Drugs and routes of administration not recommended for treatment of cancer pain

Pain & HIV/AIDS

Drugs and routes of administration not recommended for treatment of pain

Class Drug Rationale for not recommending

Opioids Meperidine Short (2-3 hour) duration. Repeated administration may lead to CNS toxicity (tremor, confusion, or seizures.)^88; ^242; ⁴⁵⁴
High oral doses required to relieve severe pain, and these increase the risk of CNS toxicity ^21; ⁵⁰⁰

Miscellaneous Cannabinoids Side effects of dysphoria, drowsiness, hypotension, and bradycardia preclude its routine use as an analgesic.²¹

Cocaine Has demonstrated no efficacy as an analgesic or coanalgesic in combination with opioids.²¹

Opioid agonist-
antagonists Pentazocine Butorphanol
Nalbuphine Risk of precipitating withdrawal in opioid-dependent patients. Analgesic ceiling.^244; ³⁴⁵ Possible production of unpleasant psychotomimetic effects (e.g., dysphoria.)^21; ^296; ⁵⁰⁰

Partial agonist Buprenorphine Analgesic ceiling. Can precipitate withdrawal.^21; ⁵⁰⁰

Antagonist Naloxone Naltrexone May precipitate withdrawal. Limit use to treatment of life-threatening respiratory depression.¹³²

Combination preparations Brompton's cocktail No evidence of analgesic benefit to using Brompton's cocktail over single opioid analgesics.^471; ^490; ^500; 509

DPT (Meperidine, Promethazine, and Chlorpromazine) Efficacy is poor compared with that of other analgesics. High incidence of adverse effects.³⁴⁶

Anxiolytics alone Benzodiazepine(e.g., alprazolam) Analgesic properties not demonstrated except for some instances of neuropathic pain. Added sedation from anxiolytics may limit opioid dosing.^21; ⁵⁰⁰

Sedative/hypnotic
drugs alone Barbiturates Benzodiazepine Analgesic properties not demonstrated. Added sedation from sedative/hypnotic drugs limits opioid dosing.²¹

Routes of administration Rationale for not recommending

Intramuscular (IM) Painful. Absorption unreliable.²¹ Should not be used for children or patients prone to develop dependent edema or in patients with thrombocytopenia.⁵⁰⁰

Transnasal The only drug approved by the FDA for transnasal administration at this time is butorphanol, an agonist-antagonist drug, which generally is not recommended. (See opioid agonist-antagonists above).

Class	Drug	Rationale for not recommending
Opioids	Meperidine	Short (2-3 hour) duration. Repeated administration may lead to CNS toxicity (tremor, confusion, or seizures.)^88; ^242; ⁴⁵⁴ High oral doses required to relieve severe pain, and these increase the risk of CNS toxicity ^21; ⁵⁰⁰
Miscellaneous	Cannabinoids	Side effects of dysphoria, drowsiness, hypotension, and bradycardia preclude its routine use as an analgesic.²¹
Cocaine	Has demonstrated no efficacy as an analgesic or coanalgesic in combination with opioids.²¹
Opioid agonist- antagonists	Pentazocine Butorphanol Nalbuphine	Risk of precipitating withdrawal in opioid-dependent patients. Analgesic ceiling.^244; ³⁴⁵ Possible production of unpleasant psychotomimetic effects (e.g., dysphoria.)^21; ^296; ⁵⁰⁰
Partial agonist	Buprenorphine	Analgesic ceiling. Can precipitate withdrawal.^21; ⁵⁰⁰
Antagonist	Naloxone Naltrexone	May precipitate withdrawal. Limit use to treatment of life-threatening respiratory depression.¹³²
Combination preparations	Brompton's cocktail	No evidence of analgesic benefit to using Brompton's cocktail over single opioid analgesics.^471; ^490; ^500; 509
DPT (Meperidine, Promethazine, and Chlorpromazine)	Efficacy is poor compared with that of other analgesics. High incidence of adverse effects.³⁴⁶
Anxiolytics alone	Benzodiazepine(e.g., alprazolam)	Analgesic properties not demonstrated except for some instances of neuropathic pain. Added sedation from anxiolytics may limit opioid dosing.^21; ⁵⁰⁰
Sedative/hypnotic drugs alone	Barbiturates Benzodiazepine	Analgesic properties not demonstrated. Added sedation from sedative/hypnotic drugs limits opioid dosing.²¹
Routes of administration	Rationale for not recommending
Intramuscular (IM)	Painful. Absorption unreliable.²¹ Should not be used for children or patients prone to develop dependent edema or in patients with thrombocytopenia.⁵⁰⁰
Transnasal	The only drug approved by the FDA for transnasal administration at this time is butorphanol, an agonist-antagonist drug, which generally is not recommended. (See opioid agonist-antagonists above).

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