Type of Drug:

Narcotic analgesics (pain relievers)

How the Drug Works:

Narcotic pain relievers relieve pain by dulling the pain perception center of the brain, They may also affect other systems in the body at higher doses, Natural narcotics include opium, codeine, and morphine, Other narcotics are synthetic (opioids) and vary in potency, addictive ability, and side effects,

Uses:

For relief of mild-to-moderate pain and for coughing induced by viral, bacterial, chemical, or mechanical irritation of the respiratory system (codeine only),

For the management of chronic pain in patients requiring continuous opioid analgesia for pain that cannot be managed by lesser means such as acetaminophen-opioid combinations, nonsteroidal analgesics, or PRN (as-needed) dosing with short-acting opioids (fentanyl only),

For the management of breakthrough cancer pain in patients with malignancies who are already receiving and are tolerant to opioid therapy for their underlying persistent cancer pain (fentanyl lozenge only),

For relief of moderate-to-severe pain (hydromorphone, meperidine, methadone, morphine, oxycodone, and oxymorphone only),

For the management of opiate dependence (levomethadyl acetate only), For the management of moderate-to-severe pain or as a preoperative medication where an opioid analgesic is appropriate (levorphanol only),

For relief of severe pain, and for detoxification and temporary maintenance treatment of narcotic addiction (methadone only),

For relief of moderate-to-severe acute and chronic pain; for the management of pain not responsive to nonnarcotic analgesics; dyspnea (short­ness of breath) associated with acute left ventricle failure and pulmonary edema; used preoperatively for patient sedation; to decrease apprehension; effective in the control of postoperative pain (morphine only),

For relief of pain in patients who require copied analgesics for more than a few days (morphine sustained-release only).

For relief of mild-to-moderate pain (propoxyphene only).

Unlabeled Uses: Occasionally doctors may prescribe inject able morphine for difficult breathing associated with acute left ventricular failure and pulmonary edema.

Precautions:

Do not use in the following situations:

Drug dependence: Narcotic pain relievers have high abuse potential.

Dependence and physical tolerance may develop upon repeated use. However, most patients who receive these agents for medical reasons and do not take more than prescribed do not develop dependence.

Tolerance: Some patients may develop tolerance to narcotic pain relievers. This may develop after days or months of continuous therapy. Consult your doctor if tolerance is suspected.

Withdrawal syndrome: Severity is related to the degree of dependence, the abruptness of withdrawal and the drug used. Generally, withdrawal symptoms begin to develop at the time the next dose would ordinarily be given. For heroin and morphine, symptoms gradually increase in intensity, reach a maximum in 36 to 72 hours and subside over 5 to 10 days. In contrast, methadone withdrawal is slower in onset and the patient may not recover for 6 to 7 weeks. Meperidine withdrawal often runs its course within 4 to 5 days. Hydrocodone withdrawal symptoms peak at 48 to 72 hours. Withdrawal precipitated by narcotic antagonists (antidotes) is manifested by onset of symptoms within minutes and maximum intensity within 30 minutes. Symptoms of withdrawal include:

Early - Yawning; tearing; runny nose; restless sleep; sweating.

Intermediate - Flushing; increased heart rate; twitching; tremor; restlessness; anxiety; irritability; goosebumps; appetite loss; dilated pupils.

Late - Muscle spasm; fever; nausea; diarrhea; vomiting; spontaneous orgasm; severe backache; stomach and leg pains; stomach and muscle cramps; hot and cold flashes; sleeplessness; intestinal spasm; repetitive sneezing; excessively runny nose; increased body temperature, blood pressure, respiratory rate and heart rate; chills; bone and muscle pain.

Pregnancy: There are no adequate and well-controlled studies in pregnant women. Regular narcotic use late in pregnancy may cause with drawl reactions in newborns. Use only if clearly needed and the potential benefits outweigh the possible risks to the fetus.

Breastfeeding: Many of these narcotics appear in breast milk, but the effect on the infant may not be significant. Consult your doctor before you begin or continue breastfeeding if narcotic if narcotic therapy is required.

Children: Safety and effectiveness of fentanyl transmucosal in children younger than 16 years of age are not established. Safety and effectiveness of codeine in children younger than 3 years of age have not been established. Do not administer fentanyl trans dermal systems to children younger than 12 years of age or patients less than 18 years of age who weigh less than 50 kg except in an authorized investigational research setting. Use of levomethadyl or levorphanol is not recommended in those less than 18 years of age. Safety and effectiveness of oxymorphone in children younger than 18 years of age have not been established. Methadone is not recommended as an analgesic in children; documented clinical experience is insufficient to establish suitable dos­age regimens. Safety of propoxyphene, morphine, opium, oxycodone, and hydromorphone are not established in children.

Elderly: Appropriately reduce the initial dose in elderly and debilitated patients. Consider the effect of the initial dose in determining supplemental doses. Use caution because opioids have the ability to depress breathing.

Sulfites: Some of these products may contain sulfite preservatives which can cause allergic reactions in certain individuals (eg, asthmatics). Check package label when available or consult your doctor or pharmacist.

Drug Interactions:

Tell your doctor or pharmacist if you are taking or if you are planning to take any over-the-counter or prescription medications or dietary supplements with narcotic pain relievers. Doses of one or both drugs may need to be modified or a different drug may need to be prescribed. The following drugs and drug classes interact with narcotic pain

• Aganist/antagonist analgesics alcohol amitriptyline (eg, Elavil)
• Anticoagulants (eg, warfarin)
• Antihistamines (eg, diphenhydramine)
• Barbiturate anesthetics (eg, thiopental)
• Carbamazepine (eg, Tegretol)
• Charcoal chloral hydrate (eg, Aquachloral)
• Chlorpromazine (eg, Thorazine)
• Clomipramine (eg, Anafranil)
• Desipramine (eg, Norpramin)
• Diazepam (eg, Valium)

Side Effects:

Every drug is capable of producing side effects. Many narcotic analgesic users experience no, or minor, side effects. The frequency and severity of side effects depend on many factors including dose, duration of therapy, and individual susceptibility. Possible side effects include:

Most Serious: Respiratory depression; skeletal muscle rigidity; difficulty breathing; slow heartbeat.

Most Frequent: Lightheadedness; dizziness; sedation; nausea; vomiting; sweating.

Digestive Tract: Nausea; vomiting; diarrhea; stomach cramps or pain; taste alterations; dry mouth; appetite loss; constipation; biliary tract spasm; ileus (obstruction of the bowels); paralytic ileus; toxic megacolon in patients with inflammatory bowel disease; gas; indigestion; difficulty swallowing.

Nervous System: Exaggerated sense of well being; restless mood; delirium; sleeplessness; agitation; anxiety; hallucinations; disorientation; drowsiness; sedation; lethargy; mental and physical impairment; uncoordinated movements; coma; mood changes; weakness; headache; mental cloudiness; blurred vision; double vision; pupil constriction; tremor; convulsions; psychic dependence; toxic psychoses; depression; increased intracranial pressure; headache; abnormal skin sensations; confusion; abnormal dreams; continual rapid eye movement; muscle twitching; amnesia; paranoid reaction; drug withdrawal; suicide attempt; decreased mobility; difficulty moving; excessive movement; speech disorder; abnormal gait; abnormal skin sensations; stupor; apathy.

Circulatory System: Flushing; faintness; peripheral circulatory collapse; change in heart rate; abnormal heart rhythm; heart pounding in the chest; chest wall rigidity; change in blood pressure; dizziness or light­headedness when rising from a seated or lying position; fainting; cardiac arrest; shock.

Urinary and Reproductive Tract: Urinary retention or hesitancy; infrequent urination; antidiuretic effect; reduced libido; difficult urination; impotence; difficult ejaculation; urinary incontinence.

Other: Depression of cough reflex; chills; asthma exacerbation; vision changes; itching; rash; hives; muscle weakness; sweating; runny nose; tearing; yawning; joint pain; general body discomfort; flu syndrome; hot flashes; hiccups; coughing up blood; sore throat; back pain; runny nose; reversible jaundice, including cholestatic jaundice (propoxyphene).

Guidelines for Use:

• Dosage is individualized.
• Do not change the dose or stop taking unless advised to do so by your doctor.
• May cause drowsiness, dizziness, or blurred vision. Use caution while driving or performing other tasks requiring alertness, coordination, or physical dexterity.
• May cause dizziness or lightheadedness when rising from a seated or lying position.
• Avoid alcohol and drowsiness-causing drugs while taking a narcotic pain reliever.
• May cause nausea, vomiting, or constipation. Notify your doctor if these occur and become a problem.
• Long-term use may lead to addiction. Early signs include drug ineffectiveness. Dependence is not an issue in terminal illness where patient comfort is more important.
• If stomach upset occurs, take with food.
• May cause constipation (long-term use). Stool softeners or fiber laxatives may be required if use is prolonged.
• These drugs work best if taken on a routine basis. Narcotics are more effective in preventing pain than in treating pain after it occurs.
• Give the drug ample time to work before determining if more is needed (at least 30 minutes to 1 hour for oral agents).
• If a dose is missed, take it as soon as possible. If several hours have passed or if it is nearing time for the next dose, do not double the dose to catch up, unless advised to do so by your doctor. If more than one dose is missed or it is necessary to establish a new dosage schedule, contact your doctor or pharmacist.
• Sometimes these drugs are given in combination with other non narcotic pain relievers such as aspirin or acetaminophen (eg, Tylenol). Make sure your doctor knows if you have had problems taking aspirin or acetaminophen in the past.
• Notify your doctor if shortness of breath or difficulty breathing occurs.
• Do not crush or chew controlled- or sustained-release medications.
• Fentanyl transdermal system - Keep both used and unused systems out of the reach of children. Used systems should be flushed down the toilet immediately upon removal. If the application site needs to be cleansed before application, the area should be washed with clear water and allowed to dry. Do not use soaps, alcohol, or other products to cleanse skin. Do not cut the patch. Remove the old patch before applying a new one. Avoid exposing the application site to a direct external heart source, such as an electric blanket.
• Fentanyl transmucosal system - This product is extremely toxic to children. Carefully follow the storage, administration, and disposal techniques included in the patient package insert and instructional video. Remove from the foil pouch just before use.
• The one should be sucked. Do not chew. Store in foil pouch at room temperature (59 0 to 86°F). Do not freeze.