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Fast Fact and Concept #71: Meperidine for pain: what is all the fuss?

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Title: Fast Fact and Concept #71: Meperidine for pain: what is all the fuss?

Author(s): David E. Weissman

What is it? Meperidine (MP) is a synthetic opioid, chemically related to the anti-diarrhea agents diphenoxylate and loperamide (Immodium). MP produces analgesia by binding to the mu opioid receptor, as does morphine, producing the same effects and toxicities as morphine. 75-100 mg of parenteral MP = 10 mg parenteral MS; MP has a shorter duration of action than Morphine, only 2.5-3.5 hours. Oral meperidine is a very weak opioid, 300 mg = 30 mg oral morphine.

Why is it controversial? Until recently, MP was the most commonly prescribed drug for post-operative pain, largely by the IM route, ordered prn at a q4-6 dosing interval. Since physicians largely learned how to manage pain from their experiences with surgical patients, MP was the parenteral opioid physicians were most familiar with, ergo, the opioid they typically used for any severe pain problem. However, due to its relatively low potency, short duration of action, and toxic metabolite (see below), MP is a poor analgesic choice.

Over 20 years ago, it became widely recognized that continued MP administration over several days leads to a syndrome of CNS excitation, with tremors, myoclonus, delirium, and seizures. This syndrome, due to accumulation of the metabolite normeperidine, is more prevalent in the elderly or in patients with renal dysfunction.

Finally, MP was established in medical lore as the drug of choice for certain pain conditions, notably pancreatitis / biliary colic and sickle cell pain. In fact, there is little data supporting the contention that MP is the drug of choice for pancreatitis. A recent review of opioid effect on biliary pressure found contradictory results from in vivo biliary manometry studies and only anecdotal reports documenting significant clinical impact. Recent consensus reports on sickle cell pain have specifically recommended not using MP, due to its short duration and toxic metabolite.

What are the recommendations? Every national pain management Clinical Practice Guideline published since 1990 has advised that parenteral MP is not appropriate for a) long-term use (beyond several days), b) any chronic pain syndrome, c) the elderly or d) patients with renal dysfunction. The American Pain Society recommends meperidine should not be used for more than 48 hours for acute pain in patients without renal or CNS disease, or at doses greater than 600 mg/24 hours, and should not be prescribed for chronic pain. In view of all the national guidelines, some hospitals have removed MP from their formulary, others restrict use to short-term, procedure related analgesia (e.g. bone marrow biopsy, colonoscopy).

What is the bottom line? There is little rationale for prescribing parenteral MP and no justification for using oral MP. Parenteral MP is a reasonable choice only when a) there is intolerance to all other opioids and/or b) very brief analgesia is needed.

References:

Principles of Analgesic use in the treatment of acute and cancer pain. 4th Ed. American Pain Society. 1999; Page 31.

Acute Pain Management Guideline Panel. Acute pain management: Operative or Medical Procedures and Trauma Clinical Practice Guideline. AHCPR Publication No. 92-0032. Management of Cancer Pain. Clinical Practice Guideline No. 9; AHCPR Publication No. 94-0592.Rockville, MD. Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service, 1992, 1994.

Cancer pain management in the long-term care setting. Clinical Practice Guideline, 1999. American Medical Directors Association.

Simopoulos TT, et al. Use of meperidine in patient-controlled analgesia and the development of normeperidine toxic reactions. Acrchives of Surgery 2002; 137:84-88.

Isenhower HL and Mueller BA. Selection of narcotic analgesics for pain associated with pancreatitis. Am J Health-Syst Pharm 1998; 55:480-486.

Guideline for the management of acute and chronic pain in sickle cell disease. American Pain Society, 1999.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Fast Facts and Concepts #71 Meperidine for Pain: What's all the Fuss? Weissman DE. June 2002. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 6/2002

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Addiction, Chronic non-malignant pain, Controlled substance regulations, Pain, Pain assessment, Pain treatment


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