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 5–6)
The incidence of snorting and inhaling heroin ("smoking") is increasing, particularly among cocaine users
Table 5–6.Opioids. ||Download (.pdf) Table 5–6. Opioids.
|Medication ||Approximate Equianalgesic Dose (compared to morphine 30 mg orally or 10 mg intravenously/subcutaneously)1 ||Usual Starting Dose |
|Adults ≥ 50 kg Body Weight ||Adults < 50 kg Body Weight |
|Oral ||Parenteral ||Oral ||Parenteral ||Oral ||Parenteral |
|Opioid Agonists2,3 |
|Buprenorphine parenteral4 (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; $14.34/300 mcg || || |
|Buprenorphine transdermal4 (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 |
|Buprenorphine sublingual4 (Belbuca) ||Sublingual strip approved for pain || || |
In opioid-naive or opioid-intolerant patients, individualize dose every 12 hours. Start: 75 mcg buccally every 12–24 hours for at least 4 days, then increase to 150 mcg buccally every 12 hours, then may increase by no more than 150 mcg buccally every 12 hours no more frequently than every 4 days.
Maximum: 900 mcg/12 hours;
| || || |
|Fentanyl ||Not available ||100 mcg every hour ||Not available ||50–100 mcg intravenously/intramuscularly every hour or 0.5–1.5 mcg/kg/h intravenous infusion; $0.80/100 mcg ||Not available ||0.5–1 mcg/kg intravenously every 1–4 hours or 1–2 mcg/kg intravenously × 1, then 0.5–1 mcg/kg/h infusion |
|Fentanyl oral transmucosal (Actiq); buccal (Fentora) ||Not available ||Not available ||200 mcg transmucosal; 100 mcg buccal; $18.80/200 ...|