PAIN DRUGS HANDBOOK TABLE
OF CONTENTS
About the
Author
About
the Handbook
Acknowledgments
Forward
to 2rd Edition
Forward
to 1st Edition
DRUGS (Alphabetical Order)
TOPICAL AGENTS
Amitriptyline
Baclofen
Clonidine
Cyclobenzaprine
2-deoxy-d-glucose
Dexamethasone
Dextromethorphan
Diclofenac
Doxepin
DMSO
Gabapentin
Ketamine
Ketoprofen
NEUROLYTIC AGENT
Phenol
APPENDICES
Appendix 1: World Health Organization
Three-step Ladder
Appendix 2: Drug Tables
Appendix 3: Infusion Tables
Appendix 4: Relative Potencies of
Opioids Effects
Appendix 5: Relative Potencies of Steroids
Appendix 6: Intravenous PCA
Standard Orders
Appendix 7: Patient Controlled Analgesia Flow Sheet
Appendix 8: Relative Potencies of Opioids
Appendix 9: Epidural Analgesia Monitoring Orders
Appendix 10: Pain Rating Scales
Appendix 11: Multiplication Factors for Converting the
Daily Dose of a Prior Opioid to the Daily Dose of Oxycontin
Appendix 12: CPR Algorithms
Appendix 13: Pediatric CPR Algorithms
Appendix 14: Trade Name Table
BIBLIOGRAPHY
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Sota
Omoigui's
Pain Drug Handbook
2nd Edition:
Butorphanol
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SECTION
ONE:
Class,
Uses, Dosing,
Elimination
SECTION TWO:
Preparation, Pharmacology, Pharmacokinetics
SECTION THREE:
Interactions, Toxicity
Guidelines/Precautions
Principal Adverse Reactions
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Class
(NARCOTIC AGONIST-ANTAGONIST)
Uses
treatment of acute pain, chronic pain, migraine headaches
Dosing
Pain:
Nasal Spray: 1 mg (one spray). Children 20-25 mcg/kg.
May repeat in one hour. Two dose sequence may be repeated every 3-4 hours as indicated..
IM 1 to 4 mg (0.02-0.08 mg/kg) q 3-4 hrs
IV 0.5 to 2 mg (0.01-0.04 mg/kg) q 3-4 hrs
Patient Controlled Analgesia IV: bolus 0.2-0.3 mg (4-6 mcg/kg)
Lockout Interval 5-15 mins
Epidural: bolus 1-2 mg (0.02-0.04 mg/kg).
Migraine:
Nasal Spray: 1 mg (one spray). May repeat in one hour. Two dose sequence may be repeated every 3-4 hours as indicated..
Due to impaired elimination, accumulation and excess sedation may occur in patients with renal or hepatic dysfunction. Analgesia may be enhanced by addition of adjuvant drugs e.g. NSAIDs, antidepressant agents (see front matter for drug combinations) and use of non-drug therapies.
Elimination
hepatic/renal
Preparation
Butorphanol (Stadol)
Injection: 1 mg/ml, 2 mg/ml
Nasal Spray: 10 mg/ml or I mg/metered spray.
DILUTION FOR INFUSION: Epidural: bolus Dilute 1-2 mg in 10 mls local anesthetic or (preservative free) NS.
Pharmacology
A synthetic benzomorphan derivative, butorphanol is a potent opioid agonist-antagonist with analgesic potency 3.5 to 7 times that of morphine or 30 to 40 times that of meperidine. Butorphanol is a competitive antagonist at mu receptors and an agonist at delta and kappa receptors. Psychotomimetic effects of butorphanol may result from agonist effects at sigma receptors. Butorphanol has a ceiling effect for respiratory depression and analgesia at high doses (> 30-60 mcg/kg). Butorphanol is not recommended for patients with cancer pain and may precipitate withdrawal in patients who have received opioids on a long term basis. Respiratory depression and psychotomimetic effects of butorphanol may be reversed by naloxone. Butorphanol crosses the placental barrier and may produce depression in the neonate. The drug may appear in breast milk and should be used with caution in nursing mothers. Usefulness of epidural butorphanol is limited by the dose dependent increases in sedation, secondary to vascular uptake and activation of kappa receptors in the central nervous system.
Pharmacokinetics
ONSET OF ACTION: IV 1-5 minutes IM 10 minutes Nasal < 15 mins
PEAK EFFECT: IV 5-10 minutes IM 30-60 minutes Nasal 1-2 hours
DURATION OF ACTION: IV 2-4 hours IM/Epidural 3-4 hours Nasal 4-5 hours
Interactions
decreases effectiveness of parenteral and epidural/spinal opioid agonists; may precipitate withdrawal in opioid dependent patients; additive effects with phenothiazines, droperidol, barbiturates and other tranquilizers
Toxicity
Toxic Range:
Not routinely monitored
Manifestations:
Somnolence
Coma
Respiratory Arrest
Apnea
Cardiac Arrhythmias
Combined respiratory and metabolic acidosis
Precipitation of withdrawal symptoms from opioids:
abdominal cramps, vomiting, skin crawling, piloerection, nasal stuffiness, lacrimation, yawning, sweating, tremor, myalgia
Circulatory Collapse
Cardiac Arrest
Death
Antidote:
Naloxone 0.4-2 mg IV/IM/SC. Repeat dose every 2 to 3 minutes to a maximum of 10-20 mg.
If withdrawal symptoms are precipitated by butorphanol, administer opioid agonists, benzodiazepines and treat withdrawal symptomatically.
Management:
Discontinue or reduce medication
Support ventilation and circulation (Patent Airway, Oxygen, IV Fluids, Vasopressors)
Administer antidote
Monitor blood gases, pH and electrolytes
Correct acidosis and electrolyte disturbance (lactic acidosis may require IV sodium bicarbonate 1-2 mEq/kg)
Symptomatic treatment
Guidelines
(1) May cause respiratory depression.
(2) In patients who have been chronically receiving opiate agonists, butorphanol may precipitate withdrawal symptoms as a result of opiate antagonist effect. Such patients should have an adequate period of withdrawal from opioid drugs prior to beginning butorphanol therapy.
(3) Patients should be warned that butorphanol may impair their ability to perform hazardous tasks requiring mental alertness or physical coordination (e.g. driving a motor vehicle, operating heavy machinery).
(4) Butorphanol crosses the placental barrier and usage in labor may rarely produce depression of respiration in the neonate. This has been associated with administration of a dose within two hours of delivery, use of multiple doses, use with additional analgesics or sedative drugs, or use in pre-term pregnancies. Resuscitation may be required; have naloxone available.
(5) Drug increases cardiac work and should be used with caution in patients with ischemic disease.
(6) Undesirable side effects of epidural butorphanol include delayed respiratory depression, pruritus, nausea and vomiting, urinary retention. Naloxone (0.2-0.4 mg IV prn or infusion 5 -10 mcg/kg/hr) is effective for prophylaxis and/or treatment. Ventilatory support for respiratory depression must be readily available. Antihistamines e.g. diphenhydramine (12.5-25 mg IV/IM q 6 hour prn) may be used in treating pruritus. Metoclopramide (10 mg IV q 6 hour prn), may be used in treating nausea and vomiting. Urinary retention that does not respond to naloxone may require straight bladder catheterization. Betanechol (Urecholine) PO 15-30 mg tid or SC 2.5-5 mg three or four times daily as required may be used as an alternative to naloxone. Betanechol increases the tone of the detrusor urinae muscle. It should not be given IV or IM, which may result in cholinergic overstimulation. Have atropine available [IV/SC 0.5 mg])
(7) Epidural/intrathecal injections should be avoided when the patient has septicemia, infection at the injection site or coagulopathy.
(8) Nasal Butorphanol is subject to control under the Federal Controlled Substances Act of 1970 as a schedule IV (C-IV) drug.
Adverse
CVS: hypertension, hypotension, palpitations
PULM: respiratory depression
CNS: euphoria, hallucinations, sedation, headache
GI: nausea, vomiting
EYE: miosis
AUTONOMIC: flushing, dry mouth, sensitivity to cold
Reactions
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NOTICE:
Every effort has been made to ensure that the drug dosage schedules
herein are accurate and in accord with the standards accepted
at the time of publication. As new research and experience broaden
our knowledge, changes in treatment and drug therapy occur. The
medications described do not necessarily have specific approval
by the Food and Drug Administration for use in the situations
and the dosages for which they are recommended. This information
is advisory only. The package insert should be consulted for use
and dosage as approved by the FDA, for any changes in indications
and dosages and for added warnings and precautions. The ultimate
responsibility lies with the prescribing physician.
No part of this information may be reproduced or transmitted electronically
in any information storage or retrieval system, or within any
monitoring system without prior permission in writing from S.O.T.A.
Technologies (Electronic Publishers).
The Universal Drug Infusion Slide Ruler (patent pending) is now
available. It incorporates an infusion data guide and enables
infusion calculations for any drug at any dose and at any concentration.
It may be obtained by calling S.O.T.A Technologies (800 9-MEDIC-9)
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Copyright 2000. Sota Omoigui, M.D. All rights reserved.
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