a. Morphine. Morphine is the basis of the narcotic effect of opium and is the standard by which other analgesics are judged. It is used in moderate to severe pain, is the analgesic of choice for myocardial infarction, and is used to treat acute pulmonary edema. Morphine is most frequently given IM or SC, 10-15 mg every 4 hours, or IV, where 4-10 mg are diluted and given slowly over 4-5 minutes. It is used less frequently by the oral route (1/15--1/6 the effectiveness of parenteral administration) in a dose of 820 mg every 4 hours. The most common side effects associated with morphine are drowsiness, nausea, and vomiting. Morphine is supplied as an injection containing 8, 10, and 15 milligrams per milliliter; in tablets of 10, 15, and 30 milligrams; and as an oral solution containing 10-milligrams per 5-milliliters. Morphine in all forms is a Note R substance.
b. Codeine. Codeine is the second naturally occurring narcotic. Its use is very widespread; in some states it can be sold without prescription in combination products if its concentration is weak enough (ETH & codeine, Robitussin AC®). For our purposes, however, when codeine is dispensed as a single agent, it is Note R, when in combination, it is Note Q. Codeine is used as an antitussive, 5-15 mg every 4-6 hours, and as an analgesic in mild to moderate pain, 30-60mg every 4-6 hours. Its most common side effects include drowsiness, nausea/vomiting, and constipation; patients must be cautioned about the drowsiness and the additive effect seen with concurrent use of alcohol. Codeine is available as an injection of 15, 30, and 60 mg/ml, and in 15 and 30 mg tablets. A powder form for compounding is also available.
c. Hydromorphone (Dilaudid®). Hydromorphone (Dilaudid®) is a drug that was obtained by chemical modification of morphine, used as an analgesic in moderate to severe pain. It is frequently used in pain associated with cancer. Its usual dose is 2 mg every 4 to 6 hours. Its major side effects are nausea and vomiting, dizziness, and constipation. Although the manufacturer states that drowsiness occurs infrequently, patients should be made aware of this possibility; also alcohol may intensify its effects. Dilaudid® is a Note R drug and is supplied in tablet or injectable form, both in 1, 2, 3, and 4 mg strengths.
d. Meperidine (Demerol®). Meperidine was the first synthetically produced narcotic. It is one of the first widely used agents for moderate to severe pain. Usual doses of this agent (50-150 mg every 3-4 hours) produce some drowsiness, nausea, and vomiting. Patients who are prescribed meperidine should be cautioned that drowsiness might occur. Further, they should be advised that alcohol might intensify this drowsiness. Meperidine is a Note R drug, which is available as an injection (25, 50, 75, and 100 mg/ml), a tablet (50 or 100 mg tablets), and in a syrup (50 mg/5ml).
e. Fentanyl (Sublimaze®, Duragesic®, Oralet®, Actiq®). Fentanyl is a synthetic agent with actions similar to morphine, but on a weight basis, Sublimaze® is 80-100 times more potent. It is used as an analgesic component in general anesthesia or conscious sedation and given intramuscularly (IM) or intravenously (IV). The dosage is dependent upon its intended role during anesthesia, and ranges from 0.025 to 0.1 mg. Respiratory depression is the side effect of concern for this agent. Fentanyl is unique in that it is available as an injection (Sublimaze®), in a topical patch formulation (Duragesic®), a lozenge (Fentanyl Oralet®) and a lozenge on a stick ("lollipop") (Actiq®) formulation. The latter three formulations are prescribed primarily for severe pain conditions. Fentanyl is handled as a Note R product.
f. Methadone (Dolophine®). Methadone (Dolophine®) is a synthetic agent that has been used as an analgesic for moderate to severe pain, and to treat withdrawal symptoms of narcotics in a dose-tapering fashion. The usual dose for analgesia is 2.510 mg every 4 hours, and common side effects include drowsiness and nausea/vomiting. The effects of methadone may be intensified by alcohol, and the patient also should be cautioned about drowsiness. The injection, 10 mg/ml, and the tablets, 5 and 10 mg, are all Note R.
g. Percodan®. Percodan® is a popular semisynthetic narcotic intended for the relief of moderate pain that contains two salts of oxycodone, combined with aspirin. It is, of course, a fixed combination and is given in a usual dose of one tablet every 6 hours. In addition to the side effects of drowsiness and nausea/vomiting, pruritis is also a fairly frequent complaint. Patient cautionary statements regarding drowsiness and alcohol apply to this agent. It is a Note R product even though it is a combination. Percodan® is available in tablet form, and a half-strength product called Percodan-Demi® is also produced.
NOTE: Combination products of acetaminophen with oxycodone are Tylox® and Percocet®.
h. Combination Products. Codeine is combined with aspirin or acetaminophen (Tylenol®) to produce products that are used to treat mild to moderate pain. Common side effects of these combination products include nausea, vomiting, and drowsiness. Patients who are taking these products should be cautioned about the drowsiness. Further, patients should be warned against taking these with alcohol. These combination products are handled as Note Q items.
(1) Empirin® with codeine. Empirin® with codeine is a combination of aspirin and codeine. The usual dosage of these products is from one to two tablets every four hours. The various products are numbered based upon the amount of codeine contained in each product as noted below:
(a) Empirin® with Codeine #2 - 15 mg of codeine per tablet.
(b) Empirin® with Codeine #3 - 30 mg of codeine per tablet (most widely used of these products).
(c) Empirin® with Codeine #4 - 60 mg of codeine per tablet.
(2) Tylenol® with codeine. Tylenol® with codeine is a combination acetaminophen with codeine. The usual dosage of these products is from one to two tablets every four hours. As with Empirin® with codeine, the products are numbered based upon the amount of codeine contained in each tablet as noted below:
(a) Tylenol® with Codeine #1 - 7.5 mg of codeine per tablet.
(b) Tylenol® with Codeine #2 - 15 mg of codeine per tablet.
(c) Tylenol® with Codeine #3 - 30 mg of codeine per tablet (most widely used of these products).
(d) Tylenol® with Codeine #4 - 60 mg of codeine per tablet. 11-6. CAUTIONS OF NARCOTIC USE
a. Narcotics should not be used in patients experiencing any form of respiratory depression (that is, asthma).
b. Narcotics cause an increase in intracranial pressure (pressure within the skull). Therefore, they should not be used in the presence of head injuries.
c. Narcotics should be used cautiously in combination with other drugs that depress the central nervous system.
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