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Narcotic "Allergies"

morphineNice little “clinical pearl” review article from EMedHome.com about opioid allergies. Seems that they aren’t as common as some patients would have us believe.

It would also seem that if the adverse reactions to opioids are due to histamine release that administering the opioids with an antihistamine such as Phenergan, Vistaril, or Benadryl would serve both to stop the “allergic” reaction and to enhance the effect of the pain medication. Just be careful giving the Phenergan … at least IV.

I often have luck giving opioid agonist/antagonist medications such as Nubain, Stadol or Buprenex to patients who describe horrific allergies to every medication except their narcotic du jour.

Opioid Allergy
True anaphylactic reactions to opioids are very rare. When patients say they are allergic to an opiod, it is much more likely that the patient has experienced GI upset or a pseudoallergy.
Flushing, itching, hives, and sweating, especially itching or flushing at the injection site only, suggests a pseudoallergy due to histamine release, a pharmacologic side effect of some opioids. Codeine, morphine, and meperidine are the opioids most commonly associated with pseudoallergy. Use of a more potent opioid is less likely to result in histamine release.
The potency of opioids, from lower to higher:
meperidine < codeine < morphine < hydrocodone < oxycodone < hydromorphone < fentanyl
If the patient describes a true allergy to an opiate, then an opioid in a chemical class different from the one to which the patient reacted may be used with close monitoring:
Phenylpiperidines: meperidine (Demerol), fentanyl (Duragesic, Actiq, Sublimaze), sufentanil (Sufenta)
Diphenylheptanes: methadone (Dolophine), propoxyphene (Darvon)
Morphine group: morphine, codeine, hydrocodone (Vicodin, Lorcet), oxycodone (Percocet, OxyContin), oxymorphone (Numorphan), hydromorphone (Dilaudid), nalbuphine (Nubain), butorphanol (Stadol), pentazocine (Talwin)

(1) Gilbar PJ, Ridge AM.  Inappropriate labeling of patients as opioid allergic. J Oncol Pharm Practice 2004;10:177-82.
(2) Middleton RK, Beringer PM. Anaphylaxis and drug allergies. In: Koda-Kimble MA, Young LY, Kradjan WA, et al., eds. Applied Therapeutics: the clinical use of drugs. 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2005.
(3) Nutescu E, et al. Multidisciplinary approach to improving allergy documentation. Am J Health-Syst Pharm 1998;55:364-8.
(4) VanArsdel PP.  Pseudoallergic drug reactions. Introduction and general review. Immunol Allergy Clin North Am 1991;11:635-44.

Read more at EMedHome.com

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  1. I’m on an opiate-blocker (Revia — no I’m not a heroin addict!!)…how do you guys medicate for that?

    Depends on the cause of the pain. There are options.
    NSAIDs for acute pain. Antidepressants. Neuro meds. Sedatives. Benadryl can be used in place of lidocaine. Local anesthetic patches for localized pain. Infusion pumps or nerve blocks for chronic pain. Work with your doc or hook up with a pain clinic if it’s a chronic problem.

  2. Thanks for the review! I’m surprised Demerol is at the bottom! Why do people love it so much? (It sure worked for me!).

  3. Demerol is a horrible drug for so many reasons. From my own observations, it seems to be better at providing a high than acting as a true analgesic. There’s unpredictability in the kinetics of its active metabolites, and concerns about it’s ability to futz around with one’s seizure threshold, though for abusers it’s fantastic because it doesn’t give the giveaway pinpoint pupils of narcotic (over)use. Oh, and that whole thing about using it in biliary colic because it might cause less spasm of the sphincter of Oddi? Rubbish… besides, the same can be said for Fentanyl and Dilaudid.

    Great reference, Whitecoat.

  4. What do you use for people who cannot use opiods? My mom goes psycho whenever she is given any kind of opiods; getting her through the week after her knee replacement was not fun.

    Hmmm. Toradol – but everyone gets that. Sometimes sedating psych meds such as Elavil will help. If there is a neurogenic component to the pain (radiculopathy, peripheral neuropathy), some patients respond to medications like Neurontin. I’ve seen docs use benzodiazepines in patients with pain just to help put them to sleep.
    Otherwise, it may just be a problem with finding the opioid and dose that work well with your mom. Morphine is usually good if the patients don’t puke – usually because it is so sedating.

  5. Tramadol! Ibuprofen! Tylenol!

    I’ve given thousands of dosages of narcotics, and I’ve never seen an allergic reaction to any of them. I like to, as you said, warn people with morphine that they may “itch” and that’s normal; otherwise, people sometimes freak out and try to say they’re allergic. I’ve been on a personal crusade to remove “N/V” as allergies when I see them on a patient’s e-chart because it’s annoying. “N/V is a side effect of that drug that can be treated, not an allergy, would you still like me to list it as an allergy?” Having 7 drugs that cause nausea listed on the allergy list is just distracting to the physician.

    • From one nurse to another, I am a patient with chronic pain. I have received all chemical interventions for my pain with disastrous results:peeling skin, skin blisters, seratonin syndrome (what fun that was), explosive migraine, itching so severe that bleeding is difficult. As to the opioids, I experience such a massive release of histamine that all sites of injury make me feel I am literally on fire. So have a little more compassion for folks like me who do suffer from true allergies, severe drug reaction, environmental toxins, and food into
      Era cues. Just lay back on a burning log and you will experience just one of my lovely days!

  6. Meperedine doesn’t screw with the sphincter of Oddi, either. But the normeperdine metabolite screws with kidney function, especially in the elderly.

  7. I have an allergy to codeine that I can’t tell if you have mentioned yet – well actually I guess they call it a “reaction”. I hallucinate (sp?). With both of my c-sections, I was given codeine derivatives and both times I had what my dh calls “spidey-senses” kick in. I could here a policeman’s whistle from them directing traffic after a car accident 3 blocks down the road. I also felt a 3.4 earthquake that no one had felt. crazy stuff! And it keeps me awake. Is this considered an allergy? but I don’t seem to have a problem with hydrocodone. Only if it is mixed with something else (which I think they did in the hospital). anyhoo.

  8. Of course, then you get the patients that claim they’re “allergic” to Toradol, Nubain, Stadol, AND Zofran. If someone tells me they’re allergic to Toradol, they might as well just leave.

    • I am confused as to why you would say the pt’s that “claim” they’re allergic to …! I was given Nubain in the ER for a migrain and out of nowhere I begin to have chest tightness, difficulty with breathing, dizzy, and blurred vision and the hospital’s Dr didn’t take it serious and tried to say that I was having anxiety and left me unattended to until someone else threatened to call 911. Then they begin to rush and give me several doses of medicines to counteract a allergic reaction. I kept trying to explain something was wrong…they never told me I had an allergic reation, but from that point on I was afriad to be treated in the ER. I had to be brought in the ER by ambulance for chest pains and they discovered along with whatever was going on with my heart rate that my BP was extremly high and after a while of trying to convince me to take meds, A nurse asked me why was I so afraid and my husband told her of the previous incident and she asked the head Dr if she could search the records to see what happened and she came back and told me exactly what happened and it was in the records that I had indeed had a severe reaction to the Nubain and they had a flag on my records “DO NOT GIVE PT NUBAIN”! She even told me all the measures that they did to back track their steps. It was also in my records from previous visits that Pt isn’t a medicine seeker, is only desiring to stop the voimiting and is willing to tolerate the pain. So I am confused when you say this…are there not supose to be a “REAL” possiblity that one can actually be allergic to these medications. Not being argumentive just trying to understand.

  9. Hallucinating isn’t an allergy… that’s a value-added feature!

  10. This is an older post so not sure who will see this, but I was told by an ED nurse that Morphine and Dilaudid were causing me to vomit.

    I presented to ED with kidney stones. The two WORST times in my life were being in the ED vomiting..incessantly along with kidney stone pain.

    So for 3 years… my mantra (to anyone who came near me in the hospital) was do not give me those drugs because of getting so sick with them.

    This past summer, back in ED and became a hospital admit (not for kidney stones) and my doc decided to try morphine and I did not get sick.

    So…it was the stuck kidney stones!

    But…I am guessing…maybe 18 hours later… I woke up scratching violently…everywhere. Could not stop! Not a pretty site and embarrassing.

    I actually thought I picked something up from the OR that night.

    It was the Morphine! It went away once it was out of my system. Dilauded gives me a headache as soon as it goes in but can counter it with Toradol.

    Demerol doesn’t give me any side effects, but they don’t use it for some reason… something about elderly population. ?? (If I understood correctly)

  11. I actually am allergic to Toradol.

  12. Would a psuedoallergy be localized at the injection site only? If rash presents on face or other arm, would this be considered a true allergic reaction? Pt with hx of morphine allergy given dilaudid and facial rash and hives on both arms occurred. Facial rash persists with oxycodone use following ER visit for nephrolithiasis. Thoughts? Thank you in advance!

  13. I have an allergic reaction when I have taken hydromorphone. I can hardly breath when I have done so. My chest becomes so congested and tight for over 24 hrs I don’t think I ever want to try this opioid again. My question is: is it safe to try other opiates such as oxymorphone that are similar to hydromorphone because I am fine on oxycodone, hydrocodone and OxyContin? The problem has only occurred with hydromorphone and ms contin..
    Please can someone tell me what options I have because I really don’t want to have breathing problems when taking medication for pain.. Danger!
    Thanks Squeal

  14. I have an aspirin allergy and had a reaction to Toradol after my c section. I do not test my luck but my symptoms have been swelling in face and neck and difficulty breathing. I feel that is a “true” allergic reaction. I have only taken Advil(as a teen) and Toradol (after cs) when I got those symptoms. I have had a “sensitivity” to hydrocodone once. Pretty much just itchy but worried me with my history of allergies so I add it to list of allergies with an explanation that it wasn’t that bad. Worst part was I took it before bed and was worried it would turn into an actual reaction. I can handle itching but have struggled my whole life to find something with anti inflammatory properties without the swelling.

  15. I have had a severe histamine mediated allergic reaction to Toradol; for any medical students or residents out there who don’t understand what this means, it means that giving me toradol can easilly kill me! I have hronic back ain (documented) and I generally refuse any medical teratment for pain, but after a recent car crash I ended up in the ER where a moralistic, immature resident told me that “nobody is allergic to toradol, you must be drug-seeking”..I refused to sign a consent for any treatment and pushed this idiot resident out of my way. The head of ortho met as I was dressing in the ER and told me that she was sorry for the way that I was treated’ she offered me narcotics and a nurse tried to give me demoral which I refused. My x-rays became available and showed ignificant damage; the ortho doc (not a resident, a real physician) told me that I had spinal damage that required admission. I asked the ortho doc if she would consent to admission after being treated th was I was; she hung her head without answering. I finally left the ER, basically crawling to my car.

  16. At a way Helen! I refused all medical care post-op until they appropriately treated my pain. Patients beware!

  17. My reactions to morphine, codeine and demerol include immediate extremely lowered blood pressure, difficulty breathing, slowed heartbeat, confusion, dizziness. Desert Springs hospital in Las Vegas gave me morphine twice following a head injury, despite my telling them I was allergic to these narcotics. All my vital signs bottomed out and only the invention of my RN daughter saved my life. I am also very sensitive to wine, liquor, etc. and antihistimines do not work on me, but hype me up. At what point do doctors and nurses become gods and decide that what I know to be true, is not?

  18. Connie:

    I agree completely. I have had severe anaphylactic reactions to both morphine and codeine. I have a very long list of tested food allergies also including soy, yet a number of doctors and anesthesiologists have scoffed at my “so called allergies”, demeaned me by insuinuating I’m both stupid and a hypochondriac, etc.

    I have to have surgery soon for diverticulitis and it’s been a complicated process to figure out how to anesthetize me without the use of propofol (contains a high concentration of soy oil) and opiates/opiods, as well as how to manage post operative pain.

    It’s insulting to have a medical professional not take a situation that to you could be life-threatening, seriously. Worse, knowing that in a surgical setting, a doctor may “override” your allergies (and I’m not talking about some redness and itching here, I’m talking past demonstrated full anaphylaxis requiring emergency room visits) and choose to inject you with something that will likely kill you.

    Another issue is that my allergist is perfectly willing to test me properly for alternative synthetic opioids like fentanyl or demerol, but it’s nearly impossible to GET these substances outside a hospital even with a prescription, so testing (to be 100% sure) is often difficult.

  19. You say you can’t be “allergic” to narcotics … bull … you give me ANY narcotics and first i start to itch and then my throat just closes right up… I have had EVERY drug out there for different surgeries over the years (i have had 12 surgeries because of PCOS/endometrosis, csect, gall bladder and Hysterectomy) If i hear those words well we have to give you something for the pain … last time i heard those words I went into anaphylactic shock and they had to give me so much stuff to counteract the ONE shot of demerol that i don’t remember the 3 days I was in the hospital i was so out of it… NOT a good thing … I can take Tylenol and Ibuprophen and that is IT!! I went to an allergist and he told me it was all in my head that is was not a real allergy.. I think i am going to find a new allergist :) I am also allergic to scents and latex. I can’t even go to the dentist and get work done because I am allergic to the lidocaine, carbocaine and novocaine!! It royally sucks.. so please don’t tell me you can’t be allergic to these drugs .. i am proof that you can.. I have had major reactions to ALL of them .. they have tried them all and i have the same reaction to them all!!

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