Which opiates?

Re: Which opiates?

Hanna Bennett — Tue, 16 Mar 2010 21:36:25 GMT

[quote user="robloxley"]

You don't know what you're missing til you've tried it!

[/quote]

ummm.... morphine after exploratory surgery to remove a whelk from my wrist (long story...) lovely stuff!

Re: Which opiates?

Rob Loxley — Tue, 16 Mar 2010 08:40:56 GMT

[quote user="Michael Woodhouse"]Our receptionist went in for a hernia repair and the pain relief she was sent home with was - paracetamol![/quote]

OK, but ask her what medications she had pre/intra/periop at hospital and I'd be super surprised if some heavyweight opiod didn't feature! Or maybe receptionists don't feel pain?!

You don't know what you're missing til you've tried it!

Re: Which opiates?

Rob Loxley — Tue, 16 Mar 2010 08:36:16 GMT

[quote user="Bouvien Brocks"]The bad thing about all of these drugs is that they have to be injected besides the morphine which can be supplied in the form of symoron.[/quote]

Fentanyl patch; buprenorphine trans mucus membrane especially in the cat. The way this thread went, following the comment in the initial post, was whether people were stocking schedule 2 CDs.

[quote user="Bouvien Brocks"]In netherlands there is an alternative which can be used at home: tramadol. This is a reliable option. If you want to learn more about analgesia and what to use (like butorphanol for dogs is less effective than buprenorfine etc) you should read veterinary clinics of north america small animal practice.[/quote]

Looking at this thread, http://www.vetsurgeon.org/forums/t/4448.aspx , many Brits are using plenty of tramadol, alongside many other oral medications for pain relief.

Re: Which opiates?

Michael Woodhouse — Mon, 15 Mar 2010 22:38:59 GMT

In response to OP - we just have butorphanol and buprenorphine as injectables. We have some tramadol and codeine as tablets.

I have never missed the pure agopnists in practice and I've seen some serious pain controlled by Vetergesic & NSAID (# pelvis springs to mind). Our bitch spays leave wagging their tails.

Our receptionist went in for a hernia repair and the pain relief she was sent home with was - paracetamol!

Re: Which opiates?

Anonymous — Mon, 15 Mar 2010 22:25:34 GMT

The bad thing about all of these drugs is that they have to be injected besides the morphine which can be supplied in the form of symoron. In netherlands there is an alternative which can be used at home: tramadol. This is a reliable option.

if you want to learn more about analgesia and what to use (like butorphanol for dogs is less effective than buprenorfine etc) you should read veterinary clinics of north america small animal practice. Robertson wrote a piece about feline pain management.

i hope this helps.

bouvien

Re: Which opiates?

james hunt — Fri, 05 Mar 2010 15:14:57 GMT

I'm a fan of methadone as part of premedication before surgical cases, I find its onset reliably short and feel it provides good analgesia. I realise it is unlicensed, but I think it has advantages over the licensed mu agonist for small animals.

We have butorphanol which I am happy to use for sedation in mammals and try for analgesia in birds/reptiles/chelonia (these species have higher percentage of kappa than mu receptors, I think, from a vague memory).

Buprenorphine I find to be a useful analgesic in cats and dogs, I tend to use it post surgery/painful medical conditions in hospitalised cases and off licence by buccal administration in cat out patients.

Short acting opioids - we have fentanyl and alfentanyl for intraop use. Very helpful, although some work has linked development of a hyperalgesic state to use of high doses of potent mu agonists, which may be prevented by pre-administration of an NMDA receptor antagonist (ketamine being the most available) so I will often administer between 0.3-0.5mg/Kg ketamine prior to using fentanyl/alfentanyl for intra-op.

Morphine ketamine (lignocaine) drips as described above I have found useful.

Re: Which opiates?

Hanna Bennett — Fri, 05 Mar 2010 13:15:57 GMT

Think we have just about everything bar pethidine!

Butorphanol for sedation, rubbish analgesic and too short acting. Buprenorphine for most routine surgeries as premed.

We use morphine/ketamine infusions, and find them very useful for certain patients. Have to admit to missing the lignocaine out quite often as it is fiddly and i'm not convinced it conveys that much benefit. Local anaesthetic infiltrated one way or another is more common for us. Often these are great for orthopaedic ops which may only be in for a night or two, and are not expected to be too mobile post op.

We use methadone as premed for more painful surgeries, but again it needs topping up quite frequently so not usually for anything that needs prolonged anagesia.

Have both fentanyl patches and injection. I love fentanyl injection for the acute rta/dog attack cat, as given i/v you get such immediate control of the pain in those cats that are freaking out, and it is short acting so even if you induce respiratory depression you can always intubate and maintain oxygenation if needed (have never needed to, but would always recommend being ready to support ventilation if doing so!). Gives me time to work out whatever infusion i'm going to start it on too. One of my nurses reports that in her old practice they would give an i/v dose of fentanyl just prior to tugging on the ovaries in bitch speys and they found the anaesthesia much more stable than otherwise. Not something we have a problem with but again a nice use of a short acting drug.

We do use fentanyl patches, don't send things home on them as i feel anything that requires that level of analgesia should be monitored by trained staff - these are background analgesia and often require topping up with other drugs - these are often applied on admission the night before a big op ie. TECA or flaps and we find the level of discomfort is massively reduced as you have lovely happy drugs on board long before any surgical intervention. Again, they often still require other opioids as top up, at least immediately post op, but certainly the level of anaesthesia required seems lower than without them. The only problem is getting good contact, but our nurses have this down pat now. Saves having the patient having to keep an i/v line in to maintain analgesia. Never had anything chew one off (think i've just jinxed myself there) but then we place them where they can't be reached if poss, bandage them up + buster collar if necc.

Yes, controlled drugs monitoring is a pain, but so is a broken leg! We have a wipeable board on the dangerous drugs cabinet where the vet can just write 'morphine vial 30mg broken leg dog'. Thankfully we rarely have two such dogs in one day, so the dispensary nurse is then responsible for finding out the details of the patient and filling in the controlled drugs book. Occasionally causes headaches but we usually end up spot on.

Re: Which opiates?

Rob Loxley — Thu, 04 Mar 2010 16:22:09 GMT

Buprenorphine, butorphanol, methadone, fentanyl patches.

The paperwork really isn't a major hassle once you get a protocol sorted out.

Re: Which opiates?

Hannah Wynne Richards — Wed, 03 Mar 2010 09:42:15 GMT

Yes I've heard the bell curve isn't a problem at "normal " dosages. I've been to several CPD courses in which Dan has been the tutor, and rate him very highly-I was very sad when he left Bristol to set up for himself-the extra distance meant that it's too far to send a really critical patient to him

Wynne

Re: Which opiates?

Laurence Webb — Tue, 02 Mar 2010 21:31:46 GMT

For dogs we use butorphanol (for sedation, not analgesia), buprenorphine (part of our standard pre-med and for mild-moderate pain) and morphine for severe pain.

We do have codine as it's in Pardale, though that's mainly kept in for its paracetemol component.. Its anti-tussive effects can be handy with bad kennel coughs too. Off licence you can use it at the same time as Metacam etc

I don't tend to use Fentanyl in dogs as it's fairly expensive, absorption can be variable due to skin thickness and I find Tramadol good for home use. If a patient is in enough pain to need an opiate and Tramadol isn't sufficient then it'd probably be hospitalised for Morphine by injection or a CRI.

In cats we use burorphanol (sedation) and buprenorphine. I rarely use Morphine as I find buprenorphine works quite well. I use oral buprenorphine and find that works quite well. I like fentanyl post orthopaedic surgery and will send a cat home with a patch. I've not encountered any problems with patches going missing at home although there may be a degree of client selection in which cats are discharged with one. All patches are removed by a vet and they need to be recorded in the controlled drug waste anyway. In humans it's got something like 20 times the analgesic effect fo morphine so it's great for severe pain.

Coincidentally I went to a talk by Dan Holden on analgesia last week and he felt that buprenorphine is at least as effective as morphine in cats. He also felt that antagonism between pure and partial opiates wasn't a clinical problem so would give a patient buprenorphine then add in a pure agonist if he felt it necessary.

Interstingly he also felt that the loss of analgesic effect as you use higher doses of partial agonists due to the bell shaped dose/effect curve wasn't a significant problem at the doses that are used clinically - effectively we only use doses on the 'upward' part of the graph so he'd quite happily use up to 1ml/10kg of vetergesic but if that wasnt effective then he'd get the morphine out.

Recording controlled drug use and disposal is a bit of a pain, but that's not enough to justify not treating severe pain adequately. I don't tend to get left over morphine as there's only 10mg in a vial, and even in small dogs I can use that up within a day as you need to top it up every 2-4 hours.

I don't use Pethidine as it's so short acting (although rapid onset is a benefit), not as potent as morphine and I found that you'd end up with half empty bottles going out of date as I work in a small practice. I'm not worried about the cascade too much with this either as, if a dog's too painful for buprenorphine to do the biz then I don't believe pethidine will be effective enough either so I think morphine's clinically indicated

Re: Which opiates?

Louisa Huntington — Tue, 02 Mar 2010 20:49:37 GMT

I have just moved to Canada where buprenorphine seems unexistant and hydromorphine used instead. Does any one know why as I dont like hydromorphine .. it is guaranteed vomit and i question its analgesic abilities.

has any one used hydromorphine?

Re: Which opiates?

Hannah Wynne Richards — Tue, 02 Mar 2010 13:48:42 GMT

Buprenorphine-my main opiate-butorphanol-good when I need more sedation, but less analgesia and VERY short -acting. Pethidine, because I do a little equine work-don't use it in SAs . Morphine.

Morphine and pethidine. I'm a little uneasy about disposal (I use the method advocated by an RCVS Past-President ).

Would not use fentanyl patches

a)scared of dog chewing patch

b)scared of owner removing and selling to local drug-adict-seriously, when I hear of veterinary surgeons sending dogs home with fentanyl patches, because it's cheaper for owners than hospitalisation, and regular injections, the legal implications horrify me

c)I once discussed it with John Hird, and he didn't like them-thought they weren't very effective, due to greater thickness of dog skin

Wynne

Re: Which opiates?

Pádraig Egan — Tue, 02 Mar 2010 11:39:42 GMT

We stock Buprenorphine, Butorph, Pethidine, Morphine, Methadone and Tramadol. Our nursing team keeps strict tabs on our controlled drug register and it is compared to the computer sales records monthly to isolate any break downs in recording.

I find Methadone an excellent drug in both Canine and Feline patients, it doesn't cause the nausea that morphine causes in dogs and in cats I find that if used correctly you get excellent analgesia without the dys/euphoria seen with morphine in cats.

Pethidine has got its uses, its a great pre-med for non-painful proceedures such and radiographs with a quick recovery time. It also provides excellent 'bridging' pain relief as it is fast acting and helps bridge the gap when waiting for other analgesics to begin working in the critical patient.

I am a fan of Morphine CRI in orthopaedic patients and have been trying a Mophine/Ketamine/Lidocaine infusion in some patients with good clinical outcomes.

Never used fentanyl patches, how do people find they work?

Re: Which opiates?

Gareth Dowdeswell — Tue, 02 Mar 2010 09:44:56 GMT

We only have Butorphanol, Buphrenorphine and Tramadol. It'd be nice to have Morphine, but we don't do many ops that need that level of pain relief and any case which was in such pain it needed morphine would probably be sent to our out of hours provider anyway, which I think does stock Morphine.

Re: Which opiates?

ms1083 — Tue, 02 Mar 2010 09:25:31 GMT

I like pethidine for the emergency patient mainly due to its very rapid onset of action compared to the others. Yes, its anaglesic affect is not as great but being a full opioid the options are left open for using whatever you like afterwards. Just don't write the date the bottle is first used on the bottle then nobody knows it has been open more than 28days!

The only 2 which are very similar is morphine & methadone, methaone not causing the vomiting that morphine does sometimes but that is useful if an animal has not been starved.

We stock buprenorphine, butorphanol, morphine, methadone, pethidine & fentanyl patches (also tramadol).

Yes, the paperwork is annoying, especially with the rule that once opened a vile must be discarded if not finished that day & must be discarded in the presence of the police! - very stupid, what is wrong with decanting it into a plain large animal blood tube, we have to keep a runnnig total anyway? Likewise why do we have to sign specially for each order - it is surely very clear to a veterinary supplier that a veterinary practice contains vets, especially once they have been delivering here for years! Anyway, we are going through the RCVS accredition inspection at the moment so have to keep them happy.

Re: Which opiates?

Clive Ansell — Tue, 02 Mar 2010 09:18:24 GMT

I can't remember the last time I used pethidine, I tend to use morphine where it is available. I did go through a phase of using it as part of a standard premed with acp, but didn't like it.

From memory: pethidine has a more rapid onset of action and doesn't have the GI side effects of morphine, which may be more useful as a premed if you don't want to wait too long. I think it used to be considered better for visceral pain and was thought to have a GI antispasmodic effect, as well as having vagolytic properties thus reducing salivation and respiratory secretions, and being a weak negative inotrope.

Its short duration and the fact it stings on i/m injection rules it out for me.

Re: Which opiates?

Glen McIntosh — Tue, 02 Mar 2010 00:23:32 GMT

Morphine, butorphanol, buprenorphine.

We no longer stock pethidine, despite the 50ml bottle being the only veterinary licensed pure agonist. For us, its very short duration of action, its contraindication for use as a cri and the pain it causes on im administration (the only way it can really be given effectively) means that morphine (or methadone) is almost always a better choice over pethidine for severe pain, and mild - moderate pain can be handled with buprenorphine. Since we would never finish a bottle within the 28 days post broaching we were in danger of becoming serial drug squad botherers.

But I would be interested in other peoples reasons for stocking pethidine.

Re: Which opiates?

Utlendigur — Mon, 01 Mar 2010 23:54:45 GMT

Ditto - buprenorphine, pethidine, morphine and butorphanol. We did have some fentanyl patches aswell, but kept forgetting about them and they went out of date

Re: Which opiates?

nikki — Mon, 01 Mar 2010 23:50:02 GMT

we have buprenorphine, butorphanol, pethidine and morphine. Vets Now have methadone and fentanyl which we can use as well if we want.