Some patients may need to take the medication every 8 hours (ie. Short gut syndrome)

Oxycodone immediate release

• Available in tablets or elixir
• Generic formulation available
• Tablets available in 5-30mg
• Elixir available in 5mg per teaspoon to 100mg per milliliter
• This medication may be taken hourly to relieve acute pain
• Pain relief usually occurs within 30 minutes after ingestion

Fentanyl

Fentanyl patches (Duragesic)

• No generic formulation available
• Patches peak 12 hours after placing on skin
• The medication in each patch usually lasts 48-72 hours
• The adhesive may cause a rash which resolves with corticosteroids (hydrocortisone)
• Some patients need to apply an occlusive dressing over the patch to keep it in place
• The patches are useful in cases where patients have persistent nausea and vomiting (can’t keep oral medications down), have short gut syndrome or difficulty remembering to take medication on a schedule

Fentanyl immediate release (Actiq)

• Available in lozenge form
• No generic available
• This medication may be taken hourly to relieve acute pain
• Pain relief usually occurs within 5-15 minutes after ingestion
• This medication is useful because you do not have to be able to swallow for it to be effective

Hydromorphone short acting

• Generic available
• Tablet form only
• This medication may be taken every 2 hours to relieve acute pain
• Pain relief usually occurs within 30 minutes after ingestion

Methadone

• Generic available
• Available in tablet and elixir forms
• Methadone is metabolized 72 hours after it is taken and therefore is long acting in it’s natural state. It’s pain relieving qualities diminish after 8 hours.
• It should be taken every 6 to 8 hours to maintain steady state blood levels and even pain relief.
• Because of its slow metabolism, dosage adjustments may only be made every 3 days. More frequent changes may result in overdose. Patients should rely on short acting medications in the interim for acute pain relief.

Weak Opioids usually combined with analgesics

Propoxyphene, Hydrocodone, Codeine

Usage is limited because the second drug in the combination may cause organ damage.

Acetaminophen

More than 4000mg of acetaminophen is toxic to your liver. Usually, the prescription will have 2 numbers separated by a down slash, the second number is the number of mg of acetaminophen. For example: 5/500 means there is 5mg of the primary opioid combined with 500mg of acetaminophen. The maximum recommended dose per day, therefore, is 8 pills.

Ibuprofen

More than 2400mg of ibuprofen is toxic to your kidneys. Most medication combined with this medication have 200mg of ibuprofen per tablet. Therefore, 12 tablets per day is the maximum recommended dose.

Aspirin

• More than 4000mg of aspirin is toxic. Most preparations come with 325mg of aspirin and therefore, the maximum recommended dose is 12 pills per day.
• Dose every 4 to 6 hrs
• Often used like short-acting opioids for breakthrough pain
• Generic available
• All available in tablet form.

Agonist/antagonists

A weak opioid combined with a narcotic antagonist

Used when intolerable side effects limit the use of opiods (nausea and vomiting)

Talwin

Generic available

Dose every 3-4 hours; maximum of 12 pills per day

Pain relief usually occurs within 30 minutes after ingestion

Stadol

• Generic available
• Supplied as a nasal spray
• Dose is usually every 6 hours
• Pain relief usually occurs within 30 minutes after ingestion

Nalbuphine

• Available in parenteral form only
• To be given Intramuscularly, Intravenously, or Subcutaneously
• Dose every 3-4 hours; maximum of 200mg per day
• Pain relief usually occurs within 15 minutes after injection

Hydrocodone and Codeine are available in elixir

Taking dosages more frequently than recommended will result in withdrawal effects from the opioid antagonist part of the medication