Now let's look at Fentanyl. Look back at that chart in your downloadable notes.
Compare the potency of oral morphine and fentanyl. Remember what it was?
That's right, fentanyl IV is 100 times more potent than morphine. That is impressive.
Now, fentanyl doesn't come just IV but when it does, it is a killer pain reliever kind of drug, right?
A hundred times more potent than oral morphine.
You can also get fentanyl transdermal. Now once you -- that's a patch.
Once you put the patch on your patient, you wanna put it on clean, dry, intact skin.
I'll take about 24 hours for that to really hit its peak and it'll last for another 48 hours
and then that patch needs to be changed.
Really important patient education point:
take the old patch off before you put the new patch on. Okay, that's really important.
You don't want patients to have more than one transdermal fentanyl patch on at a time.
So take the old patch off first then put the new patch on
and they shouldn't experience any problem in their pain relief
but we've had patients come in before with other transdermal medications
that just kept putting patches on and they didn't take the old ones off.
So, this transdermal method is really only appropriate for persistent and severe pain.
These are people who've been on other opioids and they built up a tolerance
and it's just not working for them anymore. They're not getting the pain relief they need.
That's who's the best type of candidate for a transdermal fentanyl patch.
Now we also give it transmucosal. These come in like lollipops.
Some of the special pharmacies in the States can put fentanyl in a sucker or a lollipop.
This is great for somebody who doesn't have IV access
and we can't really get this to them but we can put it underneath their tongue
and they can suck on it and they'll get that kind of pain relief.
We can also use buccal tablets, sublingual spray or tablets.
These are great for people that don't IV access and they still need the pain relief.
We can give it intranasal. I've never got to do this in my career but it is available.
It's intended for breakthrough cancer pain for patients who are already getting other opioids.
They use the intranasal route to help break through pain.
Now this is Meperidine. This is not one of my favorite medications
and thankfully, it is no longer a first line pain medication.
You only use it in the short term because if you use it for more than 48 hours,
it can lead up to a buildup of this toxic metabolite called normeperidine.
Now, this metabolite can build up and cause seizures so only use this drug
if you're gonna use it for short-term.
Greater than 48 hours, you end up with this toxic metabolite that can lead to seizures.
You also don't wanna use this with MAOIs.
And I know you've heard me say this in the rest of our series, MAOIs don't play well with other medications
but if they're given with meperidine, it causes a life-threatening serotonin syndrome.
So MAOIs are used for depression.
It's a really old medication but it doesn't play well with others
and by that I mean it just doesn't go well with any other medication.
There's multiple drug-to-drug interactions
but particularly the one if you give MAOIs and meperidine, it can be life-threatening.
Now, Codeine is a different medication. Take a back and look at that chart.
It's still an opioid, still an opioid agonist but I want you to look and compare codeine to morphine.
So codeine's a moderate to strong opioid. We usually give it PO, that means by mouth.
Just Latin for 'per os'. But liver takes whatever dose we've given the patient
and it converts 10% of it into morphine. Pretty cool.
So when someone takes codeine, 10% of that dose is converted into morphine in the liver.
Now you can give codeine alone or give it with something else like a non-opioid.
So we often give codeine with aspirin or we give it with acetaminophen which you may know as Tylenol.
Now combination therapy provides better pain relief than just monotherapy.
So believe it or not, take an opioid which you saw, aspirin is on the chart,
it doesn't have that much pain relief compared to morphine or codeine.
However, when you take codeine and you put it with something like an aspirin or an acetaminophen,
you have much better pain relief than if you just give codeine by itself. It's kinda cool.
Oxycodone also is similar to codeine and we give it by mouth.
It's available in combination with aspirin, acetaminophen, or ibuprofen.
So you often see oxycodone given with something else that's a non-opioid and it's much more effective.
Here's the bad news though, if you are taking oxycodone even with tylenol, aspirin,
ibuprofen, and you're taking any one of these medications we have listed there:
carbamazepine, phenytoin for seizures, or rifampin which is an antibiotic,
it's not gonna work as well. These three medications lower oxycodone levels and pain relief.
So those are not a good combination.
Now there is a problem in the United States and we're trying to work on fixing it
but oxycontin is the name of controlled release oxycodone.
I mean, it's gonna have a sustained release. It's gonna release over a period of time.
How it used to work is we dose it every 12 hours for 24-hour pain relief.
But here's something that people figured out: they begin crushing that medication.
Any time you crush a sustained release medication,
instead of getting the dose as you should, over 12 hours of time, if you crush it and ingest it, boom!
You get that full 12-hour dose immediately.
So that's why oxycodone became a risk for overdose.
The old formulation of oxycodone was called Oxycontin OC.
It was easy to crush and they dissolved it and you can snort it, ingest it,
or even inject it for even faster results.
This put people at a huge risk for overdose and for death.
So the newer formulation is called Oxycontin OP.
Now this was pretty smart, what they came up with to try to address this problem.
They said, "We've got to do something to discourage people
from crushing these sustained release medications, snorting them, ingesting them, or injecting them."
So Oxycontin OP is much more difficult to crush so it's not even easy to crush
but even if you figured out how to do that, it won't dissolve in water or alcohol very easily.
In fact, it makes this big glob so gummy glob thing that there's no way you could draw that into a syringe.
So it makes it much more difficult for people to do that.
Now, not that someone won't figure out a way to do it
but it was the responsible thing to do that know we have this problem
and we do have patients that need sustained release oxycontin
but we knew we have this problem and they figured out a way
to make it more difficult for people to overdose on that med.
Hydrocodone is one of the most common prescriptions overall in the United States.
It's the same analgesic equivalency as codeine just like the other medications
and you take it orally as an antitussive or cough suppressant.
Man, a cough syrup with hydrocodone is usually pretty effective.
People also use hydrocodone for pain relief. Now, hydrocodone isn't given by itself.
It's always given with something else.
If you're taking hydrocodone for pain, then we give it with acetaminophen or ibuprofen.
If you're taking to relieve a cough, then we give hydrocodone plus antihistamines and nasal decongestants.