• Heroin
• morphine
• pethidine
• codeine
• fentanyl
• oxycodone
• tramadol
• tapentadol
• methadone
• carfentanil - 100x more potent than fentanyl, used to tranquilize elephants, extremely dangerous to humans

see also:

• heroin or other opiate overdose
• opiate antagonists eg naloxone (Narcan), buprenorphine, naltrexone
• opiate and opioid dependence
• analgesics index
• neuropathic pain and its Mx
• acute pain Mx in drug dependent patients
• drug dependency
• Aust. Prescribing 2012 - Safe prescribing of opioids for persistent non-cancer pain
• Western Health policies (intranet only):
  • Patient Controlled Analgesia (PCA) and Continuous Intravenous Opioid Infusion for Adults (doc)

• pethidine:
  • pethidine is no longer regarded as having a significant role in the management of ED patients, and thus, many ED's have decided to stop using it because of its tendency for substance abuse and that there are more effective options.
  • repeated doses of pethidine runs the risk of accumulation of its metabolite causing seizures.
  • indications for pethidine are very limited and usually restricted to:
    • maternity
    • oncology
    • palliative care
    • true type I hypersensitivity reactions to opiates (but anaphylaxis to opiates is actually quite rare)
    • certain rare conditions such as systemic mastocytosis which is associated with true anaphylaxis to NM blockers and opiates.
  • pethidine is NOT the analgesic of choice for migraine, pancreatitis, biliary or renal colic
  • chronic pain patients should be considered for referral to a chronic pain service
  • patients requesting pethidine should be considered for referral to an addiction medicine specialist.
  • patients thought to have allergies to opiates should be referred to allergy testing to clarify this, either:
    • skin testing (eg. Dr Karl Bleasel, RMH Immunology, fax: 03 9349 3199) - may take 2-3 months to arrange
    • morphine RAST test (biochem serology blood tube) - takes 2-3 weeks for results.
• if opiates are needed for pain management:
  • adverse reactions related to dose, or known side effect profiles such as nausea, itch and dysphoria, should be managed with careful attention to dose, speed of administration and pre-emptive management of expected side effects, and the use of non-opiate analgesics.
  • opiates are generally a poor choice for migraine headaches and most cases of low back pain
  • the oral route should be used if not contraindicated and patient likely to tolerate oral dose and rapid onset not required:
    • eg. oxycodone, morphine, tramadol, non-opioid pain, analgesia and analgesics
    • codeine should be avoided due to its high incidence of nausea, vomiting, constipation and its variable effectiveness
  • avoid mixing routes of administration of opiates
  • for short periods of analgesia such as for joint reductions:
    • fentanyl iv is the preferred opiate due to its short duration of action
  • for most other pain conditions warranting parenteral opiates:
    • morphine iv is the preferred opiate in the ED - usually in 2.5mg titrated doses for adults.