• Opiates are effective in neuropathic/neuralgia pain (sciatica, shingles, phantom limb pain), OA, RA.


• Opiates not studied, or have limited evidence in:
• Fibromyalgia (Tramadol may be effective)
• Chronic headache
• Irritable bowel syndrome
• Pelvic pain
• TMJ dysfunction, atypical facial pain
• Non-cardiac chest pain
• Lyme disease
• Whiplash, repetitive strain injury
• Low back pain

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• See section B and C for further details on opioid choices.
• Meperidine:
• DO NOT USE. Poor oral biovailability and less effective than codeine.
• Normeperidine, toxic metabolite, can accumulate if frequent dosing. in seizures and other CNS effects.
• Parenteral use can cause seizures and other neurological events.
• Parenteral Opioids:
• DO NOT USE.

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• Codeine:
• Polymorphism in ability to metabolize codeine can lead to unpredictable effects. Up to 10% of white patients lack the enzyme P450 2D6 (CYP 2D6) that converts codeine to morphine.
• Do not convert from codeine to fentanyl patch.
• Prescribe no more than 4 days in breastfeeding women; rapid converters cause neonatal opiate toxicity.

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• Tramadol:
• Risk of serotonin syndrome if concomitant use of SSRI or SNRI (Venlafaxine, Duloxetine). This is NOT reversible with Naloxone.
• ** rapid onset of cognitive, autonomic, somatic changes: tachycardia, shivering, sweating, dilated pupils, myoclonus, hyperreflexia, hyperactive bowels, hypertension, hyperthermia, hypervigilance, agitation, acidosis, rhabdomyolysis, renal failure, DIC, death.
• Associated with seizures in patients at risk of seizures.
• Pharmacologically is an opioid, CADTH indicates insufficient evidence of lower abuse potential.
• Prodrug is weak, but conversion to M1 metabolite is 6X stronger.

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• Morphine:
• Reduce dose in renal impairment.
• M3 metabolite is neurotoxic.
• Low potential for drug interactions.

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• Oxycodone:
• Use with caution in patients at higher risk of opioid misuse and addiction.
• No advantage of OxyNeo over OxyContin or generic, for abuse potential.
• Caution when using acetaminophen combinations; not to exceed 3200 mg daily of acetaminophen.
• Low potential for drug interactions; contraindicated with MAOI, watch INR with Warfarin.

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• Hydromorphone:
• Use with caution in patients at higher risk of opioid misuse and addiction.
• Renal excretion, so lower dose in CKD.
• H3 metabolite is neurotoxic.

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• DO NOT USE Fentanyl patch on opiate naive patient. Overdose risk is HIGH.


• Patient should not be switched directly from codeine to fentanyl, as up to 10% of white patients lack the enzyme P450 2D6 (CYP 2D6) that converts codeine to morphine and might not have developed adequate tolerance to opioids.
• Patient should have titrated up to at least 60-100 mg MEQ DAILY dose for at least 2 weeks.
• High potential for drug interactions: SSRI, MAOI, anti-HIV drugs, antibiotics, epilepsy meds, etc.
• Use the MEQ table. Initial dose should be maintained for at least 6 days.
• Caution with drug interactions.
• Handling, storage and disposal safety concerns.

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• Adverse effects could be from toxicity or withdrawal.
• Tolerance develops to most adverse effects, but NOT to constipation. Prescribe stimulant laxatives. Or consider diversion if no constipation.
• Higher doses associated with:
• Sexual dsyfunction, hypogonadism.
• Sleep apnea.
• Increasing pain from opioid-induced hyperalgesia.
• Falls and fractures.

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Calculate MEQ / Calculate Narcotic Eq / Reset

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