There are over
50 different opioid combination products, available in a range of tablet
strengths and liquids. Opioid
combination products are typically used for moderate pain that is episodic
(e.g. breakthrough pain) on a prn basis.
These products contain either acetaminophen, aspirin or ibuprofen, with
an opioid: codeine (e.g.
Tylenol #2-4), hydrocodone (e.g. Lorcet, Lortab, Vicodin, Vicoprofen), oxycodone
(e.g. Percocet, Percodan, Tylox, Roxicet) or propoxyphene (e.g.
Darvocet, Wygesic). Other
formulations also may contain caffeine and/or a barbiturate. This Fast Fact will review information
for rationally choosing among the various products.
Milligram for
milligram, oxycodone and hydrocodone are the most potent opioids in this group;
they are roughly equianalgesic to each other. Codeine is less potent and propoxyphene the least potent of
the group; propoxyphene products are probably no more potent than aspirin or
acetaminophen alone.
The dose
limiting property of all the combination products is the aspirin, acetaminophen
or ibuprofen, not the opioid (see below).
Patients receiving any of the four opioids may experience classic opioid
side effects: nausea, constipation, pruritus or sedation, along with the
potential for tolerance and physical dependence with chronic use. Differences in side effect severity
among the different opioids is largely idiosyncratic; there is anecdotal
experience that codeine is the most, and hydrocodone the least, emetogenic
among the four opioids.
Propoxyphene’s major metabolite is a CNS stimulant, increasing the likelihood
of seizures in an overdose situation; it is also cardiotoxic, with
lidocaine-like effects.
Because of limited efficacy and increased toxicity, propoxyphene is not
recommend, especially in the elderly.1
Generic products
are readily available and typically much less expensive.
Codeine
products: 15-60 mg codeine/tablet
Oxycodone or
hydrocodone: 2.5–10 mg oxycodone/tablet
Propoxyphene;
50-100 mg propoxyphene/tablet
Acetaminophen
doses range from 325–750 mg/tablet
1. Propoxyphene
should rarely, if ever, be prescribed; it should not be used in the elderly.
2. Prescribe
generic products whenever possible.
3. Prescribe
only one combination product at any given time; avoid writing orders that
include multiple products; (e.g. “X” for mild pain, “Y” for moderate pain,
etc). Rather, prescribe only one
product, assess efficacy and toxicity, and modify accordingly.
4. Prescribe
codeine, oxycodone and hydrocodone products at a q4h interval; not q 4-6 or
q6h.2
5. Pay very
close attention to the total daily dose of
acetaminophen/aspirin/ibuprofen.
Note: the dose of acetaminophen per tablet can range from 325--750
mg. Thus, with a recommended limit
of < 4 gms per day, this equals 12 tablets @ 325 mg or 5 tablets @ 750 mg
tablet. Patients with renal or
liver dysfunction are at higher risk for adverse effects from the non-opioid.3
1.
The Management of chronic pain in older persons. AGS panel on chronic
pain in older persons JAGS 1998;46:635-651.
2.
Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical
Practice Guideline No. 9. AHCPR Publication No. 94-0592. Rockville, MD. Agency
for Health Care Policy and Research, U.S. Department of Health and Human
Services, Public Health Service, 1994.
3. Principles of analgesic use in the
treatment of acute pain and cancer pain. American Pain Society, 4th
edition.1999. www.ampainsoc.org
Edward E.
Rylander, M.D.
Diplomat American
Board of Family Practice.
Diplomat American
Board of Palliative Medicine.