# Zofran potentiates opiates?



## Sublime

So at my nursing clinical the other day my instructor started talking about Zofran potentiating narcotics such as morphine. I've never heard this. I'm well aware of phenergan and it's narcotic potentiating effects, but hadn't heard that about Zofran.  I did my research and found nothing on zofran potentiating opiates. 

Does anyone know of any evidence of this?


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## STXmedic

I've never heard of it either. I think your instructor may have just been confusing the two antiemetics...


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## shfd739

STXmedic said:


> I've never heard of it either. I think your instructor may have just been confusing the two antiemetics...



Yep.


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## Sublime

Definitely wasn't confusing them as she mentioned phenergan also.  Perhaps she assumed that since phenergan did than so did zofran. But not five minutes later she was lecturing a student on pulse points correlating with systolic blood pressure minimums (if you can feel a femoral it's at least 60-90 or whatever) so clearly not everything she is teaching is based on clear evidence.


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## NomadicMedic

Or ANY evidence.


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## VFlutter

The only thing I have heard about Zofran is that it can, in very high doses, cause QT prolongation as well as potentiate QT prolongation when used with Sotalol, Haldol, congenital long QT, or electrolyte imbalances. 

IRRC it took 32mg of Zofran to create clinically significant QT prolongation in normal patients.


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## mycrofft

http://www.sciencedaily.com/releases/2009/02/090217212255.htm

Zofran specifically blocks 5-HT3 receptors so it masks opioid withdrawal.
I can see where, as the opioid wears off, the tail end of analgesia not being overwhelmed by withdrawl s/s would seem like a prolongation of opioid action, when it is simply  disguising the jitters, N/V/D.

Sidebar.

We had MD's who prescribed Lomotil, a scheduled controlled antidiarrheal, PRN for withdrawing heroin addicts. You can bet those guys c/o lots of diarrhea, for weeks. Immodium, in high enough doses, is also a narcotic.


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## Carlos Danger

Chase said:


> The only thing I have heard about Zofran is that it can, in very high doses, cause QT prolongation as well as potentiate QT prolongation when used with Sotalol, Haldol, congenital long QT, or electrolyte imbalances.
> 
> IRRC it took 32mg of Zofran to create clinically significant QT prolongation in normal patients.



Zofran actually causes more qt prolongation than either promethazine or droperidol.


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## Jambi

mycrofft said:


> Immodium, in high enough doses, is also a narcotic.



Quinine allows Immodium to cross the blood-brain barrier and as a narcotic.


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## mycrofft

Jambi said:


> Quinine allows Immodium to cross the blood-brain barrier and as a narcotic.



Oh, great, now it's gone viral!h34r:

OTC Immodium overdose was a drug of abuse in the local gay/AIDS culture here in the Eighties.


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## mycrofft

That's *19*80's.


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## Handsome Robb

Chase said:


> The only thing I have heard about Zofran is that it can, in very high doses, cause QT prolongation as well as potentiate QT prolongation when used with Sotalol, Haldol, congenital long QT, or electrolyte imbalances.
> 
> IRRC it took 32mg of Zofran to create clinically significant QT prolongation in normal patients.



I point that out on a daily basis and people still insist that I'm wrong even when I pull up the study. 

"You need to be careful even at 4 mg! I don't give it if they're throwing ectopy to avoid the R-on-T phenomenon!"


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## Christopher

Robb said:


> I point that out on a daily basis and people still insist that I'm wrong even when I pull up the study.
> 
> "You need to be careful even at 4 mg! I don't give it if they're throwing ectopy to avoid the R-on-T phenomenon!"



Although do know that syncopal episodes occur at normal dosages if you push it too quickly.


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## TheLocalMedic

Wait wait wait...  Imodium can get you HIGH???  Brb...  I think I won't be pooping for the next month....


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## mycrofft

MIx it with Exlax.


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## morbusstrangularis

mycrofft said:


> MIx it with Exlax.



Haha, that's great! Senna would also work...

On a side note, I was under the impression that loperamide (Immodium) worked as an opioid receptor agonist that was too hydrophilic / lipophobic to cross the BBB. Mixing it with something to act as a carrier protein or increase its affinity for lipids would make sense to get the opiate properties... Wouldn't taking it in excess do nothing for getting it to the target receptors? Unless a small amount already crosses the BBB, and by increasing dosage you'd also increase the amount that hits CNS receptors? Where is Goodman and Gilman when you need them?


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## usalsfyre

Use Google Scholar to look up whether promethazine actually potentiates opiate. The results will likely be surprising....


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## Christopher

usalsfyre said:


> Use Google Scholar to look up whether promethazine actually potentiates opiate. The results will likely be surprising....



Not much on the subject since the 70's, and most say it "potentiates" by slowing the removal of opiates by the liver... that being said, phenothiazine derivatives have some pretty strong effects on their own.

The following table illustrates this nicely:


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## mycrofft

NIH article for laypersons. LOTS of drug interactions.
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601209.html
Doesn't mention narcotics of any sort, maybe they are "other". ?

I'm not finding anything about prolonging action of narcotics, just that it masks s/s of withdrawl so the upward curve of detox discomfort isn't there to mask the last of the downward curve of analgesia. The subjective difference is nil (other than no detox s/s), but it should not prolong the objective activity (vital signs, labs).


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## dixie_flatline

I don't have anything to cite that hasn't already been listed here, but I can confirm that several of the docs I deal with routinely push zofran with morphine/opiates as a standard precaution against nausea side effects.


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## Christopher

dixie_flatline said:


> I don't have anything to cite that hasn't already been listed here, but I can confirm that several of the docs I deal with routinely push zofran with morphine/opiates as a standard precaution against nausea side effects.



If you _need_ an antiemetic when you push opiates, it is probably because they're being given too quickly.


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## jwk

dixie_flatline said:


> I don't have anything to cite that hasn't already been listed here, but I can confirm that several of the docs I deal with routinely push zofran with morphine/opiates as a standard precaution against nausea side effects.



Zofran is routinely given for surgery patients who have received opiates.




Christopher said:


> If you _need_ an antiemetic when you push opiates, it is probably because they're being given too quickly.




Opiates frequently cause nausea whether they're pushed fast or not, although having been admitted for PONV following surgery because I got 10mg of MS pushed, I agree that giving them fast can make it worse.  We give antiemetics to virtually every general anesthetic patient that gets any narcotics at all.  Most patients would actually prefer to have a little more pain if it means less nausea, although pain can cause nausea as well.


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## abckidsmom

jwk said:


> Zofran is routinely given for surgery patients who have received opiates.
> 
> 
> 
> 
> 
> Opiates frequently cause nausea whether they're pushed fast or not, although having been admitted for PONV following surgery because I got 10mg of MS pushed, I agree that giving them fast can make it worse.  We give antiemetics to virtually every general anesthetic patient that gets any narcotics at all.  Most patients would actually prefer to have a little more pain if it means less nausea, although pain can cause nausea as well.



And opiates combined with significant stress and an hour long ride backwards over curvy roads means I always give Zofran with opiates in my standard practice.


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## Medic Tim

abckidsmom said:


> And opiates combined with significant stress and an hour long ride backwards over curvy roads means I always give Zofran with opiates in my standard practice.



This ^^^

If I have to transport, most people get Zofran, dimenhyrdinate or metoclopramide as it is a REALLY rough and long 2 hours to the highway.


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## TransportJockey

abckidsmom said:


> And opiates combined with significant stress and an hour long ride backwards over curvy roads means I always give Zofran with opiates in my standard practice.



Same here... Unfortunately all we have are ODT zofran tabs... I'm trying to get my medical director to get us IV antiemetics again though.


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## truetiger

Where'd they go?


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## TransportJockey

truetiger said:


> Where'd they go?



Is this to me? If it is... The county formulary we used when we stood up our operation took phenergan out because too many medics were using it with the intention of snowing pain management patients. We are operating under our own protocols and formulary now and I'm trying to get that part changed


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## truetiger

Ahh, that's got to be rough. I've never had much success with the tablets.


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## TransportJockey

truetiger said:


> Ahh, that's got to be rough. I've never had much success with the tablets.



Neither have we. That's why I'm advocating for change


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## jwk

abckidsmom said:


> And opiates combined with significant stress and an hour long ride backwards over curvy roads means I always give Zofran with opiates in my standard practice.



Even with no stress or opiates, I'd need Zofran for an hour long ride backwards over a curvy road!


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## RocknRollRPh

*Unfortunately only hydroxyzine does this*

Thank you for this discussion.  Clinically, the only phenothiazine antihistamine that actually potentiates the analgesic activity of narcotics is hydroxyzine.  And this is in short supply if it can be found at all. Had a patient who needed it and it could not be sourced!  Promethazine (Phenergan) does not actually potentiate analgesia; studies have shown pretty clearly that it actually decreases it, although this combination has long been in the hallowed halls of medicine.  It does help the nausea, it does potentiate the CNS depression of narx - along with a host of others - but alas, hydroxyzine is the only antinauseant that truly increases pain relief.


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## Carlos Danger

RocknRollRPh said:


> Thank you for this discussion.  Clinically, the only phenothiazine antihistamine that actually potentiates the analgesic activity of narcotics is hydroxyzine.  And this is in short supply if it can be found at all. Had a patient who needed it and it could not be sourced!  Promethazine (Phenergan) does not actually potentiate analgesia; studies have shown pretty clearly that it actually decreases it, although this combination has long been in the hallowed halls of medicine.  It does help the nausea, it does potentiate the CNS depression of narx - along with a host of others - but alas, hydroxyzine is the only antinauseant that truly increases pain relief.



Awesome to see a pharmacist on here. Are you also a paramedic or EMT?

Either way, welcome.


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## chaz90

Halothane said:


> Awesome to see a pharmacist on here. Are you also a paramedic or EMT?
> 
> Either way, welcome.



Concur, welcome to the forum!


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