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The Prescription Drug Abuse
Epidemic
Incidence, Treatment, Prevention, and Policy
Ty S. Schepis, PhD, Editor
Copyright © 2018 by ABC-CLIO, LLC
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, except for the inclusion of brief quotations in a
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Library of Congress Cataloging-in-Publication Data
Names: Schepis, Ty S.
Title: The prescription drug abuse epidemic : incidence, treatment,
prevention, and policy / Ty S. Schepis, PhD, editor.
Description: Santa Barbara, California : Praeger, an imprint of ABC-CLIO,
LLC, [2018] | Includes bibliographical references and index.
Identifiers: LCCN 2018010856 (print) | LCCN 2018011814 (ebook) | ISBN
9781440852657 (ebook) | ISBN 9781440852640 (set : alk. paper)
Subjects: LCSH: Medication abuse—United States. | Opioid abuse—United
States. | Drug abuse—United States. | Drug abuse—Treatment—United
States. | Drug abuse—Political aspects—United States.
Classification: LCC RM146.7 (ebook) | LCC RM146.7 .P76 2018 (print) | DDC
362.29/90973—dc23
LC record available at https://lccn.loc.gov/2018010856
ISBN: 978-1-4408-5264-0 (print)
978-1-4408-5265-7 (ebook)
22 21 20 19 18 1 2 3 4 5
This book is also available as an eBook.
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Contents
Acknowledgments vii
Chapter 1 Introduction 1
Ty S. Schepis
Chapter 2 Opioids6
Gregory B. Castelli and Winfred T. Frazier
Chapter 3 Stimulants 31
Christian J. Teter, Marcus Zavala, and Linh Tran
Chapter 4 Benzodiazepines 47
Michael Weaver
Chapter 5 Misuse and Abuse of Over-the-Counter Medicines 69
Richard Cooper
Chapter 6 Nonmedical Prescription Drug Use in Adolescents
and Young Adults 83
Lian-Yu Chen, Alexander S. Perlmutter, Luis Segura,
Julian Santaella-Tenorio, Julia P. Schleimer, Mariel Mendez,
Lilian Ghandour, Magdalena Cerdá, and Silvia S. Martins
Chapter 7 Misuse of Prescription Drugs among Young Adults 115
Mark Pawson and Brian C. Kelly
Chapter 8 Prescription Drug Misuse in Older Adults 133
Yu-Ping Chang
Chapter 9 Opioids: Misuse and Guideline-Concordant
Use in Pain Management 150
William C. Becker and Joanna L. Starrels
Chapter 10 Opioids in the Emergency Setting 164
Travis L. Hase and Francesca L. Beaudoin
viContents
Chapter 11 Regulation of Opioid Medications in the
United States 193
Kenneth Kemp Jr. and Martin Grabois
Chapter 12 Promoting Prescription Drug Monitoring
Programs for Population Health: Research
and Policy Implications 206
David S. Fink, Julia P. Schleimer, Aaron Sarvet,
Kiran K. Grover, Chris Delcher, June H. Kim,
Alvaro Castillo-Carniglia, Ariadne E. Rivera-Aguirre,
Stephen G. Henry, Magdalena Cerdá, and
Silvia S. Martins
Chapter 13 Harm Reduction Approaches to Opioids 227
Lucas Hill
Chapter 14 A Comparison of Recent Trends in Prescription
Drug Misuse in the United States and the
United Kingdom 242
Trevor Bennett, Katy Holloway, and Tom May
Chapter 15 Using Health Behavior Theory to Understand
Prescription Drug Misuse 265
Niloofar Bavarian, Sheena Cruz, and Ty S. Schepis
Chapter 16 Understanding Nonmedical Prescription Drug Use:
The Importance of Criminological Theory 283
Jason A. Ford and Alexis Yohros
Chapter 17 Conclusions 303
Ty S. Schepis
About the Editor and Contributors 307
Index319
Acknowledgments
It should probably go without saying that the completion and publication of
a book such as this is impossible without a host of individuals who contrib-
ute, and no one is more aware of this than I am, as editor. Nonetheless,
please allow me to reiterate: the completion and publication of this book
would not have been possible without the authors who submitted thoughtful
and well-researched chapters, the editorial and production staff at Praeger/
ABC-Clio, and the support of colleagues and family. I am truly indebted to
each of them for their help with this project.
First, I am grateful for the contributions of every author to this volume.
Enclosed within this book is the work of a truly staggering number of tal-
ented researchers and clinicians who work daily to reduce the societal toll of
prescription misuse. Perhaps more importantly, every author I interacted
with was helpful, thoughtful, and quick to reply—all of which are appreci-
ated by a stressed editor. While easy to overlook, I would strongly urge you
to spend some time reading the author biographies in the “About the Authors”
section of this book. It was particularly gratifying to me that individuals
were included from such a variety of academic and clinical disciplines and
across a wide span of career stages. Chapter authors are not just the current
authorities on prescription misuse, as many students, who are the future of
the field, were included as coauthors on chapters. For their time and effort, I
want to sincerely thank the authors of the chapters in this book. I believe our
book (and it is most certainly our book) is a substantive contribution to the
emerging literature on prescription misuse.
In addition, I want to thank Praeger/ABC-Clio for approaching me to serve
as the editor of this book. When I accepted this challenge over two years ago,
I had little idea of what I was truly getting into. The fact that I both survived
and helped produce a strong book is due in no small part to the help and
guidance I received from the staff at Praeger/ABC-Clio. My thanks also go
out to these staff members for their help in shepherding a novice editor
through his first book.
viiiAcknowledgments
I am also fortunate to work in a wonderful department, Psychology, at
Texas State University. My departmental colleagues are a great source of sup-
port, and they almost certainly (and patiently) listened to me complain in the
times I was having unanticipated difficulty finding authors for chapters or
was dealing with a crisis or two related to this book. I am quite lucky to work
in such a collegial and academically diverse department.
Most importantly, I want to dedicate this book to my very understanding
and supportive family. I spent the good part of many evenings seeking
authors, editing chapters, and completing the chapters for which I was an
author. Throughout it all, my wife did not complain—in fact, she was a sym-
pathetic and helpful ear throughout the process. Making time to play with
our two wonderful sons, William and Daniel, was also a very important way
for me to cope during frustrating times. Finally, I would not be here (nor
would this book) without my mother’s patient and probably exhausting par-
enting. She was both parents in one, and I am forever grateful to her for that.
CHAPTER ONE
Introduction
Ty S. Schepis
From a variety of public health, medical, and other clinical experts (Cobaugh
et al., 2014; DeVane, 2015; Kanouse & Compton, 2015; Kolodny et al., 2015)
to the executive branch of the U.S. government (Newman, 2017) and the
president of the United States (Ford, 2017), a consensus has emerged that
prescription opioid misuse in the United States is an epidemic and a national
crisis. While the attention to the topic has accelerated greatly in the past year,
misuse of opioid medications, such as oxycodone (e.g., OxyContin), hydro-
codone (e.g., Vicodin or Lortab), and fentanyl, and the consequences of such
misuse have been increasing since the early 2000s in the United States.
Increases in opioid misuse have occurred concomitantly with increases in
emergency department visits (Substance Abuse and Mental Health Services
Administration (SAMHSA), 2012), the number of individuals enrolling in
addiction treatment (SAMHSA, 2014), and overdoses related to opioids
(Rudd, Aleshire, Zibbell, & Gladden, 2016). More recent evidence points to
an increase in heroin use driven by individuals who had previously misused
opioids transitioning to heroin (Compton, Jones, & Baldwin, 2016) and
continuing to use heroin (Palamar & Shearston, 2017). Furthermore, the
United States is not the only country affected by opioid misuse, as commen-
tators in Canada (Fischer, Gooch, Goldman, Kurdyak, & Rehm, 2014),
Europe (Morley, Ferris, Winstock, & Lynskey, 2017), and Australia (Roxburgh
et al., 2017) and a chapter of this volume can attest.
Opioid misuse is not the only form of prescription misuse to be concerned
about, however. Stimulant medications that are often used to treat attention-
deficit/hyperactivity disorder, including methylphenidate (e.g., Ritalin or
2 The Prescription Drug Abuse Epidemic
Concerta), lisdexamfetamine (e.g., Vyvanse), and various amphetamine for-
mulations (e.g., Adderall) and benzodiazepine medications used in the treat-
ment of anxiety and insomnia, including alprazolam (Xanax) and lorazepam
(Ativan), are also commonly misused medications and the source of great
potential harms to those engaged in misuse (Weaver, 2015; Weyandt et al.,
2016). Although the rates of misuse of these medications have been more
stable than the rates of opioid misuse, emergency department visits and the
number of individuals enrolling in addiction treatment have increased over
the past 15 years (SAMHSA, 2012, 2014).
This book aims to introduce readers to the phenomenon of prescription
medication misuse by providing a broad perspective on this ongoing public
health crisis. The chapters primarily focus on opioid misuse, given its out-
sized role in the overall prescription misuse crisis, with coverage included of
stimulant, benzodiazepine, and over-the-counter medication misuse. Chap-
ters on special populations (e.g., older adults), settings where prescription
misuse is likely to be a particular issue (e.g., emergency departments), pre-
scription misuse outside of the United States, the U.S. legal and policy envi-
ronments, and a pair of theories with potential utility in preventing misuse
are included herein. While not exhaustive, this work will grant readers a
strong base of knowledge with which to engage policy makers and elected
representatives and serve as a starting point for further study of the scientific
literature.
Before proceeding into an overview of the chapters to follow, a pair of
points need to be addressed. First, readers may note that the terminology in
the chapters varies somewhat from author to author. In part, this is because
of an unfortunate lack of consensus regarding prescription misuse terminol-
ogy that other commentators have been noting for years (Barrett, Meisner, &
Stewart, 2008; Boyd & McCabe, 2008; Compton & Volkow, 2006). While I
considered imposing external specific definitions for such terms as misuse,
abuse, and nonmedical use, the authors were free to choose their preferred
terms. Unless otherwise specified, the definitions of misuse and nonmedical
use basically correspond with the definition offered by Compton and Volkow:
“any intentional use of a medication with intoxicating properties outside of a
physician’s prescription for a bona fide medical condition, excluding acci-
dental misuse” (Compton & Volkow, 2006, p. S4). Use of the term abuse was
generally discouraged because of potential confusion with the DSM-IV psy-
chiatric diagnosis of substance abuse; this diagnosis does not correspond
with the definition offered above, though use of the abuse label as a stand-in
for misuse or nonmedical use is seen in the literature.
Second, all terminology in this volume was written in a person-centered
fashion. In simpler terms, the use of potentially stigmatizing labels such as
misuser, addict, and abuser was avoided in favor of such terms as person
engaged in misuse or person endorsing nonmedical use. As noted by Becker and
Introduction 3
Starrels in chapter 9 of this volume, there is ample reason to believe that the
use of potentially stigmatizing labels does just that: it places a negative value
judgment on a person. The use of these labels has inherent ethical problems,
conflicting with the important principles of beneficence and respect for per-
sons, and there is evidence that such labeling is counterproductive, as it dis-
courages people from seeking treatment or taking other steps to cease
prescription misuse (Kelly, Wakeman, & Saitz, 2015; Scholten et al., 2017).
Chapter Overview
The initial four chapters cover the background material on the medication
classes of interest: opioids (chapter 2), stimulants (chapter 3), benzodiazepines
(chapter 4), and other misused over-the-counter medications (chapter 5).
The first three chapters examine the medical uses and pharmacological
properties of the medication classes, and the fourth covers such risks as mis-
use, intoxication, and consequences of inappropriate use. The chapter on
over-the-counter medications takes a brief look at a variety of medications,
including antihistamines and laxatives.
The next three chapters examine populations of special interest for pre-
scription misuse: adolescents and university students (chapter 6), young
adults (chapter 7), and older adults (chapter 8). For younger individuals,
focus is warranted due to the uniquely elevated rates of misuse in university
students and young adults and, in all cases, due to the potential for misuse to
adversely affect both neurobiological and psychosocial developmental trajec-
tories. After the chapters on populations of interest, the next two chapters
focus on prescription misuse through the lens of two particularly impacted
medical settings: primary care pain management (chapter 9) and the emer-
gency department (or emergency room; chapter 10).
The next two subsections of the book cover prescription misuse on
national scales. First, chapters 11, 12, and 13 examine policy, law, and public
health related to prescription misuse in the United States. Specifically, chap-
ter 11 addresses federal law and policy, chapter 12 addresses the use of pre-
scription drug monitoring programs (or PDMPs) to reduce prescription
misuse, and chapter 13 addresses a variety of harm reduction approaches to
reduce the opioid epidemic. Chapter 14 examines prescription misuse out-
side the United States, in the United Kingdom.
Finally, two chapters consider larger theories that may be relevant to pre-
scription misuse. Chapter 15 describes and applies three health behavior
theories to prescription misuse, while chapter 16 describes criminological
theory and applies it to misuse. The book ends with a final and brief chapter
that points toward future directions for research and policy that may help
reduce rates of both prescription misuse and the associated consequences
that have so significantly affected tens of millions or more worldwide.
4 The Prescription Drug Abuse Epidemic
References
Barrett, S. P., Meisner, J. R., & Stewart, S. H. (2008). What constitutes prescrip-
tion drug misuse? Problems and pitfalls of current conceptualizations.
Current Drug Abuse Reviews, 1(3), 255–262.
Boyd, C. J., & McCabe, S. E. (2008). Coming to terms with the nonmedical use
of prescription medications. Substance Abuse Treatment, Prevention, and
Policy, 3, 22. doi:10.1186/1747-597X-3-22.
Cobaugh, D. J., Gainor, C., Gaston, C. L., Kwong, T. C., Magnani, B., McPherson,
M. L., . . . Krenzelok, E. P. (2014). The opioid abuse and misuse epidemic:
Implications for pharmacists in hospitals and health systems. American
Journal of Health-System Pharmacy, 71(18), 1539–1554. doi:10.2146
/ajhp140157.
Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Relationship between
nonmedical prescription-opioid use and heroin use. New England Journal
of Medicine, 374(2), 154–163. doi:10.1056/NEJMra1508490.
Compton, W. M., & Volkow, N. D. (2006). Abuse of prescription drugs and the
risk of addiction. Drug and Alcohol Dependence, 83 Supplement 1, S4-7.
DeVane, C. L. (2015). An epidemic of opioid prescriptions. Pharmacotherapy, 35(3),
241–242. doi:10.1002/phar.1571.
Fischer, B., Gooch, J., Goldman, B., Kurdyak, P., & Rehm, J. (2014). Non-medical
prescription opioid use, prescription opioid-related harms and public
health in Canada: An update 5 years later. Canadian Journal of Public Health,
105(2), e146–149.
Ford, M. (2017, Aug 10). Trump informally declares the opioid crisis a national
emergency. The Atlantic. https://www.theatlantic.com/politics/archive/2017
/08/president-trump- declares-the- opioid-crisis- a-national- emergency
/536514/.
Kanouse, A. B., & Compton, P. (2015). The epidemic of prescription opioid abuse,
the subsequent rising prevalence of heroin use, and the federal response.
Journal of Pain & Palliative Care Pharmacotherapy, 29(2), 102–114. doi:10.31
09/15360288.2015.1037521.
Kelly, J. F., Wakeman, S. E., & Saitz, R. (2015). Stop talking “dirty”: clinicians,
language, and quality of care for the leading cause of preventable death
in the United States. American Journal of Medicine, 128(1), 8–9. doi:10.1016
/j.amjmed.2014.07.043.
Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T.
W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis:
a public health approach to an epidemic of addiction. Annual Review of
Public Health, 36, 559–574. doi:10.1146/annurev-publhealth-031914-122957.
Morley, K. I., Ferris, J. A., Winstock, A. R., & Lynskey, M. T. (2017). Polysub-
stance use and misuse or abuse of prescription opioid analgesics: A multi-
level analysis of international data. Pain, 158(6), 1138–1144. doi:10.1097
/j.pain.0000000000000892.
Introduction 5
Newman, K. (2017, Aug 8). Health Secretary Tom Price calls opioid epidemic “an
emergency.” U.S. News and World Report. https://www.usnews.com/news
/national-news/articles/2017-08-08/tom-price-vows-to-treat- opioid- epi
demic-as-an-emergency.
Palamar, J. J., & Shearston, J. A. (2017). Nonmedical opioid use in relation to
recency of heroin use in a nationally representative sample of adults in
the United States. Journal of Psychoactive Drugs, 1–8. doi:10.1080/027910
72.2017.1368747.
Roxburgh, A., Hall, W. D., Dobbins, T., Gisev, N., Burns, L., Pearson, S., &
Degenhardt, L. (2017). Trends in heroin and pharmaceutical opioid over-
dose deaths in Australia. Drug and Alcohol Dependence, 179, 291–298.
doi:10.1016/j.drugalcdep.2017.07.018.
Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in
drug and opioid overdose deaths—United States, 2000–2014. MMWR:
Morbidity and Mortality Weekly Report, 64(50–51), 1378–1382. doi:10.15585
/mmwr.mm6450a3.
Scholten, W., Simon, O., Maremmani, I., Wells, C., Kelly, J. F., Hammig, R., &
Radbruch, L. (2017). Access to treatment with controlled medicines ration-
ale and recommendations for neutral, precise, and respectful language.
Public Health, 153, 147–153. doi:10.1016/j.puhe.2017.08.021.
Substance Abuse and Mental Health Services Administration. (2012). Drug Abuse
Warning Network, 2010: National Estimates of Drug-Related Emergency
Department Visits. Rockville, MD: Substance Abuse and Mental Health
Services Administration.
Substance Abuse and Mental Health Services Administration. (2014). Treatment
Episode Data Set (TEDS): 2002–2012. National Admissions to Substance
Abuse Treatment Services (BHSIS Series S-71, HHS Publication No. (SMA)
14-4850). Rockville, MD: Substance Abuse and Mental Health Services
Administration.
Weaver, M. F. (2015). Prescription sedative misuse and abuse. Yale Journal of Biology
and Medicine, 88(3), 247–256.
Weyandt, L. L., Oster, D. R., Marraccini, M. E., Gudmundsdottir, B. G., Munro, B. A.,
Rathkey, E. S., & McCallum, A. (2016). Prescription stimulant medication
misuse: Where are we and where do we go from here? Experimental and Clin-
ical Psychopharmacology, 24(5), 400–414. doi:10.1037/pha0000093.
CHAPTER TWO
Opioids
Gregory B. Castelli and Winfred T. Frazier
Opioids are a class of medications that have been widely used to relieve acute
and chronic pain for millennia. Opioid is the modern term used to describe
all substances that bind to opioid receptors, including agonists and antago-
nists (Hemmings & Egan, 2013). Narcotics describe medications with the
potential for abuse. Both terms are routinely used interchangeably in the
clinical setting, with opioids as the overarching label for the entire class. Opi-
ate is a less frequently used term that describes drugs directly derived from
the opium poppy plant. As it is all encompassing, opioid is the most accurate
nomenclature. For more on the history of opioids, see chapters 9 and 13.
Opioids are divided into several different chemical and structural classes;
each opioid is available in various doses and delivery modalities (Ballantyne
& Mao, 2003). Table 2.1 provides an overview of major opioid analgesic
products. Commercially available products have different rates of onset and
durations of action, which is important for clinicians to be aware of when
prescribing these medications for patients (DiPiro et al., 2017). In addition to
various dosage forms, rates of onset, and durations of action, prescription
opioids come in several formulations, including immediate- and extended-
release preparations, and various routes, including oral, transdermal, intra-
venous, and intramuscular.
Opioids have a high abuse and misuse potential, with some (e.g., heroin)
commonly used illegally despite lacking clinical indications (Jamison & Mao,
2015). Opioid use and misuse is a major public health concern in the United
States, with many federal agencies noting that the deleterious consequences
of opioid misuse, including death, have reached epidemic proportions.
Opioids 7
Pharmacology
Opioids that are used clinically share many structural features. Morphine
and codeine are naturally occurring opioids. They are both found in Papaver
somniferum, which is commonly known as the poppy plant (Thorn, Klein, &
Altman, 2009). A methyl group contained in codeine is the only structural
difference between these two opioids. Many semisynthetic opioids are cre-
ated through modification of the morphine molecule (see Table 2.1). Syn-
thetic opioids, while clinically active, do not occur in nature and have been
engineered for medical purposes.
Opioids simulate the properties exerted by endogenous chemicals of pain
perception. Endogenous opioids, including enkephalins, endorphins, and
dynorphins, are chemicals found in the human body that act on opioid
receptors. In addition to the body’s natural pain response, these chemicals
have been implicated in many neurological and psychological conditions,
including anxiety, legal and illegal drug use, reward pathways, and the body’s
response to pain (Vallejo, Barkin, & Wang, 2011). This effect on the body’s
reward pathway may help explain the negative effects of long-term prescrip-
tion opioid use, such as dependence and hyperalgesia.
Opioids exert their main pharmacologic pain effects through interacting
with opioid receptors found primarily throughout the body’s nervous sys-
tem, including the brain, spinal cord, peripheral sensory nerves, and auto-
nomic nerves. Three main classes of opioid receptors have been identified:
mu (μ), kappa (κ), and delta (δ). Opioid receptors are also widely distributed
in other tissues, including cardiovascular, pulmonary, and gastrointestinal;
the activation of receptors at these sites can lead to the adverse effects dis-
cussed later in this chapter. These receptors are guanine (G) protein-linked
receptors; agonists binding to these receptors will activate G-protein path-
ways to produce an inhibitory effect (Pardo & Miller, 2018). Adenylate
cyclase of the cyclic AMP pathway and influx of calcium are inhibited, and
potassium efflux and production of prostaglandins and leukotrienes are
increased, causing hyperpolarization of presynaptic cells and reduced excit-
ability of neurons. In addition to opioid receptor binding, opioids have effects
at multiple other sites in the body, attenuating the pain response. Opioids
inhibit the release of the neuromodulator substance P, producing a dimin-
ished pain stimulus that travels through the spinal cord and dorsal horn (De
Felipe et al., 1998).
Physical dependence and tolerance are two important and characteristic
traits of opioids (Vallejo et al., 2011). Physical dependence is the need to keep
using a drug to avoid withdrawal syndrome. Tolerance, where larger doses
are needed to provide similar analgesia, develops after chronic exposure to
opioids. Tolerance can also be defined as a diminished analgesic effect to the
same dose of an opioid following extended use. Tolerance is an innate and
Table 2.1 Commonly Used Opioid Analgesic Products
Medication: Chemical Equianalgesic Dose Typical Starting Doses Onset Duration Available Available
Generic (Brand) Source Formulations Routes of
Parenteral Oral Parenteral Oral Administration
Onset Onset
15–30 min 30–60 min
Phenanthrenes (morphine-like agonists)
Morphine Naturally 10 mg 30 mg 1–5 mg IV/ 5–15 mg 10 min ed Capsule (ER); oral IV, PO
(Embeda, MS occuring IM q3–4h q3–4h solution; tablet
Contin, Kadian) (IR, ER); tablet
(ER); suppository;
IV solution
Oxycodone Semisynthetic N/A 20 mg N/A 10 mg 30–60 min 4–6h 12h Capsule (IR, ER); PO
(Oxycontin, q4–6h (ER) tablet (IR, ER) oral
Roxicodone, solution; tablet
8
Percocet) (IR with APAP)
Oxymorphone Semisynthetic 1 mg 10 mg 1–1.5 mg 5–10 mg 10–20 min 3–6h Tablet (IR, ER); IV IV, PO
(Opana, q4–6h q4–6h solution
Numorphan)
Hydromorphone Semisynthetic 1.5 mg 7.5 mg 0.5–1 mg 2–4 mg 10–20 min 4–5h Tablet (IR, ER); IV, PO
(Dilaudid, IV/IM q3–4h (IV) 13h (ER) oral solution; IV
Exalgo) q3–4h 6h (Oral ER) solution;
suppository
Hydrocodone Semisynthetic N/A 20 mg N/A 5–10 mg 30–60 min 2–4h Capsule (ER); PO
(Norco, Hysingla, q4–6h 12–24h (ER) tablet (ER); tablet
Zohydro) (IR with APAP)
Codeine Naturally 120 mg 200 mg 30 mg IM 30–60 mg 30–60 min 4–6h Tablet (IR); oral PO
occuring q3–4h q3–4h solution; tablet
(IR with APAP)
Phenylpiperidines (meperidine-like agonists)
Fentanyl Synthetic 50–100 *Varies 25–50 mcg Transdermal: 7–15 min (IV) 1–2h (IV) Buccal film; IV IV, transdermal,
(Duragesic, mcg IV q1–2h 25 mcg/h q72h 6h 72–96h solution; sublingual,
Fentora, (transdermal) (transdermal) sublingual/buccal buccal
Lazanda) products; patch;
intranasal
solution; tablet
Meperidine Synthetic 75–100 300 mg 50–100 mg Not 10–15 min 4–6h Tablet (IR); oral IV, PO
(Demerol) mg IV/IM q2–3h Recommended solution; IV
solution
Diphenylheptanes (methadone-like agonits)
Methadone Synthetic *Varies *Varies 2.5–10 mg 2.5 mg q8–12h 30–60 min 4–8h Tablet (IR); oral IV, PO
IV/IM concentrate; IV
q8–12h solution;
9
Agonist-antagonist derivatives
Buprenorphine Synthetic *Varies *Varies 0.3 mg IM 75 mg q12–24h 10–20 min 6h Buccal film; patch; IV, sublingual,
(Buprenex, q6–8h Transdermal: IV solution; tablet; buccal,
Butrans) 5 mcg/h q7d implant transdermal,
subcutaneous
Central analgesics
Tramadol Synthetic N/A N/A N/A 50–100 mg 60 min 4h Capsule (ER); PO,
q4–6h (max 10h (ER) tablet (ER, IR); oral transdermal
400 mg daily) suspension; cream
IR = immediate release, ER = extended release, IV = intravenously, PO = by mouth, APAP = acetaminophen
