Analgesics Narcotic

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Opioid Prescribing guidelines can be found at www.okhca.org/opg

Prescribing guidelines and quantity limits for Analgesic, NSAIDs, and Antipyretics

Date of Quantity Limit Implementation	Medications Affected
Phase 1 - November 2014	Hydromorphone Immediate Release Products Morphine Immediate Release Products Codeine and Codeine Combination Products Oxymorphone Immediate Release Products
Phase 2 - December 2014	Oxycodone Immediate Release Products Oxycodone Combination Products
Phase 3 -January 2015	Hydrocodone Combination Products Butalbital Combination Products

Short Acting Opioid Analgesics - Alphabetically by Generic Name (Oral and Topical ONLY)

Drug Generic Name	Drug Brand Name	Quantity Limit Amount per 30 Days
Acetaminophen/Codeine	Tylenol with Codeine # 2®, Tylenol with Codeine #3®, Tylenol with Codeine #4®	120
Codeine Acetaminophen, Aspirin, Butalbital Combination Products	Cogesic®, Fioricet®, Fiorinal with Codeine® Ascomp®	180
Dihydrocodeine acetaminophen, aspirin, caffeine combination products	Synalgos®, Trezix®	120
Codeine Sulfate	Codeine	120
Fentanyl oncology formulations	Actiq®, Subsys® Fentora® Abstral®	120 112 128
Hydrocodone – Acetaminophen	Norco®, Vicodin®, Lorcet®, Maxidone®, Xodol®, Zamicet®, Primlev®	120
Hydrocodone-Ibuprofen	Vicoprofen®, Reprexian®, Ibudone®	120
Hydromorphone HCL	Dilaudid®	120
Meperidine	Demerol®, Meperitab®	64 per 8 days
Morphine Sulfate Immediate Release	MSIR®	120
Oxycodone - Acetaminophen	Percocet®, Magnacet®, Roxicet®	120
Oxycodone - Aspirin	Percodan®, Endodan®	120
Oxycodone - Ibuprofen	Combunox®, Xylon-10®	120
Oxycodone - Acetaminophen	Percocet®, Magnacet®	120
Oxycodone Immediate Release	OxyIR®, Roxicodone®, Oxecta®	120
Oxymorphone Immediate Release	Opana IR®	120
Tapentadol	Nucynta®	120
Tramadol	Ultram®	240
Tramadol- Acetaminophen	Ultracet®	180

Long Acting Opioid Analgesics - Alphabetically by Generic Name (Oral and Topical ONLY)

Drug Generic Name	Drug Brand Name	Quantity Limit Amount per 30 Days
Buprenorphine transdermal	Butrans®	10
Fentanyl transdermal system	Duragesic®	10
Hydrocodone Extended Release	Zohydro ER®, Xartemis XR®	60* and 120**
Hydromorphone Extended Release	Exalgo®	30*
Levorphanol	Levo-dromoran®	60
Morphine Controlled Release	MS Contin®	90
Morphine Extended Release Capsule	Avinza®	30
Morphine Extended Release Capsule	Kadian®	60
Morphine Sulfate- Naltrexone	Embeda®	60
Oxycodone Controlled Release	Oxycontin®	60
Oxymorphone Extended Release	Opana ER®	60
Tapentadol	Nucynta ER®	60
Tramadol Extended Release	Ultram ER®, Ryzolt®, ConZip®	30

* Special PA or other restrictions apply
** Xartemis XR special PA or other restrictions apply

Clinical Notes:

Acetaminophen Hepatotoxicity

Acetaminophen has been associated with severe hepatotoxicity following acute and chronic ingestion.
Maximum recommended dose of acetaminophen for adults is (4) four grams/day.
Be sure to consider and ask about all potential sources of acetaminophen (e.g., OTC, combination analgesics) when determining daily acetaminophen dose.
Risk may increase with concurrent alcohol use, underlying liver disease, and/or the fasting state.

Constipation

Common adverse effect with chronic opioid use; prescribe stool softener +/- laxative with narcotic.

Black Box Warning – Long-acting opioid analgesics
The FDA requests that practitioners who prescribe extended-release and long-acting opioid analgesics should be used ONLY for pain severe enough to require daily, around-the-clock long-term opioid treatment for which alternative therapies are inadequate. Due to the risk of addiction, abuse, and misuse, these drugs should be reserved for patients in whom non-opioid alternatives or immediate-release opioids have not been tolerated or ineffective in managing pain.
The FDA has approved class-wide label changes for ALL extended release and long acting opioid products. In addition, a the black box warning cautions that long-term maternal use of opioid analgesics during pregnancy can lead to neonatal opioid withdrawal syndrome, which can be life-threatening.
Please reserve these medications for only the most severe pain and consider tapering and withdrawing these products whenever possible.

For more information visit the FDA website here: http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm363722.htm

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Analgesics - Opioids