Narcotic “Allergies”
Posted by WhiteCoat on November 21, 2008
Nice little “clinical pearl” review article from EMedHome.com about opioid allergies. Seems that they aren’t as common as some patients would have us believe.
It would also seem that if the adverse reactions to opioids are due to histamine release that administering the opioids with an antihistamine such as Phenergan, Vistaril, or Benadryl would serve both to stop the “allergic” reaction and to enhance the effect of the pain medication. Just be careful giving the Phenergan … at least IV.
I often have luck giving opioid agonist/antagonist medications such as Nubain, Stadol or Buprenex to patients who describe horrific allergies to every medication except their narcotic du jour.
Opioid Allergy
True anaphylactic reactions to opioids are very rare. When patients say they are allergic to an opiod, it is much more likely that the patient has experienced GI upset or a pseudoallergy.
Flushing, itching, hives, and sweating, especially itching or flushing at the injection site only, suggests a pseudoallergy due to histamine release, a pharmacologic side effect of some opioids. Codeine, morphine, and meperidine are the opioids most commonly associated with pseudoallergy. Use of a more potent opioid is less likely to result in histamine release.
The potency of opioids, from lower to higher:
meperidine < codeine < morphine < hydrocodone < oxycodone < hydromorphone < fentanyl
If the patient describes a true allergy to an opiate, then an opioid in a chemical class different from the one to which the patient reacted may be used with close monitoring:
Phenylpiperidines: meperidine (Demerol), fentanyl (Duragesic, Actiq, Sublimaze), sufentanil (Sufenta)
Diphenylheptanes: methadone (Dolophine), propoxyphene (Darvon)
Morphine group: morphine, codeine, hydrocodone (Vicodin, Lorcet), oxycodone (Percocet, OxyContin), oxymorphone (Numorphan), hydromorphone (Dilaudid), nalbuphine (Nubain), butorphanol (Stadol), pentazocine (Talwin)References:
(1) Gilbar PJ, Ridge AM. Inappropriate labeling of patients as opioid allergic. J Oncol Pharm Practice 2004;10:177-82.
(2) Middleton RK, Beringer PM. Anaphylaxis and drug allergies. In: Koda-Kimble MA, Young LY, Kradjan WA, et al., eds. Applied Therapeutics: the clinical use of drugs. 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2005.
(3) Nutescu E, et al. Multidisciplinary approach to improving allergy documentation. Am J Health-Syst Pharm 1998;55:364-8.
(4) VanArsdel PP. Pseudoallergic drug reactions. Introduction and general review. Immunol Allergy Clin North Am 1991;11:635-44.
Read more at EMedHome.com
hannah said
I’m on an opiate-blocker (Revia — no I’m not a heroin addict!!)…how do you guys medicate for that?
Depends on the cause of the pain. There are options.
NSAIDs for acute pain. Antidepressants. Neuro meds. Sedatives. Benadryl can be used in place of lidocaine. Local anesthetic patches for localized pain. Infusion pumps or nerve blocks for chronic pain. Work with your doc or hook up with a pain clinic if it’s a chronic problem.
William said
F/U PMD PRN?
whitecap nurse said
Thanks for the review! I’m surprised Demerol is at the bottom! Why do people love it so much? (It sure worked for me!).
R. S. Sahsi said
Demerol is a horrible drug for so many reasons. From my own observations, it seems to be better at providing a high than acting as a true analgesic. There’s unpredictability in the kinetics of its active metabolites, and concerns about it’s ability to futz around with one’s seizure threshold, though for abusers it’s fantastic because it doesn’t give the giveaway pinpoint pupils of narcotic (over)use. Oh, and that whole thing about using it in biliary colic because it might cause less spasm of the sphincter of Oddi? Rubbish… besides, the same can be said for Fentanyl and Dilaudid.
Great reference, Whitecoat.
Marilyn said
What do you use for people who cannot use opiods? My mom goes psycho whenever she is given any kind of opiods; getting her through the week after her knee replacement was not fun.
Hmmm. Toradol – but everyone gets that. Sometimes sedating psych meds such as Elavil will help. If there is a neurogenic component to the pain (radiculopathy, peripheral neuropathy), some patients respond to medications like Neurontin. I’ve seen docs use benzodiazepines in patients with pain just to help put them to sleep.
Otherwise, it may just be a problem with finding the opioid and dose that work well with your mom. Morphine is usually good if the patients don’t puke – usually because it is so sedating.
Nurse K said
Tramadol! Ibuprofen! Tylenol!
I’ve given thousands of dosages of narcotics, and I’ve never seen an allergic reaction to any of them. I like to, as you said, warn people with morphine that they may “itch” and that’s normal; otherwise, people sometimes freak out and try to say they’re allergic. I’ve been on a personal crusade to remove “N/V” as allergies when I see them on a patient’s e-chart because it’s annoying. “N/V is a side effect of that drug that can be treated, not an allergy, would you still like me to list it as an allergy?” Having 7 drugs that cause nausea listed on the allergy list is just distracting to the physician.
Adam said
Meperedine doesn’t screw with the sphincter of Oddi, either. But the normeperdine metabolite screws with kidney function, especially in the elderly.
Liz said
I have an allergy to codeine that I can’t tell if you have mentioned yet – well actually I guess they call it a “reaction”. I hallucinate (sp?). With both of my c-sections, I was given codeine derivatives and both times I had what my dh calls “spidey-senses” kick in. I could here a policeman’s whistle from them directing traffic after a car accident 3 blocks down the road. I also felt a 3.4 earthquake that no one had felt. crazy stuff! And it keeps me awake. Is this considered an allergy? but I don’t seem to have a problem with hydrocodone. Only if it is mixed with something else (which I think they did in the hospital). anyhoo.
Flea said
Of course, then you get the patients that claim they’re “allergic” to Toradol, Nubain, Stadol, AND Zofran. If someone tells me they’re allergic to Toradol, they might as well just leave.
R. S. Sahsi said
Hallucinating isn’t an allergy… that’s a value-added feature!
Dan said
The Euphoric Violet Delight
Often, medications for severe pain are made from opoid plants. These purple-flowered plants produce opium poppies, which are used in the production of opium. Opium is what we in the U.S. call narcotics, and they dull and numb one who ingests what may be made by these opium poppies, as there are several drugs that have been developed from what these plants provide that are these prevalent narcotics.
Some medications are from natural opium, such as cocaine, or the opiates from the poppy seeds can be used to create semi-synthetic medications, such as Heroin. Heroin was marketed by Bayer Pharmaceuticals for 12 years, and during that time this company told others that heroin was a non-addicting form of morphine (pure opiate drug), since there were many soldiers addicted to morphine after the U.S Civil War. During that same period of time, Bayer marketed heroin for children who coughed. Of course, Heroin is very addictive, and is pointless creation is no longer available.
While Poppy plants exist and are grown in areas of IndoChina, Afghanistan is the number one producer of poppy plants. The United States is the number one country that consumes what is derived from these plants. Opium-derived medicines once could be bought freely in the U.S. by anyone less than 100 years ago. Yet now, they are classified by the Drug Enforcement Agency as narcotics, and are scheduled by them, according to the danger they potentially could cause another who takes them.
While prescribed to patients for such issues aside from pain on occasion, such as chronic coughing and diarrhea, their greatest benefit is for the relief of pain experienced often by patients is the primary reason doctors prescribe opoid drugs, and they do so often. Vicodin, a mild narcotic, is the most frequently prescribed medication in the U.S. presently.
If patients take opium-derived drugs for long periods of time, tolerance may develop, and the patient may need to take more of the drug to acquire an effect of relief. In addition, the patient may develop a dependence on these types of drugs, which can lead to addiction and possible abuse. This is why overdose of these types of medicine occur- as the reasons for taking these drugs initially become replaced with relief due to addiction in some who take narcotics for a long period of time.
Dan Abshear
crys said
i have been told that i am allergic to codine so far i have had very bad reactions to tylenol 3, vicodin, darvocet, and was ok with percocet until now.. seems i am able to take them a few times just fine, but then after a few times of taken any of them my eyes swelled shut.. no other major problems then that.. but i am told that is an allergy and have run out of things i can get for pain other then tramadol which looses its affectiveness really fast!