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AI-Generated response:

Is it safe to prescribe my patient two different long acting narcotics?

Answer generated on June 4, 2024

The AI-generated responses are for illustration purposes only and should not be used for medical purposes.

Prescribing two different long-acting narcotics concurrently is generally not recommended due to the increased risk of profound sedation, respiratory depression, and potential overdose.[1-2]

  • Concomitant use of long-acting opioids can potentiate the effects on respiration, blood pressure, and alertness, leading to severe outcomes including coma.[1]

  • The CDC advises caution with extended-release/long-acting (ER/LA) opioids, recommending predictable pharmacokinetics to minimize overdose risks.[2]

  • When using ER/LA opioids, starting doses should be adjusted for incomplete cross-tolerance between different opioids to avoid high plasma levels that could lead to toxicity.[2]

  • Monitoring for signs of respiratory depression and sedation is crucial when prescribing any opioid, especially when combining long-acting types.[1]

  • Consideration of the patient's previous opioid use, tolerance, and overall health condition is necessary to adjust dosages appropriately and safely.[1]

Additional info

The decision to prescribe multiple long-acting opioids should be approached with extreme caution. The CDC guidelines emphasize the importance of using ER/LA opioids judiciously, reserving them for severe, continuous pain that cannot be managed with lower dosages or immediate-release formulations. The unique pharmacokinetics of each opioid, such as methadone's risk for QT prolongation, necessitates a thorough understanding and careful patient monitoring. Clinicians must assess the patient's opioid tolerance, potential for drug interactions, and overall health status, including renal and hepatic function, which can affect drug clearance and increase the risk of adverse effects. In cases where multiple opioid therapies might be considered, alternative pain management strategies, including non-opioid medications and physical therapy, should also be explored to provide a balanced approach to pain management while minimizing risks associated with opioid use.

References

Reference 1

1.

Elsevier ClinicalKey Drug Monograph

Content last updated: May 4, 2024.

Interactions Methadose: (Major) Concomitant use of opium tincture with Methadose can potentiate the effects of both drugs on respiration, blood pressure, and alertness. Profound sedation and coma may also occur. Prior to concurrent use, assess the level of tolerance to CNS depression that has developed and the patient's overall response to treatment. Consider the patient's use of alcohol or illicit drugs. A reduced dosage of opium tincture and/or Methadose is recommended; for extended-release products, start with the lowest possible dose of opium tincture (i.e., 15 mg PO every 12 hours, extended-release tablets; 30 mg or less PO every 24 hours; extended-release capsules). Monitor patients for sedation and respiratory depression.

Interactions Methadone: (Major) Concomitant use of depodur with methadone can potentiate the effects of both drugs on respiration, blood pressure, and alertness. Profound sedation and coma may also occur. Prior to concurrent use, assess the level of tolerance to CNS depression that has developed and the patient's overall response to treatment. Consider the patient's use of alcohol or illicit drugs. A reduced dosage of depodur and/or methadone is recommended; for extended-release products, start with the lowest possible dose of depodur (i.e., 15 mg PO every 12 hours, extended-release tablets; 30 mg or less PO every 24 hours; extended-release capsules). Monitor patients for sedation and respiratory depression.

Interactions B & O Supprettes: (Major) Concomitant use of msir with opium can potentiate the effects of msir on respiration, blood pressure, and alertness. Profound sedation and coma may also occur. Prior to concurrent use, assess the level of tolerance to CNS depression that has developed and the patient's overall response to treatment. Consider the patient's use of alcohol or illicit drugs. A reduced dosage of msir and/or opium is recommended; for extended-release products, start with the lowest possible dose of msir (i.e., 15 mg PO every 12 hours, extended-release tablets; 30 mg or less PO every 24 hours; extended-release capsules). Monitor patients for sedation and respiratory depression. (Moderate) Monitor for signs of urinary retention or reduced gastric motility during concomitant msir and belladonna use. Concomitant use may increase the risk of urinary retention and/or severe constipation, which may lead to paralytic ileus.

Reference 2

2.

Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1. Copyright License: CC0

Publish date: November 5, 2022.

ER/LA opioids should be reserved for severe, continuous pain and should be considered only for patients who have received certain dosages of immediate-release opioids daily (e.g., 60 mg daily of oral morphine, 30 mg daily of oral oxycodone, or equianalgesic dosages of other opioids) for at least 1 week (193). When changing to an ER/LA opioid for a patient previously receiving a different immediate-release opioid, clinicians should consult product labeling and reduce total daily dosage to account for incomplete opioid cross-tolerance. Clinicians should use additional caution with ER/LA opioids and consider a longer dosing interval when prescribing to patients with renal or hepatic dysfunction because decreased clearance of medications among these patients can lead to accumulation of medications to toxic levels and persistence in the body for longer durations. Although in certain situations clinicians might need to prescribe immediate-release and ER/LA opioids together (e.g., when transitioning patients from ER/LA opioids to immediate-release opioids by temporarily using lower dosages of both, for temporary postoperative use of short-term opioids in a patient already receiving ER/LA opioids, or in patients with opioid use disorder treated and stabilized on methadone who need short-acting opioids for acute pain), clinicians should consider the potential for increased overdose risk and use caution when prescribing immediate-release opioids in combination with ER/LA opioids. When an ER/LA opioid is prescribed, using one with predictable pharmacokinetics and pharmacodynamics is preferred to minimize unintentional overdose risk. In particular, unique characteristics of methadone and transdermal fentanyl make safe prescribing of these medications for pain especially challenging. Methadone should not be the first choice for an ER/LA opioid. Only clinicians who are familiar with methadone’s unique risk profile and who are prepared to educate and closely monitor their patients, including risk assessment for QT prolongation and consideration of electrocardiographic monitoring, should consider prescribing methadone for pain. A clinical practice guideline regarding methadone prescribing for pain has been published previously (200).

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