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P A R T 4  Drugs acting on the central and peripheral nervous systems

TABLE 26.1

DRUGS IN FOCUS Opioids

Drug name

Dosage/route

Usual indications

Opioid agonists (continued) hydromorphone (Dilaudid, Jurnista)

2–4 mg PO q 4–6 hours, or 3 mg PR q 6–8 hours, or 1–4 mg SC or IM q 4–6 hours

Relief of moderate to severe pain in adults

methadone (Biodone, Physeptone)

5–10 mg SC, IM, PO q 6–8 hours

Relief of severe pain; detoxification and temporary maintenance treatment of opioid addiction in adults Relief of moderate to severe chronic and acute pain; preoperatively and postoperatively and during labour Relief of moderate to severe pain in adults Relief of moderate to severe pain, preoperative analgesia and support of anaesthesia, and obstetrical analgesia Analgesic for use during general anaesthesia Special considerations: must be under the direct supervision of anaesthesia practitioner Relief of moderate to severe chronic pain Relief of moderate to moderately severe pain Special considerations: limit use in people with a history of addictions

Adult: 5–20 mg IM or SC or 15–30 mg PO q 4–6 hours Paediatric: 0.1–0.2 mg/kg IM or SC 5–30 mg PO q 6 hours or 30 mg PR q 6–8 hours as needed Adult: 25–100 mg IM, SC or 25–50 mg slow IV q 3–4 hours Paediatric: 0.5–2 mg/kg IM or SC q 3–4 hours Adult and children >2 years: dose determined by general anaesthetic being used

morphine (Anamorph, Kapanol, MS Contin)

oxycodone (OxyContin, Oxynorm, Endone, Proladone)

pethidine (generic)

remifentanil (Ultiva)

tapentadol (Palexia SR) tramadol (Durotram XR, Lodam)

Adult: 50 mg PO b.d.

Adult: rapid relief of pain: 50-100 mg PO q 4–6 hours to a maximum 400 mg/day Chronic pain: 25 mg/day PO titrated slowly to a maximum 400 mg/day

Opioid agonists–antagonists buprenorphine (Norspan, Temgesic)

200–400 mcg SL q 6–8 hours, 300–600 mcg IM or IV q 6–8 hours or 1 transdermal patch every 7 days

Treatment of mild to moderate pain

Opioid antagonists naloxone (Narcan)

Adult: 0.4–2 mg IV, IM or SC q 2–3 minutes as needed Paediatric: 0.01 mg/kg IV, IM or SC Neonatal: 0.01 mg/kg IV, IM or SC q 2–3 minutes or 0.06 mg/kg IM immed at birth

Diagnosis of opioid overdose, reversal of opioid effects

naltrexone (ReVia)

Adult: 50 mg/day PO

Adjunct treatment of alcohol or opioid dependence in adults

control is determined by the relative ability of each drug to cause physical dependence. Opioid agonists include alfentanil ( Rapifen ), codeine (generic), dextro- propoxyphene ( Doloxene ), fentanyl ( Actiq , Duragesic , Sublimaze ), hydromorphone ( Dilaudid , Jurnista ), meth- adone ( Biodone , Physeptone ), morphine ( Anamorph , Sevredol , MS Contin and others), oxycodone ( Endone , OxyContin , Oxynorm , Proladone ), pethidine (generic), remifentanil ( Ultiva ), tapentadol ( Palexia SR ) (not avail- able in New Zealand) and tramadol ( Durotram XR , Lodam , Tramal and others). Therapeutic actions and indications The opioid agonists act at specific opioid receptor sites in the CNS to produce analgesia, sedation and a sense of

well-being. These preparations are also used as antitus- sives and as adjuncts to general anaesthesia to produce rapid analgesia, sedation and respiratory depression. Indications for opioid agonists include relief of severe acute or chronic pain, preoperative medication, analgesia during anaesthesia and specific individual indications, depending on their receptor affinity. (See Table 26.1 for usual indications for each opioid agonist.) Accurate cal- culation of a dose is crucial to prevent overdosing. In deciding which opioid to use in any particular sit- uation, it is important to consider all of the aspects of the person’s condition and to select the drug that will be most effective in each situation with the fewest adverse effects. Each person is different, and their response to a drug is also different (Box 26.2). For instance, if