Finally, clarification on all the opiods. Read if confused

Discussion in 'Fibromyalgia Main Forum' started by Jen F, Jul 8, 2003.

  1. Jen F

    Jen F New Member

    I got this info from a Southern California RLS support group page and I find the info very helpful and very clear.

    Scroll down to the particular drug you want info on.

    Maybe now we can put all our questions and confusion to rest! Applause, please :)

    jen

    (3) Analgesic (pain-killing) Medications - Opiates/Narcotics

    These medications are very helpful for treating RLS. Many patients will get relief from this class of drugs. Many physicians have significant fears about patients getting addicted to these mainly narcotic derived drugs (derived from opium, hence the term opiates). This generally does not happen if the medications are used to just blunt the majority of the RLS symptoms, rather than increasing the dose to completely eradicate all symptoms and possibly "overshoot" using more drug than really needed. Intermittent use and drug holidays (using other medication in place of the narcotic for a few days) can often insure that no tolerance/dependence will occur. In patients who use the opiates daily and cannot stop them, keeping them at the lowest dose to relieve most of the symptoms should greatly reduce the chance of addiction. There are many patients who have been using these medications daily for years without problems. A recent study (Walters, A.S. et al, Long-term follow-up on restless legs syndrome patients treated with opioids. Mov Disord 2001;16:1105-1109) which found the narcotics to be very safe even when used for long -term use in RLS patients.

    Constipation can also occur with this class of drugs. This may limit the use of this class of medication, but adding fiber (Metamucil, for example) may help this problem. Nausea can also be a significant problem and can be overcome by adding an anti-nausea pill before taking the opioid.

    Below is a chart comparing equianalegesic doses (doses that have the same pain relieving effect) of the different narcotic pain medications. These doses are calculated for the relief of severe post-surgical pain and may not be accurate for their effect when used to treat RLS. The combination drugs (Propoxyphene, Codiene, Hydrocodone, and Oxycodone) have considerably more effect for post surgical pain due to the added aspirin or acetaminophen. Since aspirin and acetaminophen have no effect on RLS, these drugs are less potent than listed when used for RLS treatment. This chart is just a rough reference guide to the potency of the narcotics.

    DRUG APPROXIMATE EQUIANALGESIC ORAL DOSE
    Morphine 30-60 mg every 3-5 hours
    Morphine, controlled-release (MS Contin) 60-120 mg every 12 hours
    Hydromorphone (Dilaudid) 7.5 mg every 3-4 hours
    Levorphanol (Levo-Dromoran) 4 mg every 6-8 hours
    Meperidine (Demerol) 300 mg every 2-3 hours
    Methadone (Dolophine) 20 mg every 6-8 hours
    Propoxyphene (Darvon, Darvocet N-100, etc.) 270-300 mg every 3-4 hours
    Codiene (with aspirin or acetaminophen) 180-200 every 3-4 hours
    Pentazocine (Talwin) 150-170 mg every 3-4 hours
    Hydrocodone (Lorcet, Lortab, Vicodin, etc.) 30 mg every 3-4 hours
    Oxycodone (Percodan, Percocet, Tylox, ****Norco"***** [Note: Applyn says this is an error, that Norco is hydrocodone, which is what it says below, actually] ", etc.) 30 mg every 3-4 hours
    Fentanyl (Duragesic patches) 50 mcg/hour patch


    Darvon (Propoxyphene)/Darvocet-N, 50,100

    Darvon is the weakest drug in this class of medication. It comes in several forms. Darvon comes in a plain form with 65 mg of Propoxyphene hydrochloride (this is equal to 100 mg of propoxyphene napsylate) and as a compound (Darvon Compound-65) combined with 389 mg of ASA and 32 mg of caffeine. Darvon-N has 100 mg of propoxyphene napsylate, Darvon-N 50 has 50 mg of propoxyphene napsylate with 325 mg of acetaminophen, Darvocet-N 100 has mg of propoxyphene napsylate with 650 mg of acetaminophen. The drug has a rapid onset of action (less than 30 minutes) and will last hours.

    The dose Darvon, Darvon Compound, Darvocet-N 100, or Darvocet-N (all of these have about the same effective amount of propoxyphene) is from 1 to 8 tablets per day taken on an as needed basis of 1-2 tablets every 4-6 hours. The average daily dose for patients with significant RLS is about 3-4 tablets per day. The choice of the various forms of Darvon will depend on trial and error and intolerance of the additives (for example patients with ASA/aspirin intolerance should not take the Darvon Compound). For regular daily usage, the compound with Tylenol or ASA are best avoided to lessen the chance of side effects from a second drug.

    This drug may also decrease the arousals from PLMS, but does not seem to decrease the amount of PLMS.


    Codeine/Tylenol with Codeine No. 2, 3, or 4

    This is the next in potency at its lower dose formulation (15 mg). At the higher doses, it may be just as potent as the other narcotic agents. Codeine comes in 15 mg, 30 mg, and 60 mg tablets. Tylenol with Codeine has 3 strengths each in combination with 300 mg of acetaminophen; No. 2 has 15 mg of codeine, No. 3 has 30 mg of codeine, and No. 4 has 60 mg of codeine. It has rapid onset of action (less than 30 minutes) and will last 3-6 hours.

    Codeine doses range from 15 mg to 240 mg per day. The medication can be given at 15 mg to 60 mg every 3-6 hours. For regular daily usage, the compound with Tylenol is best avoided to lessen the chance of side effects from a second drug.

    Warning: Some of the SSRI antidepressants (Paxil, Prozac, and Luvox) can cause a decrease in the effectiveness of codeine. These drugs inhibit the O-demethylation of codeine to its active form of morphine. The pain killing effect of codeine can be significantly decreased if you are taking one of the above antidepressants. This problem does not occur with other pain killers on this list.


    Talwin/Talacen (Pentazocine)
    This medication comes in a 50 mg tablets. This is equivalent to a codeine dose of 60 mg. The dose range is 50 - 200 mg per day, taken at 1 tablet every 3-6 hours as needed. The onset of action is 15-30 minutes and lasts 3-6 hours.

    N.B. There is a new formulation of Talwin called Talwin Nx which contains pentazocine and naloxone which is an opioid antagonist which can worsen RLS. This drug may help RLS at first but chronic users may need larger doses and develop tolerance to the drug and experience renewed symptoms.


    Vicodin/Lorcet/Lortab/Tylox/Zydone/Norcco (Hydrocodone)

    Vicodin and Lorcet are trade names for the same drugs. Vicodin and Lorcet HD each contain hydrocodone 5 mg and acetaminophen 500 mg. Vicodin ES and Lorcet Plus each contain hydrocodone 7.5 mg and acetaminophen 750 or 650 mg respectively. Lorcet 10/650 contains the highest dose with hydrocodone 10 mg and acetaminophen 650 mg. Lortab comes in 3 strengths, each combined with acetaminophen 500 mg; and hydrocodone 2.5 mg, 5 mg, or 7.5 mg.

    A new medication is Zydone which has a lower amount of acetaminophen at only 400 mg combined with 5, 7.5 or 10 mg of hydrocodone. Another newer preparation of the medication is Norco, which also has lower doses of acetaminophen at 325 mg combined with either 5 or 7.5 mg of hydrocodone." [Note from applyn: Also, it is available in the higher dose of 10mg ]


    "The daily dose ranges between 5 mg to 40 mg of hydrocodone per day. The drug will last and should be given every 3-6 hours as needed. The onset is rapid with effect noted in less than 30 minutes.


    Percodan/Percocet/Percolone/OxyContin (Oxycodone)

    This drug is amongst the strongest of this class of medications. It comes in 5 mg tablets combined with ASA 325 mg (Percodan) or with acetaminophen 325 mg (Percocet). It also comes in a smaller dose of 2.5 mg called Percodan-Demy. It also comes in a 7.5 mg tablet with 500 mg of acetominophen and a 10 mg tablet with 650 mg of acetaminophen. You can also get pure oxycodone in the form of Percolone at 5 mg tablets without any additives.

    The dose range is 2.5 mg to 20 mg per day divided into doses every 4-6 hours. The average dose was 16 mg per day in one study. This medication works very well for RLS but also may have some benefits for PLMD. Some studies have shown decreased PLMD, and even decreased arousals from the existing PLMS.

    OxyContin is a potent 12 hour duration medication that is used mainly in patients with severe pain (like cancer patients). It come in 10, 20, 40 mg, and 80 mg tablets which can be taken on a twice daily basis. It is a slower acting drug and will not be active for at least one hour. It has potential benefits for RLS patients who are taking other narcotic agents at high doses every 3 to 6 hours (by being in a more convenient 12 hour preparation and it does not contain acetaminophen (Tylenol)), but experience in RLS with this medication is minimal, and for now this drug should be reserved for severe pain patients.

    There is also a quick release formula called OxyIR which contains 5 mg of oxycodone and can give immediate relief for pain or RLS discomfort.

    Dilaudid (Hydromorphone)
    This drug is a very potent narcotic pain killer. It is on a par with the strongest narcotic medications and has similar side effects. It comes in 2 mg, 4 mg, and 8 mg tablets. Its use in RLS has been limited, but it is an option for difficult RLS cases. Some RLS specialists have found this drug to be very effective for severe RLS patients.

    Demerol (Meperidine)
    This drug is very frequently used by intramuscular injection but can be used orally with a significant decrease in effectiveness. The amount of this decrease is not well established. 60-80 mg of Demerol (given by intramuscular injection) is roughly equal to 10 mg of Morphine.

    Demerol causes less constipation and depression than equal pain killing doses of Morphine. Demerol comes in 50 mg and 100 mg tablets and can be given every 4 to 6 hours for pain/RLS relief. Its use in RLS is quite rare and really no data is available.

    Duragesic Transdermal Patches (Fentanyl)
    This is another potent narcotic, but with a unique delivery system. Instead of a pill, a patch is placed on the skin which contains the active drug and slowly, but steadily releases it over 3 days. There are four different patches named by the amount of the drug released per hour; 25 ug, 50 ug, 75 ug, and 100 ug.

    These patches are used for patients with chronic pain syndrome such as cancer, arthritis, etc. We have seen a few patients who have been on Duragesic patches for RLS with some success, but its use in RLS has been quite limited so far. As with all narcotics, the smallest dose should be tried first, and increased only if necessary.


    Dolophine (Methadone)
    This drug is actually very effective in RLS. Most physicians will not prescribe Methadone due to its association with drug dependency treatment. Many patients may get relief from this drug when other ones in this class have failed. It should be reserved for when patients fail the other narcotic drugs.

    Methadone comes in 5 mg and 10 mg tablets. The dosage range is from 5 mg to 30 mg per day. When given for pain relief, the drug lasts 3-4 hours. In RLS, many patients report much more prolonged duration of effect, often up to 6-12 hours.


    Morphine
    This is the one of the most potent medication in this class. Because of this, and its reputation as a potent narcotic, Morphine is seldom used in the treatment of RLS.

    Morphine comes in 15 mg and 30 mg tablets. These should be used in the smallest dose necessary to achieve relief of about 90% of RLS symptoms on a 3-6 hour basis. There are two 12 hour sustained release forms of Morphine, called Oramorph SR and MS Contin. They comes in 15 mg, 30 mg, 60 mg and 100 mg tablets dosed every 12 hours. This might be a useful medication for severe RLS if used carefully, but we do not yet know of much experience with this sustained release form of Morphine.

    Levo-Dromoran (levorphanol tartrate)
    Levo-Dromoran is a synthetic analgesic that is as potent as morphine. It can be used by injection or by tablet and is as potent by either route. This drug is a narcotic and has an addiction potential equal to morphine. The drug should thus be given all the precautions of morphine. It is a long acting drug, each dose lasts 6-8 hours by injection or by tablet.

    Levo-Dromoran comes in 2 mg tablets with the usual dose being one tablet every 6 to 8 hours. The dose can be increased to 1 1/2 tablets.


    Ultram (Tramodol)
    Ultram is a new synthetic medication for pain relief and is not chemically related to the opiates, like all the above medication in this class. It works on the central nervous system by two different mechanisms. First of all it is a weak opioid inhibitor as it binds to the mu receptor. It also works by blocking the reuptake of two different neurotransmitters in the brain, norepinephrine and serotonin. Ultram is metabolized to another compound which actually is more potent than the original tramadol in helping to block pain. The drug does not appear to be as addictive as others in this class of RLS medications, but cases of addiction have occurred. Special care should be taken in patients with a history of addiction to opiates, as they may be more susceptible to addiction with Ultram.

    This drug can be very effective for treating RLS and many RLS sufferers have gotten excellent relief from the intermittent use of this drug. Some patients have used Ultram for drug holidays from the other pain killers above (in the narcotic family). This seems to have been very helpful for many, and no cross tolerance has developed. This information however, is only anecdotal, and is not proven yet in a clinical study or trial.

    There have been reports of aggravation of seizures in patients with a prior seizure history, although the incidence appears to be small occurring in 1 out of 100,000 patients. It also may be riskier in patients who are on antidepressants (especially serotonin reuptake inhibitors such as Prozac, Zoloft or Paxil for example) or tricyclic antidepressants such as Elavil. Tramadol may need to be reduced in dosage or eliminated in patients who are on other tranquilizers or sedating medication.

    Ultram comes in 50 mg tablets. It has a half life of 5.6 hours after a single dose and 7 hours after multiple doses. It can be given at 50 - 100 mg every 4-6 hours with a maximum daily dose of 400 mg. Some RLS patients have reported longer duration of action of 6-8 hours, but 4-6 hours is quite common.



    [This Message was Edited on 07/08/2003]
    [This Message was Edited on 07/08/2003]
  2. Mikie

    Mikie Moderator

    I appreciate the info. Geez, when I was taking Morphine, one 15 mg. immediate release table was all it took overnight to help immensely with my pain. I didn't use it regulary but only as needed. I never needed to increase my dosage.

    I know we are all different and I am very grateful that so little Morphine was so effective in handling my pain.

    Love, Mikie
  3. mamafurr

    mamafurr New Member



    thank you sooo much for your post. i have a book called "the pill book" but have to flip back and forth for info and how each med relate etc. i am pasting and copying to my notebook. take 3 of the above. see my other post.
    great!
    have a great day.
    alice
  4. Shirl

    Shirl New Member

    Jen, just email it to myself! Will print it out and read it more comfortably.

    Shalom, Shirl
  5. Jen F

    Jen F New Member

    Or do you need me to email it to you?

    or rather I could email you the url where I got the info.

    Let me know.

    I gotta get off the computer and eat.

    Ciao
  6. Shirl

    Shirl New Member

    I emailed it to MYSELF! I always do that when I want to read something later. Sometimes I don't have the time to read what is posted, so I just send it to myself and read it later.

    If I don't I 'forget' where I read it in the first place:)

    Thank you hon.

    Shalom, Shirl
  7. Applyn59

    Applyn59 New Member

    Just wanted to say that in the oral dose section
    there is a mistake. Norco is not oxycodone it is
    hydrocodone. Also, it is available in the higher
    dose of 10mg

    I do remember finding out last year that there
    is a med that is just 10mg hydrocodone without
    the acet. I think it has two syllables and begins
    with H. LOL

    I see further down that it is in the right category.
    I asked for this drug because it had the least
    about of acetaphet in it.

    Make sure you research yourself. Who knows
    what other mistakes are contained in this
    article. I didn't read the whole thing but this
    is what I picked up so far.

    Lynn

    PS This is not an attack on you, Jen!!![This Message was Edited on 07/08/2003]
  8. Jen F

    Jen F New Member

    thanks for the hero worship, Nancy :) :)


    Lynn, I added your corrections and I hope shirl, mama, and ziggy and Nancy will make the corrections to the copies they already cut and pasted for themselves.

    Good eyes!
    Jen
  9. Jen F

    Jen F New Member

  10. Jen F

    Jen F New Member

    It was from an RLS site that I got the above info.

    One of my FM friends has RLS.
  11. Sunshyne1027

    Sunshyne1027 New Member

    Jen, great info and share! Thanks so much..

    I got the RLS too. But then at the time reading the initials.. LOL.. Didn't realize that is what that stood for.

    Have had RLS since a teenager. Its great info for alot of people, and its so appreciated!
  12. Momskelleygirl

    Momskelleygirl New Member

    In the group of fentanyl, actually they are oral trans-mucosal fentanyl citrate (they come in sucker form) they are used mainly for cancer patients. They are for break through pain mainly. They come in dosages of 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1200 mcg, and 1600 mcg. They are great for when you need just a little extra help with pain and it is not quite time for your next pain med. Some days I actually get by on just the Actiq itself. You don't get the taste of the medicine, and they are fast acting it takes about 15 minutes to finish the sucker, and by then the pain is usually getting better.

    kelley
  13. pinkquartz

    pinkquartz New Member

    i am in the UK and i take dihydrocodeine for pain.
    i can't work out what that is in the US.
    can you tell me what it is ?

    thanks, pinkquartz