Epidural and Intrathecal Epidural and intrathecal routes are useful for pain that has not responded

to less invasive measures. Local anesthetics may be added to spinal opioids and may produce additive analgesia. Special care is given to the site where the catheter enters the skin since an infection at the site can cause meningitis or an epidural abscess. Itching and the inability to pass urine (urinary retention) are more common than with other means of opioid administration. These modes of pain medicine administration require special physician and nursing expertise and need careful monitoring. The infusion pump may be expensive to rent and there may also be recurring charges for disposable supplies required for medication infusion. >combinations of local anesthetics and opiate pain killers (drugs similar to morphine and meperidine) >Morphine, Hydromophone, Oral administration - Giving an opioid analgesic orally is the most common route of administration, and is the preferred route of administration whenever possible. Enteric-coated tablets and controlled release or sustained release forms of opioids delay the drug from dissolving quickly in the stomach and are slower to be absorbed. Liquid preparations of opioids are absorbed more rapidly than solid tablets. Oral opioids, such as morphine, hydromorphone, hydrocodone and oxycodone, can be used for acute or chronic pain. There is no ceiling dose limit on single opioid drugs unless the adverse effects of excessive sedation or respiratory depression occur. The onset of pain relief is not as rapid as opioids that are given intravenously. Sublingual and buccal administration When a drug is given sublingually, it is placed under the tongue. Buccal administration refers to placing a tablet between the teeth and the mucous membranes of the cheek. Opioids given via these routes are absorbed rapidly. >Fentalyn Rectal administration This route may be used for patients who cannot swallow or when intravenous sites are not available. There are many suppository combinations available. Subcutaneous administration - When a drug is given subcutaneously, it is absorbed beneath the skin into the connective tissue or into fat under the dermis. Drug solubility and vasoconstriction of blood vessels may cause delays in drug absorption when an opioid is given subcutaneously. However, the subcutaneous route can provide rapid pain relief without requiring intravenous access. >morphine, hydromorphone, and oxymorphone. However, other opioids (eg, oxycodone, codeine, and meperidine Intramuscular administration When this route is used, the drug is injected into a muscle, most often the deltoid or vastus lateralis muscles. Giving analgesics by the intramuscular route is not recommended for pain management, because intramuscular injections are often painful and drug absorption is variable and unpredictable. >Demerol Inj, morphine IM, methadone Inj, Buprenex Inj, ketorolac Intravenous administration When this route is used, the drug is given directly into a vein where it immediately enters the systemic circulation. Almost all opioids can be given by the intravenous route. An intravenous bolus provides the most rapid onset of pain relief. For a patient with severe acute pain or exacerbated cancer pain, repeated intravenous boluses may be used to titrate the analgesic to concentrations that provide effective pain relief, followed by a maintenance infusion if necessary. Intravenous drug administration should always be done slowly to minimize adverse effects. Extreme caution is needed in administering a continuous infusion of opioids to opioid "naive" patients*, either as a sole infusion or in combination with patient controlled analgesia (PCA) bolus doses. Intravenous opioid administration requires skilled nursing and pharmacy support and requires an infusion pump for continuous or patient controlled administration. >fentanyl citrate-0.9%NaCl (PF) IV Transdermal administration When the transdermal route is used, the opioid is absorbed through the surface of the skin. Fentanyl is available in a transdermal drug delivery system that provides continuous opioid administration without pumps or needles. Transdermal fentanyl may be given to patients with chronic pain who can benefit from continuous opioid administration. Transdermal fentanyl has a long duration of action and can be used in patients who cannot take medications orally. Transdermal opioids are contraindicated for use in acute post-operative pain or in opioid naive patients, due to the risk of respiratory depression. Transdermal fentanyl has a slow onset of action and the side effects of respiratory depression and sedation may not be quickly reversible. It is difficult to titrate an optimum dose, requiring additional short acting oral opioids to manage breakthrough pain. Adherence of the patch to the skin may be problematic for some patients. > fentanyl Inhalational Route A number of authors have found highly variable results after using inhaled morphine or diamorphine solutions in postoperative pain and healthy volunteers.30-32 Current knowledge about the absorption and pharmacokinetics of morphine administered by the inhaled route is still quite limited. The absorption and pharmacokinetics of nebulized narcotics should be studied in more detail before reliable clinical trials can be designed. >flurane

SHORT-ACTING OPIOIDSA Equivalent Doses Drug Oral Morphine 30 mg q 3-4 h Parenteral 10 mg q 3-4 h 1.5 mg q 3-4 h

LONG-ACTING OPIOIDSA Equivalent Doses Drug Oral MS-Contin Levorphanol Methadone 90 - 120 mg q 12 h 4 mg q 6-8 h 20 mg q 6-8 h . 2 mg q 6-8 h 10 mg q 3-6 h . . 1 mg q 3-4 h Parenteral

Hydromorphone 7.5 mg q 3-4 h Codeine Hydrocodone Oxycodone Meperidine Fentanyl

200 mg q 3-4 h . 30 mg q 3-4 h 30 mg q 3-4 h . .

Propoxyphene . Oramorph SR 90 - 120 mg q 12 h Oxymorphone . Fentanyl

300 mg q 2-3 h 100 mg q 3 h IM or IV

Transdermal: 25 g patch 45 -135 mg Morphine p.o. over 24 h

Opioid-naive adults and children > 50 kg body weight