| Class | Drug | Rationale for not recommending |
|---|---|---|
| Opioids | Meperidine | Short (2-3 hour) duration. Repeated administration may lead to CNS toxicity (tremor, confusion, or seizures)(Cleeland, 1985; Kaiko, Foley, Grabinski, et al., 1983; Szeto, Inturrisi, Houde, et al., 1977). High oral doses required to relieve severe pain, and these increase the risk of CNS toxicity (American Pain Society, 1992;Weissman, Burchman, Dinndorf, et al.,1992). |
| Miscellaneous | Cannabinoids | Side effects of dysphoria, drowsiness, hypotension, and bradycardia preclude its routine use as an analgesic (American Pain Society, 1992). |
| Cocaine | Has demonstrated no efficacy as an analgesic or coanalgesic in combination with opioids (American Pain Society, 1992). | |
| Opioid agonist- antagonists |
Pentazocine Butorphanol Nalbuphine |
Risk of precipitating withdrawal in opioid-dependent patients. Analgesic ceiling (Kallos and Caruso, 1979;Nagashima, Karamanian, Malovany, et al., 1976). Possible production of unpleasant psychotomimetic effects (e.g., dysphoria) (American Pain Society, 1992; Martin, 1984; Weissman, Burchman, Dinndorf, et al., 1992). |
| Partial agonist | Buprenorphine | Analgesic ceiling. Can precipitate withdrawal (American Pain Society, 1992; Weissman, Burchman, et al., 1992). |
| Antagonist | Naloxone Naltrexone | May precipitate withdrawal. Limit use to treatment of life-threatening respiratory depression (Ellison, 1993). |
| Combination preparations | Brompton's cocktail | No evidence of analgesic benefit to using Brompton's cocktail over single opioid analgesics (Twycross, 1977; Walsh, 1984; Weissman, Burchman, Dinndorf, et al., 1992; Wisconsin Cancer Pain Initiative, 1988). |
| DPT (Meperidine, Promethazine, and Chlorpromazine) | Efficacy is poor compared with that of other analgesics. High incidence of adverse effects (Nahata, Clotz, and Krogg, 1985). | |
| Anxiolytics alone | Benzodiazepine(e.g., alprazolam) | Analgesic properties not demonstrated except for some instances of neuropathic pain. Added sedation from anxiolytics may limit opioid dosing (American Pain Society, 1992; Weissman, Burchman, Dinndorf, et al., 1992). |
| Sedative/hypnotic drugs alone |
Barbiturates Benzodiazepine | Analgesic properties not demonstrated. Added sedation from sedative/hypnotic drugs limits opioid dosing (American Pain Society, 1992). |
| Routes of administration | Rationale for not recommending | |
| Intramuscular (IM) | Painful. Absorption unreliable (American Pain Society, 1992). Should not be used for children or patients prone to develop dependent edema or in patients with thrombocytopenia (Weissman, Burchman, Dinndorf, et al., 1992). | |
| Transnasal | The only drug approved by the FDA for transnasal administration at this time is butorphanol, an agonist-antagonist drug, which generally is not recommended. (See opioid agonist-antagonists above). | |
Transdermal
Nasal
Intravenous or Subcutaneous
Sedation
Adjuvant Drugs
Antidepressants
Hydroxyzine
General comments and cautions regarding the use of opioid analgesics
Index