FAST FACT AND CONCEPT #71: Meperidine for Pain -What’s All the Fuss?

2nd Edition

Author: David E. Weissman

Meperidine (MP) is a synthetic opioid, chemically related to the anti-diarrhea agents diphenoxylate and loperamide (Immodium). MP produces analgesia by binding to the mu opioid receptor, as does morphine, producing the same effects and toxicities as morphine. 75-100 mg of parenteral MP = 10 mg parenteral MS; MP has a shorter duration of action than Morphine, only 2.5-3.5 hours. Oral meperidine is a very weak opioid, 300 mg = 30 mg oral morphine.

Why is it controversial? Prior to the 1990s, MP was the most commonly prescribed drug for post-operative pain, largely by the IM route, ordered prn at a q4-6 dosing interval. Since physicians learned how to manage pain from their experiences with surgical patients, MP was the parenteral opioid physicians were most familiar with, ergo, the opioid they typically used for any severe pain problem. However, due to its relatively low potency, short duration of action, and toxic metabolite (see below), MP is a poor analgesic choice.

Over 25 years ago, it became widely recognized that continued MP administration over several days leads to a syndrome of CNS excitation, with tremors, myoclonus, delirium, and seizures. This syndrome, due to accumulation of the metabolite normeperidine, is more prevalent in the elderly or in patients with renal dysfunction.

Finally, MP was established in medical lore as the drug of choice for certain pain conditions, notably pancreatitis / biliary colic and sickle cell pain. In fact, there is little data supporting the contention that MP is the drug of choice for pancreatitis. A review of opioid impact on biliary pressure found contradictory results from in vivo biliary manometry studies and only anecdotal reports documenting significant clinical impact. Recent consensus reports on sickle cell pain have specifically recommended not using MP, due to its short duration and toxic metabolite.

What are the recommendations? Every national pain management Clinical Practice Guideline published since 1990 has advised that parenteral MP is not appropriate for a) long-term use (beyond several days), b) any chronic pain syndrome, c) the elderly or d) patients with renal dysfunction. The American Pain Society recommends “…meperidine should not be used for more than 48 hours for acute pain in patients without renal or CNS disease, or at doses greater than 600 mg/24 hours, and should not be prescribed for chronic pain. In view of all the national guidelines, some hospitals have removed MP from their formulary; others restrict use to short-term, procedure related analgesia (e.g. bone marrow biopsy, colonoscopy).

What is the bottom line? There is little rationale for prescribing parenteral MP and no justification for using oral MP. Parenteral MP is a reasonable choice only when a) there is intolerance to all other opioids and/or b) very brief analgesia is needed.

References

1. Principles of Analgesic use in the treatment of acute and cancer pain. 5th Ed. American Pain Society. 2003.
2. Cancer pain management in the long-term care setting. Clinical Practice Guideline, 1999. American Medical Directors Association.
3. Simopoulos TT, et al. Use of meperidine in patient-controlled analgesia and the development of normeperidine toxic reactions. Archives of Surgery 2002; 137:84-88.
4. Isenhower HL and Mueller BA. Selection of narcotic analgesics for pain associated with pancreatitis. Am J Health-Syst Pharm 1998; 55:480-486.
5. Guideline for the management of acute and chronic pain in sickle cell disease. American Pain Society, 1999.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman DE. Fast Facts and Concepts #71: Meperidine for pain: what is all the fuss? 2nd Edition, July 2006. End-of-Life / Palliative Education Resource Center: www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 6/2002

Purpose: Instructional Aid, Self-Study Guide

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Pain>opioids