Tolerance and withdrawal are major concerns with continued use of opioids
Withdrawal causes only moderate morbidity (similar in severity to a bout of "flu")
Addicted patients sometimes consider themselves more addicted than they really are and may not require a withdrawal program
The terms "opioids" and "narcotics" both refer to a group of drugs with actions that mimic those of morphine
"Opioids" include a group of drugs with actions that mimic those of morphine
Natural derivatives of opium (opiates)
Synthetic surrogates (opioids)
A number of polypeptides, some of which have been discovered to be natural neurotransmitters
The principal opioid of abuse is heroin (metabolized to morphine), which is not used as a legitimate medication
Other common opioids are prescription drugs, which differ in milligram potency, duration of action, and agonist and antagonist capabilities (Table 5–8)
The incidence of snorting and inhaling heroin ("smoking") is increasing, particularly among cocaine users
Table 5–8.Opioids. |Favorite Table|Download (.pdf) Table 5–8. Opioids.
|Medication ||Approximate Equianalgesic Dose (compared to morphine 30 mg orally or 10 mg intravenously/subcutaneously)1 ||Usual Starting Dose ||Potential Advantages ||Potential Disadvantages |
|Adults ≥ 50 kg Body Weight ||Adults < 50 kg Body Weight |
|Oral ||Parenteral ||Oral ||Parenteral ||Oral ||Parenteral |
|Opioid Agonists2,3 |
|Buprenorphine parenteral (Buprenex) || ||300 mcg intravenously slowly once, may be repeated after 30–60 minutes once; or 600 mcg intramuscularly once || ||300 mcg intravenously slowly once, may be repeated after 30–60 minutes once; or 600 mcg intramuscularly once; $18.20/300 mcg || || || || |
|Buprenorphine transdermal (BuTrans) ||Not available ||Not available || |
Not available orally.
Transdermal doses available: 5, 10, and 20 mcg/h. Initiate 5 mcg/h patch for opioid-naïve patients (may currently be using nonopioid analgesics); $114.77/10 mcg/h.
|Not available ||Not available ||Not available || |
analgesia; may be initiated in opioid-naïve patients with 5 mcg/h.
Can titrate up dose by 5 mcg/h after 72 hours, to a maximum dose of 20 mcg/h.
Concomitant use of other opioids for acute pain could be difficult due to strong receptor binding of buprenorphine, although this is often not found in clinical practice.
|Buprenorphine sublingual (Belbuca) ||Sublingual strip approved for pain || || |
In opioid-naive or opioid-intolerant patients, individualize dose every 12 h. Start: 75 mcg buccally every 12–24 h for at least 4 days, then increase to 150 mcg buccally every 12 h, then may increase by no more than 150 mcg buccally every 12 h no more frequently than every 4 days.
Maximum: 900 mcg/12 h; $6.07/75 mcg.
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