CATL_tblMedsHB¾"Ô˾"Ô˾"ÔËDATACATL ¶TKŸ6¿šõê ­ É GLong term use is not recommended. Buprenorphine has an analgesic ceiling, which limits its usefulness in the management of chronic cancer pain.BuprenorphineCodeine is usually combined with Tylenol or aspirin, and that is the limiting factor in the dosage of this drug. Opioid combined with non-opioid in doses of 325-750 mg. Potential toxic effects of non-opioid concentration limits doses of opioid that can be used. DOSAGE MUST BE MONITORED FOR SAFE LIMITS OF NON-OPIOID. Equivalence data not substantiated. Clinical experience suggests use as a mild, initial-use opioid but clinical experience may be variable. Dose refers to opioid portion.CodeineDrug of choice for the World Health Organization for management of chronic pain. Available in many different dosage forms, strengths, duration of action, and routes of administration. Upper limit of dose is individualized, based on control of pain and presence or absence of side effects such as constipation, somnolence, nausea.MorphineEffective oral opioid available in both immediate release and sustained release form. May have less constipating side effect than morphine.OxycodoneOpioid combined with non-opioid in doses of 325-750 mg. Potential toxic effects of non-opioid concentration limits doses of opioid that can be used. DOSAGE MUST BE MONITORED FOR SAFE LIMITS OF NON-OPIOID. Equivalence data not substantiated. Clinical experience suggests use as a mild, initial-use opioid but clinical experience may be variable. Dose refers to opioid portion.HydrocodoneCan be used oral, IV, or Sub-Q. More water soluble than morphine makes it an attractive alternative for prolonged sub-q infusion in patients who do not have good IV access, but cannot take an oral agent.HydromorphoneLong half-life, observe for drug accumulation and side effects after 2-5 days.LevorphanolNot recommended because of short duration of action and accumulation of toxic metabolite, particularly in patients with renal insufficiency or poor hydration. Nor-meperidine accumulation leads to neuro-excitation, including seizures.MeperidineSemi-synthetic derivative of morphine. Closely related to hydromorphone. Available as a 5 mg rectal suppository. 5 mg of rectal oxymorphone is equivalent to 5 mg parenteral morphine.OxymorphoneAvailable as a single agent (Darvon) or in combination with acetaminophen (Darvocet). Presence of acetaminophen limits total dose of medication because of acetaminophen liver toxicity. Elimination may be delayed in elderly patients, or in individuals with hepatic or renal impairment, leading to increased risk of toxicity.PropoxypheneWeak µ agonist opioid with concomitant anti-depressant-like activity. For mild to moderate pain. Maximum recommended daily dose is 400 mg. Adverse effects are most CNS, including seizures.TramadolAvailable in IV form for acute pain. This form is also used by anesthesiologists. The oral transmucosal preparation (Actiq) is only used in individuals who are already taking regular opioid medication. The transdermal system (Duragesic) also is only used in indivuals who are already taking regular scheduled opioid medication. Fentanyl has the potential to cause respiratory depression in individuals who are opioid naïve, and neither the transmucosal or transdermal form are approved for use in opioid naïve patients. Transdermal fentanyl is contraindicated as post-operative pain management for the same reason. The Rule of Thumb This is based on observation only, not on formal dose finding studies, and should be used only as a general guideline. Transdermal fentanyl is not to be used in opioid naïve patients because of the risk of respiratory depression. (Oral Morphine mg/24 hours to Transdermal Fentanyl µg/hr transdermal patch) 50 mg - 25 µg/hr 100 mg - 50 µg/hr 150 mg - 75 µg/hr 200 mg - 100 µg/hr Transdermal fentanyl is not to be used in opioid naïve patients because of the risk of respiratory depression.FentanylMixed Agonist-Antagonist Agents - Pentazocine - Nalbuphine - Butorphanol These agents should not be used in patients on chronic opioid therapy, because of a property they have in common, to act as an opioid antagonist, similar to Naloxone. This means that these drugs can neutralize opioids in patients, and can precipitate an acute opioid withdrawl syndrome, loss of pain control, or both. They are not useful in chronic pain management, and should not be used in patients who are already taking chronic opioid medications. Meperidine Short duration of action, and presence of toxic metabolite normeperidine limit usefulness of this agent in management of chronic pain. Normeperidine is neuroexcitatory, and can lead to seizures, particularly in patients who are elderly, dehydrated, or have renal impairment.Drugs to Avoid