Opioid therapy involves the use of either weak or strong opiates, and often both are prescribed in conjunction to adequately control acute pain. Weak opiates typically come in oral preparations and are combined with varying formulations of acetaminophen, aspirin, or ibuprofen. All of these drugs have ceiling doses related to the non-opioid ingredient. For example, acetaminophen poisoning is one of the common causes of acute liver failure in the United States, and oftentimes these patients are on acetaminophen-containing opiates. Acetaminophen, also known as paracetamol or N-acetyl-p-aminophenol, causes centrilobu-lar necrosis leading to nausea, vomiting, abdominal pain, renal failure and can progress to fulminant hepatic failure (Abram 2006).
Strong opiates are not mixed with other combination medications and are indicated for severe pain. These drugs do not have ceiling doses and toxicity relates directly to the dose-dependent effects of the opiate, for example, respiratory depression. Formulations include immediate release and sustained release preparations. Patients must be instructed not to crush sustained or extended release tablets as this can potentially lead to toxicity. Strong opiates often have additional routes beyond oral administration. Some of these include transdermal, parenteral, and neuraxial.
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