Injectable Opioids Research Articles

Brief HIV assessment for screening CJ offenders in addiction treatment

their non-opioid substance use andmultinomial logistic regression was used to predict these substance use groups based on type of opioid drugs used and other characteristics (demographics, pain, treatment history). Results: The most frequently used non-opioid drugs were cannabis (40%), antianxiety medications (34%) and cocaine (25%). LCA identified a 5-class (C) model. C1 (58.7%), had low risk of using non-opioid drugs. C2 (23.5%) had high risk of using anti-anxiety drugs and moderate risk of cannabis. C3 (8.8%) had high risk of using non-opioid prescription drugs (anti-anxiety, sleep, andmuscle relaxant drugs) and cannabis. C4 (6.2%) had high risk of using marijuana and cocaine. C5 (2.8%) had high risk of using all nonopioid drugs. Compared toC1 (the low-using group), participants in the other classes were younger, female, tobacco users, had chronic pain, inject opioids, and used both prescription opioids and heroin. The two non-opioid prescription drug groups (C2, C3) were more likely to report chronic pain and use prescription opioids. C4 (marijuana/cocaine users) and C5 (polydrug users) were more likely to report injection. Conclusions: Aggregation of substance usemay obscure important subgroup differences in patterns of illicit non-opioid drug use. The identification of two groups that primarily misuse prescription drugs and that have comparatively high rates of chronic pain suggests that self-medicationmay play a role among sub-groups of OTP patients. Financial support: Denver Health is part of the Researched Abuse Diversion and Addiction-Related Surveillance (RADARS®) System.

Gender differences in circumstances surrounding first injection experience of rural injection drug users in the United States

BackgroundResearch has demonstrated that there can be substantial gender differences in circumstances surrounding initiation of injection drug use; however, little is known about the gendered dynamics of first injection in rural areas where syringe exchange is inaccessible or among those who predominantly inject prescription medications. The present study examines gender differences in first injection experience among rural residents who predominantly inject prescription opioids. MethodsInterview-administered questionnaires collected data from a sample of injection drug users (n=394) recruited from Appalachian Kentucky using respondent-driven sampling. ResultsWomen were more likely to have initiated injection due to social-pressure (p=0.001), received the drugs as a gift (p=0.011), initiated in their partner's home (p=0.004) and in their partner's presence (p<0.001), been injected by their partner (p<0.001), used an unclean syringe (p=0.026), and received the syringe from their partner (p<0.001). Women were also more likely to report having engaged in sexual intercourse before or after initiation (p<0.001). Men were more likely to have personally purchased the drugs (p=0.002), to have acquired the syringe from a pharmacy/clinic (p=0.004), and to have injected with a friend (p=0.001) or family member (p=0.020). Men were also more likely to have a friend administer the first injection (p=0.007). ConclusionsIn this population of rural drug users, notable gender differences in injection initiation were observed. Social pressure played a more substantial role in women's first injection experience, and male partners had an integral role in women's initiation.

Pain management for women in labour: an overview of systematic reviews.

Pain management for women in labour: an overview of systematic reviews.

Investigating the effect on public behaviour of patients of a Medically Supervised Injectable Maintenance Clinic

Purpose – The behaviour of patients of alcohol and other drug treatment services in the communities where the services are based has often been a major problem for the services. This study seeks to investigate the street behaviour of patients enrolled in a Medically Supervised Injectable Maintenance Clinic (MSIMC) implemented as part of the Randomised Injectable Opioid Treatment Trial (RIOTT), into the effectiveness and efficacy of providing injectable opioids versus conventional oral methadone.Design/methodology/approach – Patient behaviour on the streets of Camberwell was recorded via data from records of the fortnightly Camberwell Street Population Forum (CSPF), between 12/11/2004 and 08/09/2006.Findings – In total, 81 individuals were identified as engaging in anti‐social behaviour or being part of the street population, including seven (8.6 per cent) who had also taken part in the RIOTT. There was a clear treatment effect for RIOTT participants.Originality/value – The use of CSPF records suggests a s...

The community impact of RIOTT, a medically supervised injectable maintenance clinic in south London

Background: One of the major issues facing treatment services for alcohol and other drug users (current or ex-) around the world is community backlash, which has led to the closure of some much-needed drug treatment services. Aims: This study investigates the impact on the local community of a Medically Supervised Injectable Maintenance Clinic (MSIMC) implemented as part of the Randomised Injectable Opioid Treatment Trial (RIOTT), a trial into the effectiveness and efficacy of the provision of injectable opioids versus conventional oral methadone. The clinic model is based around a small number of the most entrenched and refractory patients (approx. 30) being treated by the service at any one time. Methods: The clinic and the trial were conceived primarily over 2002–2005, and the clinic began actual clinical operation in October 2005. The research was conducted between July 2005 and October 2007. Methods involved: pre-trial community key informant interviews; two-year follow-up key informant interviews; a...

Opioid-sparing properties of intranasal ketorolac: a pooled analysis of patients experiencing moderate-to-severe acute pain

Ketorolac is a nonopioid mixed COX1/2 inhibitor used for short-term (up to 5 days) management of moderate-to-severe acute pain. An intranasal (IN) formulation of ketorolac is in development as a self-administered alternative to injectable ketorolac and opioids for pain management. The pharmacokinetics of IN ketorolac are similar to those of ketorolac administered intramuscularly. The efficacy and tolerability of IN ketorolac were assessed in phase 2/3 clinical trials in 705 patients (men and women, ≥18 yr). Abdominal and orthopedic surgery models were used to assess IN ketorolac efficacy in managing moderate-to-severe acute pain. Patients received IN ketorolac (31.5 mg) (n=455) or placebo (n=250) 3 or 4 times a day for up to 5 days. Statistically significantly greater reductions in the summed pain intensity difference over 48 hr occurred in patients receiving IN ketorolac compared to placebo (P<0.05). The most common adverse events in the IN ketorolac group were transient nasal discomfort (15% vs. 2% placebo) and rhinalgia (12% vs <1% placebo). Most patients received concurrent opioid analgesics for the first 48 hr. Morphine use (mg) was calculated by adding all PCA morphine and morphine equivalents (using American Pain Society guidelines for other analgesic medications). Patients in the IN ketorolac group used 34% less morphine over 48 hours after surgery compared to the placebo group (P<0.001). In the first 8 hr after surgery, patients receiving IN ketorolac undergoing orthopedic surgery had greater decreases in opioid use relative to placebo than did abdominal surgery patients. Reductions in opioid use were similar when stratified by age and sex. Efficacy in this clinical model indicates that IN ketorolac provides a noninjection parenteral option for management of acute moderate-to-severe pain that may be particularly useful for ambulatory patients, particularly where avoidance of, or reductions in, opioid use are desirable. (Supported by ROXRO PHARMA). Ketorolac is a nonopioid mixed COX1/2 inhibitor used for short-term (up to 5 days) management of moderate-to-severe acute pain. An intranasal (IN) formulation of ketorolac is in development as a self-administered alternative to injectable ketorolac and opioids for pain management. The pharmacokinetics of IN ketorolac are similar to those of ketorolac administered intramuscularly. The efficacy and tolerability of IN ketorolac were assessed in phase 2/3 clinical trials in 705 patients (men and women, ≥18 yr). Abdominal and orthopedic surgery models were used to assess IN ketorolac efficacy in managing moderate-to-severe acute pain. Patients received IN ketorolac (31.5 mg) (n=455) or placebo (n=250) 3 or 4 times a day for up to 5 days. Statistically significantly greater reductions in the summed pain intensity difference over 48 hr occurred in patients receiving IN ketorolac compared to placebo (P<0.05). The most common adverse events in the IN ketorolac group were transient nasal discomfort (15% vs. 2% placebo) and rhinalgia (12% vs <1% placebo). Most patients received concurrent opioid analgesics for the first 48 hr. Morphine use (mg) was calculated by adding all PCA morphine and morphine equivalents (using American Pain Society guidelines for other analgesic medications). Patients in the IN ketorolac group used 34% less morphine over 48 hours after surgery compared to the placebo group (P<0.001). In the first 8 hr after surgery, patients receiving IN ketorolac undergoing orthopedic surgery had greater decreases in opioid use relative to placebo than did abdominal surgery patients. Reductions in opioid use were similar when stratified by age and sex. Efficacy in this clinical model indicates that IN ketorolac provides a noninjection parenteral option for management of acute moderate-to-severe pain that may be particularly useful for ambulatory patients, particularly where avoidance of, or reductions in, opioid use are desirable. (Supported by ROXRO PHARMA).

The virtual disappearance of injectable opioids for heroin addiction under the ‘British System’

Aims: Injectable opioids were prescribed unsupervised under the ‘British System’ for heroin dependence. National guidelines (1999 and 2003) confirmed that injectable opioids have a legitimate ‘limited clinical place’ and should be dispensed daily, with ‘mechanisms for supervision’. This study assesses whether national guidelines impacted on prescriptions of injectable opioids.Methods: A 25% random sample of community pharmacists (n = 2473) in England were surveyed by a questionnaire in 2005, with 95% response (n = 2349). Opioid maintenance prescription data for anonymous patients (n = 9620) were compared to the prescription data in 1995 (n = 3721) from a matched survey.Findings: Injectable opioid prescriptions reduced significantly from 10.5% (1995) to 1.8% (2005) of all opioid maintenance prescriptions. Daily doses significantly increased, as did daily dispensing from 28.8% (1995) to 57.8% (2005), whilst weekly dispensing reduced from 39.5% (1995) to 14.5% (2005). In 2005, injectable opioids accounted for 27.2% of private opioid prescriptions, versus 1.5% National Health Service (NHS) prescriptions. Private prescriptions were for larger take-home doses than NHS prescriptions. Regional variation was present.Conclusions: Injectable opioid maintenance treatment for heroin dependence under the unsupervised ‘British System’ is disappearing, although not extinct. If injectable opioids are prescribed, this is more in line with national guidelines. However, many prescriptions are less than daily instalments.

How we do it: postoperative analgesia with a novel indwelling continuous wound infiltration system

he accepted approach for the management of acute postoprative pain is to provide regular and continuous analgesia o counteract it early. This allows for a smooth and speedy ecovery, and a more rapid return to normal function. Several approaches to achieve this have been used and eported, which include oral or injectable non-steroidal antinflammatory drugs and opioids, or both, long-acting local naesthetics administered intraoperatively, and “epidural” atheters for postoperative infiltration of wounds. Intermittent opioid injections by nurses require good taffing levels to minimise delays between need and injection. taffing shortages, distractions on the ward, and regulations bout controlled drugs can all result in a delay in administraion, and inadequate doses may be given because clinicians nd nurses are anxious about adverse events. Patient-controlled analgesia can overcome some of these ogistical problems, but its effectiveness using morphine ulphate in maxillofacial surgery has been questioned in a andomised controlled trial when pain had not been conrolled successfully, and the rate of emesis was unacceptably igh.1 We present a new method of postoperative pain control hat we have used after temporomandibular joint surgery. It an also be used similarly after other types of operation such s repair of open condylar fractures or mandibular ramus steotomy. To our knowledge, it has not been previously eported.

Scientific and political challenges in North America's first randomized controlled trial of heroin-assisted treatment for severe heroin addiction: rationale and design of the NAOMI study.

Heroin addiction is a chronic relapsing disease, best treated with opioid-agonist substitution therapy such as methadone maintenance. However, a subset of the most severely affected individuals do not benefit sufficiently from this treatment. The North American Opiate Medication Initiative (NAOMI) is a randomized clinical trial (RCT) to evaluate the hypothesis that pharmaceutical-grade heroin, diacetylmorphine (DAM) is more effective in retaining patients and improving their outcomes than Methadone Maintenance Treatment (MMT) among those with chronic, refractory injection opioid dependence. The study aimed at randomizing 253 participants to two intervention arms: (1) MMT alone or (2) injectable opioids (DAM or hydromorphone) plus adjunctive MMT if deemed appropriate. The planned study duration was 3 years, with a 1-year intake period, 1 year of treatment, and an additional year of follow-up. The NAOMI trial was initiated in March 2005 at two Canadian sites (Vancouver and Montreal). This was the first multicenter RCT in North America to compare the relative efficacy of these different therapeutic strategies. We discuss the rationale behind the NAOMI study design, as well as the scientific and political issues and methodological challenges arising from the conduct of a trial that involves the prescription of a controlled substance to individuals with dependence on that substance. Restrictive entry criteria led to the exclusion of many otherwise eligible participants, slowing recruitment into the study. Inability to offer DAM treatment beyond 12 months led to artificial boundary effects in the trial. Addiction treatment research navigates between science and politics, and evidence-based medicine is many times confronted by moral beliefs. Political considerations influence study design to a further degree than in RCTs treating less-stigmatized disorders with more-reputable medications.

A Prospective Comparison of Postoperative Pain and Medication Use Between Single and Double Bundle Anterior Cruciate Ligament (ACL) Reconstruction (SS-45)

There are several studies in the ACL literature comparing the clinical outcomes, such as stability and function, of double and single bundle ACL reconstructions. However, there is little known about more immediate post-operative outcomes such as patient pain and medication use. The purpose of this study was to obtain preliminary data comparing pain levels and medication consumption during the first 14 days post-operative between patients receiving a single versus double bundle hamstring tendon ACL reconstruction. Two groups: (1) Single-bundle group (S)-patients enrolled in a randomized clinical trial investigating post-operative immobilization following single-bundle reconstruction and (2) Double-bundle group (D)-a consecutive series of patients receiving a double-bundle ACL reconstruction. Both groups completed a pain and medication log book for 14 days after surgery. Visual analoge scores (VAS) were recorded (0 mm=no pain to 100 mm=worst pain) at: 8am and 8pm for the first two days postoperative, and 5pm for days 3-14 postoperative. Patients also recorded the type of medication consumed and time of consumption. For analysis, medications were categorized into: a) opioids-oral, b) opioids-injected, c) non-steroidal anti-inflammatories (NSAIDs), d) acetaminophen, and e) other (i.e. antiemetic). Patients in both groups were not braced post-operatively. Two surgeons performed both procedures and patients were examined within 1 month postoperative. Thirty-one patients (19 male, 12 female) with a mean (SD) age of 29.2 (5.9) years underwent single bundle ACL reconstruction and 14 patients (9 male, 5 female) with a mean (SD) age of 21.7 (5.9) years had a double bundle ACL reconstruction. Pain scores were lower for the single bundle group at all intervals during the first 14 days post-operative except the evening of surgery (Mean [SD]: S=31.4 [21.1] and D=30.0 [21.7]). The greatest mean difference in VAS pain scores between groups was seen on Day 1am post-operative (Mean difference=13.1; p=0.051, 95% CI 0.035, 26.1) and on Day 2am (mean difference=13.8; p=0.077, 95% CI −1.57, 29.2). Regardless of procedure, the greatest pain reported was on the evening of Day 1 post-operative (Mean [SD]: S=50.9 [21.2] and D=57.4 [18.2]; mean difference = 6.5; p=0.331, 95% CI −6.7, 19.6). Oral opioid consumption was slightly higher in the double bundle group on Day 1 (Mean number of pills [SD]: S=6.7 [2.9] and D=9.4 [1.9]) and on Day 2 post-operative (S=5.2 [3.0] and D=7.8 [3.1]). However, the single bundle patients consumed more injectable opioids on the day of surgery (Mean [SD] Morphine: S=7.7 [16.2] mg and D=6.2 [7.5] mg; and Mean [SD] Fentanyl: S=13.7 [24.8] mcg and D=7.1 [26.7] mcg). NSAID and acetaminophen consumption was the same between the two groups at all intervals. The most common medication in the ‘other' category was gravol for both groups. The results of this preliminary study suggested that patients who had double bundle ACL reconstruction had higher pain levels during the first 14 days post-operative than patients who had single bundle ACL reconstruction. Despite the higher pain levels, medication consumption was similar between the two groups.

Postoperative Pain And Medication Use: Single Versus Double Bundle Anterior Cruciate Ligament (acl) Reconstruction

PURPOSE: Several studies have compared clinical outcomes for double and single bundle ACL reconstructions. However, little is known about immediate post-operative outcomes such as patient pain and medication use. The purpose was to obtain preliminary data on pain levels and medication use during the first 14 days post-operative between patients having a single versus double bundle hamstring tendon ACL reconstruction. METHODS: Two groups: (1) Single-bundle(S) - patients enrolled in a randomized clinical trial investigating post-operative immobilization following single-bundle ACL reconstruction and (2) Double-bundle(D) - a consecutive series of patients receiving a double-bundle ACL reconstruction. Visual analog scores (VAS) were recorded (0mm = no pain to 100mm = worst pain) at: 8am and 8pm for the first two days and 5pm for days 3-14 postoperative. Patients also recorded the type of medication consumed and time of consumption. Patients in both groups were not braced post-operatively. RESULTS: Thirty-one patients (19 male, 12 female) with a mean (SD) age of 29.2 (5.9) years underwent single bundle reconstruction and 17 patients (10 males, 7 female) with a mean (SD) age of 24.3 (8.8) years had a double bundle reconstruction. Pain scores were lower for the single bundle group at all intervals during the first 14 days post-operative except the evening of surgery, Day 9 and Day 11 (Mean (SD): S=31.4 (21.1); 26.4 (20.9); 21.9 (18.9), respectively and D=30.4 (23.3); 21.3 (19.3); 20.7 (15.2), respectively). The greatest mean difference in pain scores between groups were seen on Day 1am (mean difference=12.4; p=0.050, 95% CI -0.023, 24.9) and on Day 2am (mean difference=12.6; p=0.076, 95% CI -1.39, 26.8). Regardless of procedure, the greatest pain was Day 1pm (mean (SD): S=50.9 (21.2) and D=53.4 (20.1); mean difference=2.5; p=0.701, 95% CI -10.2, 15.1). With respect to medication use: oral and injectable opioids, NSAIDs, and acetaminophen consumption were similar between the two groups at all intervals. CONCLUSIONS: The results of this study suggested that patients who had double bundle ACL reconstruction had higher pain levels during the first 14 days post-operative than patients who had single bundle ACL reconstruction. Despite the higher pain levels, medication consumption was similar between the two groups.

Agenda for specialty section in addiction medicine

Byline: T. Sathyanarayana Rao, M. Anil Kumar Introduction Addictive behavior is any activity or behavior that has become the major focus of a person's life to the exclusion of other activities, or that has begun to harm the individual or others physically, mentally, or socially. Addictive behavior increases the risk of disease and/or associated personal and social problems. They are often experienced subjectively as loss of control, that is, the behavior continues to occur despite volitional attempts to abstain or moderate use. Addiction implies psychological dependence, physical dependence, and a set of withdrawal symptoms if the substance is unavailable.[sup] [1] There are many common characteristics among the various addictive behaviors. First, the individual becomes obsessed (constantly thinks) of the object, activity, or substance and will seek it out, often to the detriment of work or interpersonal relationships. The person will compulsively engage in the activity even if he does not want to. Upon cessation of the activity, withdrawal symptoms of irritability, craving, and restlessness will often occur. The person does not appear to have control as to when, how long, or how much he will continue the behavior. He often denies problems resulting from his engagement in the behavior even though others can see the negative effects of it. Further, individuals with addictive behaviors will usually have low self esteem.[sup] [2] Burden of Problem Substance-related disorders have become matters of global concern because of impact on individual health, familial and social consequences, criminal and legal problems, and the effects on national productivity and economy. All the problems from use to dependence and from the most innocuous substance like tea/coffee to the most hard substances, contribute to the cost that the human society or a particular nation has to bear. In India, although alcohol use in ancient times and cannabis/affim (opium) in more recent times have been known and reported for some time, substance use problems have been recognized to have a significant importance as a public health problem only very recently. They are of particular concern among slum dwellers, transport workers, and youth.[sup] [3] Tobacco is the substance most easily accessible worldwide as well as in India. About one-fifth of the Indian population abuse tobacco, about 70% of this in the smoking form.[sup] [4] Passive smoking is a significant health hazard. There are 700,000 deaths per year due to smoking and 800,000-900,000 deaths per year due to all forms of tobacco use in India. Many of the deaths (>50%) are occurring below 70 years.[sup] [5] An estimated 34-42% of adult Indian population reports having used alcohol in their lifetime; 5-7% has been estimated to be abuser of alcohol; and 10-20 million persons have been estimated to be in need of treatment for dependence. A survey in India revealed that medical professionals had a higher rate of use and heavy use than general population.[sup] [5] Nearly 20-30% of admissions and consultations are due to alcohol-related problems in different healthcare settings but are under-recognized by primary care physicians.[sup] [6] With respect to heroin, India has now changed from being a transit country to a user country. General population surveys in India show opioid abuse rate as high as 24.8%. Another great concern especially with injectable opioids is spread of AIDS. Further, cannabis abuse in general population in India is 33% and abuse of tranquilizers is as high as 54%.[sup] [3] Remediation at central level: 'The Drug Deaddiction Program' was started in 1987-88 with the establishment of five deaddiction centers in central institutions, viz. AIIMS, New Delhi; Dr. RML Hospital, New Delhi; Lady Harding Medical College and Hospital; New Delhi; JIPMER, Pondicherry; and PGI, Chandigarh. The center at NIMHANS, Bangalore was established later as the sixth center. …

News and Notes

News and Notes

Safety of injectable opioid maintenance treatment for heroin dependence

Background There is a growing debate about injectable opioid treatment programs in many Western countries. This is the first placebo-controlled study of the safety of injectable opioids in a controlled treatment setting. Methods Twenty-five opioid-dependent patients on intravenous (IV) heroin or IV methadone maintenance treatment were randomly assigned to either their individual prescribed IV maintenance dose or placebo. Acute drug effects were recorded, focusing on electrocardiography, respiratory movements, arterial blood oxygen saturation, and electroencephalography (EEG). Results After heroin injection, marked respiratory depression progressing to a Cheyne–Stokes pattern occurred. Peripheral arterial blood oxygenation decreased to 78.9 ± 8.7% (mean ± SD) ranging from 52%–90%. During hypoxia, 7 of the 16 subjects experienced intermittent and somewhat severe bradycardia. Five subjects exhibited paroxysmal EEG patterns. After methadone injection, respiratory depression was less pronounced than after heroin injection. No relevant bradycardia was noted. Conclusions Opioid doses commonly prescribed in IV opioid treatment induce marked respiratory and circulatory depression, as well as occasionally irregular paroxysmal EEG activity. Further studies are needed to optimize the clinical practice of IV opioid treatment to prevent serious complications. Moreover, the extent of the observed effects raises questions about the appropriateness of IV opioid treatment in the present form.

CANADIAN ILLICIT OPIATE USERS’ VIEWS ON METHADONE AND OTHER OPIATE PRESCRIPTION TREATMENT: AN EXPLORATORY QUALITATIVE STUDY

Although methadone treatment has been available in North America for decades, only a small proportion of opiate addicts (some 25% of estimated opiate users in Canada) are receiving methadone treatment. Many users have tried methadone treatment, often multiple times, but leave treatment prematurely. Others would not consider it as a worthwhile treatment option for themselves. This exploratory study examines regular opiate users’ attitudes towards and experiences with methadone treatment in Canada, primarily setting out to determine what makes methadone an unsuccessful or even an undesirable treatment option for considerably large groups of opiate users. This empirical effort to explore the limitations of existing methadone treatment comes at an appropriate time, when alternative forms of opiate pharmacotherapy treatment are being proposed in Canada as complementary modes of intervention that hope to address the shortcomings of methadone treatment. The rationale for this study were feasibility questions and development efforts for a clinical trial in North America evaluating the effectiveness of using injectable opioids (heroin, dilaudid) in attracting and engaging treatment-resistant opiate users into treatment. Data for this exploratory qualitative study was collected in 1999 through a series of focus groups involving 47 treatment-experienced and treatment-naive opiate users in Vancouver, Montreal, and Toronto, with the objective of identifying key themes and issues on the described topic as a basis for further systematic research.

Randomised trial of heroin maintenance programme for addicts who fail in conventional drug treatments

Objective: To evaluate an experimental heroin maintenance programme.Design: Randomised trial.Setting: Outpatient clinic in Geneva, Switzerland.Subjects: Heroin addicts recruited from the community who were socially marginalised and in poor health and...

Combined administration of opioids with selected drugs to manage pain and other cancer symptoms initial safety screening for compatibility

Cancer patients suffer multiple symptoms and require numerous drug therapies. Parenteral administration of multiple medications from a single container can simplify drug regimens for patient self-administration. This simplification reduces drug preparation costs and risk of infection. Therapeutic options are limited by the lack of published information on the compatibility of opioids and adjuvant drugs. We report the results of a study evaluating the physical compatibility of injectable opioids with selected drugs for pain and symptom management. Fentanyl citrate, hydromorphone hydrochloride, methadone hydrochloride, and morphine sulfate solutions were physically compatible with 14 of 15 supportive care drugs tested through visual examination using a high intensity light beam and through measured examination using a turbidimeter over a range of times up to 48 hr. Phenytoin sodium was the only drug found to be incompatible with all opioid solutions tested. This compatibility information will assist clinicians in selecting the most efficient, safe, and cost-effective supportive care drug regimen.

Impact of non-narcotic oral analgesics on pain management

Of the four categories of oral analgesics, three have been available since the 19th century. Although adequate doses of the more potent oral opioids such as morphine and methadone are effective even in severe pain, the commonly used “weak” narcotics such as codeine and propoxyphene are no more effective than usual doses of aspirin or acetaminophen. Furthermore, the opioids produce gastrointestinal and central nervous system adverse effects, and, during long-term administration, tolerance may develop and there is a risk of drug dependence. Aspirin and acetaminophen are the traditional agents of choice for oral analgesic therapy; until 10 years ago, there were no single-entity, oral analgesics—with the exception of large doses of oral narcotics—that were more effective than usual doses of aspirin or acetaminophen. However, there is a ceiling on the analgesic effect attainable with safe doses of these drugs, which may in part be overcome through the use of the third category of oral analgesics, combinations of aspirin or acetaminophen with oral opioids. The fourth category of oral analgesics constitutes the most important recent development in pain management with analgesic drugs: the newer peripherally acting, nonsteroidal anti-inflammatory analgesics, some of which are clearly more efficacious than aspirin or acetaminophen and compare favorably not only with full doses of narcotic combination products but even, in some cases, with strong injectable opioids. On repeated dosing, some nonsteroidal anti-inflammatory drugs are better tolerated than aspirin and some have a much longer duration of analgesic effect than aspirin or acetaminophen. Further study is needed to compare nonsteroidal anti-inflammatory drugs among themselves and to determine their value in chronic pain and in combination therapy.