Codeine for analgesia

mebeafrn · Jul 4, 2005

Hi,
I just found out from a dear friend that her mom is dying from advanced terminal CA (mets everywhere)--recently discovered.
Her mom can't take morphine and reportedly is on codeine.
I was a bit surprised, because I don't think of codeine as, generally, a particularly strong analgesic (I couldn't even find it on any of the equalanalgesic charts) and hadn't heard of it being used for CA pain (but what do I know? I'm only a 2nd/2 yr student).
Could someone enlighten me? My friend also mentioned something about demerol--maybe it had been used in the hospital? I'm not sure. But I understand that many places shy away from demerol because it tends to make pts loopy. I told her that we've used dilaudid for some folks for whom morphine didn't work--though I'm not sure if there is any cross-sensitivity between morphine and dilaudid. Can anyone help me out ?
Thanks very much in advance,
NurseFirst

oxycodone- or hydrocodone-- can be very effective for Ca pain control plus no acetaminophen for the liver to try and manage. Fentanyl patch if she has enough subq tissue is good and there are fentanyl pops-like a lollipop for quick acting break thru relief. My opinion as a long time Hospice nurse-Demerol and Darvocet suck,result in confusion and constipation. Dilaudid is great and can be converted to an infusion if needed-at 1/3 of what the oral dose was. Often with bone pain mix in some NSAID and that can really help. We also use a compounding pharmacy that makes us topical gels for pain,anxiety and antiemetics when our precious folks can't swallow.Hope this helps

z's playa · Jul 4, 2005

Codeine? Gosh..I can't say enough when it comes to how poorly I find this drug to be for pain. 7 to 10 % of the pop can't use it because they lack the enzyme that metabolizes codeine to morphine. So it's inneffective. My own doctors at the hospital laugh at it.

For oncology pain? I can't believe it's being used. I'm sorry. I know there's some who will swear by it but I and the entire faculty of nursing and medicine over here would never consider using it for anything except a headache. IF absolutely necessary. NSAIDS are so much better :)

Z

mebeafrn · Jul 5, 2005

Codeine? Gosh..I can't say enough when it comes to how poorly I find this drug to be for pain. 7 to 10 % of the pop can't use it because they lack the enzyme that metabolizes codeine to morphine. So it's inneffective. My own doctors at the hospital laugh at it.
For oncology pain? I can't believe it's being used. I'm sorry. I know there's some who will swear by it but I and the entire faculty of nursing and medicine over here would never consider using it for anything except a headache. IF absolutely necessary. NSAIDS are so much better :)
Z

so true! the s/e are such a barrier too w/ codiene ie n/v,itching,constipation. I really like a q 12 hr. long acting w/a q 2hr. break thru narcotic or synthetic narc and add an NSAID for deep or bone pain. Does anybody else out there use subq Ativan or Haldol for terminal delirium? We have great results esp.in CD situations,the Ativan works as in detox/seiz. control. We also use Ativan as a buccal paste.

aimeee, BSN, RN · Jul 16, 2005

Demerol has its place as short term acute pain relief but is inappropriate for those with impaired renal function (which a CA patient with mets everywhere is almost certain to have). I would doubt the patient is actually on straight codeine but is probably using oxycodone or hydrocodone. Dilaudid can be a very effective option. Fentanyl can also be good but is frequently misused or inappropriate doses applied. In its Duragesic form, the long delay between application and peak action makes titration difficult. If the patch is misapplied or if the patient has very little subq depot, then its difficult to know how much medication is actually being utilized. Breakthrough medication with Duragesic is frequently under-prescribed. The pops are very fast to take effect but once again, very difficult to titrate up when needed because you don't know how much was taken. And VERY expensive.

If bony mets are involved, then effective pain relief will probably not be acheived without some form of NSAID or/and steroid. Relying on narcotics alone to achieve relief of bony pain will usually result in the patient being quite sedated before relief is achieved.

aimeee, BSN, RN · Jul 16, 2005

so true! the s/e are such a barrier too w/ codiene ie n/v,itching,constipation. I really like a q 12 hr. long acting w/a q 2hr. break thru narcotic or synthetic narc and add an NSAID for deep or bone pain. Does anybody else out there use subq Ativan or Haldol for terminal delirium? We have great results esp.in CD situations,the Ativan works as in detox/seiz. control. We also use Ativan as a buccal paste.

CD situations? I'm drawing a blank at that term.

We use Ativan for terminal restlessness, Haldol would be preferred for actual delirium. I have not seen Ativan as a buccal paste. Is it compounded for you that way?

leslie :-D · Jul 16, 2005

I have not seen Ativan as a buccal paste. Is it compounded for you that way?

aimeee,

quite often i have made ativan into a buccal paste just by crushing it and adding a gtt of h20 and stirring it to a pasty consistency. it's really quite easy to do and much less invasive than the injectables.

leslie

letina · Jul 16, 2005

Can I just ask, are syringe drivers not used in the US? I don't think I've ever seen it mentioned on any of the threads and was just wondering, as they are widely used in the UK in terminal/palliative care.

leslie :-D · Jul 16, 2005

Can I just ask, are syringe drivers not used in the US? I don't think I've ever seen it mentioned on any of the threads and was just wondering, as they are widely used in the UK in terminal/palliative care.

are syringe drivers the same as syringes with plungers? are they used to administer meds? if so, yes they are used if unable to swallow effectively or the amt is excessively small (such as in roxanol concentrate). if able to swallow po then med cups are often used. i'm just unsure if we're talking about the same thing.....

leslie

letina · Jul 16, 2005

are syringe drivers the same as syringes with plungers? are they used to administer meds? if so, yes they are used if unable to swallow effectively or the amt is excessively small (such as in roxanol concentrate). if able to swallow po then med cups are often used. i'm just unsure if we're talking about the same thing.....
leslie

It's a portable battery driven device which allows patients to receive continuous sub-q infusion of drugs. Most commonly used here at end stage for administration of analgesia, anti-emetic, sedative and anti-muscarinics. The syringe and contents are renewed each 24 hours. When all the drugs are mixed together, there can be as much as 20mls in the syringe, then the "driver" is set to infuse the contents continuously over the 24 hour period.

If we're talking about the same thing, what do you call this in the US?

Tina :)

aimeee, BSN, RN · Jul 17, 2005

Interesting, I have not seen such a device.

Leslie, I've done the same thing with ativan. I just wondered if maybe there was a pre-prepared form of "paste" out there.

leslie :-D · Jul 17, 2005

letina- i haven't seen that type of device either, although it sounds wonderful but imagine it would be costly. unfortunately cost of care is a major factor in the care we give (most times). which brings me to:

aimeee- yes they do have an ativan paste through one of our hospice pharmacies but again, our medical director thought it to be an extravagant purchase when we could create such a paste right in the facility. i don't know. maybe it was just my facility where cost was a consideration for so many things....but at least pt. care was never compromised. our medical director expected us to be creative, however. i never got into the intracasies of costs, reimbursements but i didn't want to know either-i'm sure i would have found some of the dynamics quite disturbing.

leslie