Why not use Demerol for pain?

By Blaine Carmichael, MPAS, PA-C, DFAAPA

 One of the most widely used opioid analgesics, meperidine (Demerol) is rapidly falling out of favor. In spite of its FDA-labeled indication, there are many reasons why meperidine is not suitable for chronic pain. Repeated dosing with meperidine will cause an accumulation of the toxic metabolite normeperidine, especially of concern in patients with renal impairment. Normeperidine is a potent central nervous system irritant. Symptoms of normeperidine accumulation progress from irritability, to tremors and myoclonus, to generalized seizures. There is no benefit in using meperidine over other parenteral opioids for the treatment of common pain problems including biliary colic, pancreatitis, labor, and migraine.

IM injections of meperidine are painful and absorption is erratic. The oral dosage form should not be used due to high first pass liver metabolism and the ensuing increased concentration of normeperidine. Meperidine is seldom indicated for analgesia in children. It is inappropriate therapy for migraine headache. Do not use it in patients with renal insufficiency, untreated hypothyroidism, Addison's disease, benign prostatic hyperplasia, or urethral stricture. Meperidine should not be used for longer than 48 hours or at doses greater than 600 mg/24 hours in patients with normal renal function.

What are the side effects of meperidine? It can cause anxiety, fluctuations in awareness levels, hallucinations, agitation, delusions, disorientation, restlessness, bizarre feelings (eg, feeling frightened), seizures, diaphoresis, shakiness, myoclonic jerks, nervousness, tremors, and confusion.

In cases of normeperidine neurotoxicity, naloxone should not be used. Naloxone is effective in reversing episodes of nonseizure apnea induced by meperidine.

Use with extreme caution in patients with pre-existing convulsive disorders, and in patients receiving drugs that are known to predispose them to seizures (e.g., imipenem).

 

FURTHER READING

Chalverus, CA. Clinically significant meperidine toxicities.  J Pharm Care in Pain & Symptom Control 2001;9:37-55

Latta, KA, Ginsberg, B, Barkin, RL. Meperidine: A critical review. Am J Therapeutics. 2002;9:53-68

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