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Discussion in 'Anaesthetics' started by Gayathriy, Nov 24, 2007.
What is your view? Do you think there is a better opioids than morphine and why?
It depends on what you want to use it for and how long you want it to last.
Morphine is actually a fabulous drug, IMO. Although it has many side-effects.
Depends what do you mean by 'better'?
For concious sedation I prefer pethidine as it acts quicker and has a shorter duration of action. Many consider it 'better' in this context. Costs a lot though, while morphine is insanely cheap.
Oxycodone is (relatively) new and has advantages over morphine in some situations.
Pethidine is a dirty drug and should be banned.
Diamorphine and fentanyl are both 'stronger' than morphine if that is what you are asking.
i dont think there are a great many people searching for 'better' painkillers when the opiates we have do the job pretty well. Most of the big drugs companies are playing in the realms of immunomodulation and chemotherapy where there is muchos money to be made.
The problems largely come down to biology and economics - the receptors which opioids act through ('opioid receptors') mediate both the analgesic effects or opioids and the side effects (nausea, sedation, respiratory depression etc...) - whilst there is some differences between the effects mediated by the various sub-classes of the receptors no one has yet designed a drug which is specific for the analgesic effects without the other side effects.
The other issue is economics - morphine is cheap as chips, it works well and doctors are familiar with it. Millions of people get morphine based analgesia every year and it is effective. There are other forms of analgesia, but they are either expensive and cumbersome (epidurals), not as effective on their own and with their own side effects (e.g. Non-steroidals) or have similar or worse side effects (e.g. ketamine).
Pain research is actually reasonably well funded, with a lot of work looking at chronic pain treatments - however most of the work on opioid based treatments has produced more potent opioids (fentanyl, remifentanil, sufentanil) which have great intra-operative use, but aside from fentanyl, tend not to be used in other situations due to the risks of overdose and respiratory depression.
Thankyou for your help!
one more question: where will i be able to find the prices of different opioids? i want to be able to compare equidoses of the main ones.
Tramadol is also allegedly a great complete opioid alternative - according to my current supervisor.
it acts in 2 ways - 50% acts on opioid receptors, and 50% acts on noradrenaline and serotonin receptors, hence it also acts against neuropathic pain and gets involved in descending modulation, which helps inhibit pain.
but as the guys say above there are loads (well, some) alternative opioids - fentanyl, alfentanil, buprenorphine, diamorphine, remifentanil, oxycodone and others which i can't be bothered to think of.....sorry
If you are going to compare the price of equal doses then remember that drugs like fentanyl are more potent than plain old morphine, so you will need a smaller dose to get the same effect......just something to think about.
If you have ever seen a decent Tramadol overdose you will never prescribe it. They fit, fit some some, then continue fitting until the end of your shift. Sometimes they are still fitting the next day when you come on shift again.
if we used the effects of overdose as the guide as to what to prescribe then one would never prescribe paracetamol, Tri-cyclic anti-depressants, methotrexate, or infact many other commonly used and effective drugs contained in the BNF - all of the above named drugs are excellent in their place, but all can kill you in very nasty ways.
Tramadol has its place, although the serotinergic and adrenergic effects do lead to disproportionate levels of confusion in the elderly. The evidence for tramadol in neuropathic pain is not great, although it works better than placebo there is little comparative work (i.e. is it better than morphine, or morphine plus adjuvants, which is the real question which needs answering). Tramadol is a weak opioid, not a strong opioid and certainly could not replace morphine or fentanyl in most acute post-operative pain situations (other than day surgery when strong opioids are seldom prescribed). In addition if one looks comparative efficacy tramadol is less effective than codine/paracetamol (60mg/1G) - although it is less constipating.
As with all drugs you need to know the side effect profile and the comparative utility. It is useful to have a range of medications at your disposal so that you can choose the right one for the right patient -and be able to modify your therapy if required. As a house officer/FY1 its worth having a few drugs you know really well, but as you get more senior (and build on your pharmacology knowledge) you should be able to expand your repertoire. I would always caution against the advice of someone who claims 'this is the best drug for X', or anyone who says 'never use Y' - rigid dogmatism is seldom helpful.