Introduction

Opiate partial agonist; phenanthrene derivative.

Uses for Butorphanol

Pain

Relief of pain that is severe enough to require an opiate analgesic and for which alternative treatment options (e.g., nonopiate analgesics) have not been, or are not expected to be, adequate or tolerated.

Preoperative sedation and analgesia and as a supplement to surgical anesthesia.

Obstetric analgesia during labor.

Management of pain associated with migraine headache.

In equianalgesic doses, parenteral butorphanol is as effective as morphine, meperidine, and pentazocine, but relative potential for abuse reportedly is less than that of codeine or propoxyphene.

In symptomatic treatment of acute pain, reserve opiate analgesics for pain resulting from severe injuries, severe medical conditions, or surgical procedures, or when nonopiate alternatives for relieving pain and restoring function are expected to be ineffective or are contraindicated. Use smallest effective dosage for shortest possible duration since long-term opiate use often begins with treatment of acute pain. Optimize concomitant use of other appropriate therapies. (See Managing Opiate Therapy for Acute Pain under Dosage and Administration.)

Butorphanol Dosage and Administration

General

Managing Opiate Therapy for Acute Pain

• Optimize concomitant use of other appropriate therapies.

• When opiate analgesia required, use conventional (immediate-release) opiates in smallest effective dosage and for shortest possible duration, since long-term opiate use often begins with treatment of acute pain.

• Consider prescribing naloxone concomitantly for patients who are at increased risk of opiate overdosage or who have household members, including children, or other close contacts who are at risk for accidental ingestion or overdosage. (See Respiratory Effects under Cautions.)

• When sufficient for pain management, use lower-potency opiate analgesics given in conjunction with acetaminophen or an NSAIA on as-needed (“prn”) basis.

• For acute pain not related to trauma or surgery, limit prescribed quantity to amount needed for expected duration of pain severe enough to require opiate analgesia (generally ≤3 days and rarely >7 days). Do not prescribe larger quantities for use in case pain continues longer than expected; instead, reevaluate patient if severe acute pain does not remit.

• For moderate to severe postoperative pain, provide opiate analgesic as part of a multimodal regimen that also includes acetaminophen and/or NSAIAs and other pharmacologic (e.g., certain anticonvulsants, regional local anesthetic techniques) and nonpharmacologic therapy as appropriate.

• Oral administration of conventional opiate analgesics generally preferred over IV administration in postoperative patients who can tolerate oral therapy.

• Scheduled (around-the-clock) dosing frequently is required during immediate postoperative period or following major surgery. When repeated parenteral administration is required, IV patient-controlled analgesia (PCA) generally is recommended.

Administration

Administer IM, by IV injection, or by nasal inhalation.

Nasal Administration

Assemble the nasal solution spray pump according to the manufacturer’s instructions. Prior to initial use, fully prime the spray pump; reprime pump whenever it has not been used for ≥48 hours.

Consult the manufacturer’s patient instructions regarding use of the nasal solution spray pump.

The nasal solution spray pump is an open delivery system; aim the pump spray away from the patient, other individuals, or animals to minimize environmental exposure.

IV Administration

For drug compatibility information, see Compatibility under Stability.

Dosage

Available as butorphanol tartrate; dosage expressed in terms of the salt.

After initial priming, the nasal solution spray pump delivers about 14–15 metered doses containing 1 mg per spray. If repriming of the pump is necessary, the spray pump will deliver about 8–10 metered doses, depending on the extent of repriming.

Use lowest effective dosage and shortest duration of therapy consistent with treatment goals of the patient.

When used concomitantly with other CNS depressants, use lowest effective dosages and shortest possible duration of concomitant therapy. (See Specific Drugs under Interactions.)

Adults

Pain

IV

Initially, 1 mg; may repeat dose every 3–4 hours as necessary. Usual effective dosage, depending on severity of pain, is 0.5–2 mg repeated every 3–4 hours.

IM

Initially, 2 mg in patients able to remain recumbent; may repeat dose every 3–4 hours as necessary. Usual effective dosage, depending on severity of pain, is 1–4 mg repeated every 3–4 hours.

Intranasal

Initially, 1 mg (1 spray in 1 nostril); if adequate analgesia is not achieved, may give an additional 1-mg dose within 60–90 minutes. May repeat this initial dose sequence in 3–4 hours, if needed.

For management of severe pain: Initially, 2 mg (1 spray in each nostril) in patients who can remain recumbent if drowsiness or dizziness occurs. Do not administer additional 2-mg doses at intervals <3–4 hours, since the incidence of adverse effects may be increased.

Preoperative Sedation and Analgesia

Usual dosage is 2 mg administered 60–90 minutes before surgery.

Supplement to Surgical Anesthesia

2 mg shortly before induction of anesthesia and/or 0.5–1 mg administered during anesthesia in increments up to 0.06 mg/kg (depending on previous administration of sedatives, analgesics, and hypnotic agents). Usual total dose is 4–12.5 mg (approximately 0.06–0.18 mg/kg).

Obstetric Analgesia

1–2 mg administered in patients at full term in early labor; may repeat after 4 hours. Use alternative analgesia if delivery expected within 4 hours.

Prescribing Limits

Adults

Pain

For acute pain not related to trauma or surgery, limit prescribed quantity to amount needed for the expected duration of pain severe enough to require opiate analgesia (generally ≤3 days and rarely >7 days).

Some states have set prescribing limits for opiate analgesics (e.g., maximum daily dosages that can be prescribed, dosage thresholds at which consultation with a specialist is mandated or recommended).

IM

Maximum 4 mg as a single dose.

Special Populations

Hepatic Impairment

Pain

IV

Initially, 0.5 mg. If necessary, repeat dose at an interval of ≥6 hours.

IM

Initially, 1 mg. If necessary, repeat dose at an interval of ≥6 hours.

Intranasal

Initially, 1 mg (1 spray in 1 nostril); may give an additional 1-mg dose within 90–120 minutes, if necessary. May repeat this initial dose sequence at an interval of ≥6 hours.

Renal Impairment

Patients with renal impairment may receive the same IV, IM, or intranasal dosages as patients with hepatic impairment.

Geriatric Patients

Geriatric patients may receive the same IV, IM, or intranasal dosages as patients with hepatic impairment.

Contraindications

• Known hypersensitivity to butorphanol or benzethonium chloride (contained in the multiple-dose vials of the injection or in the nasal solution).

Warnings/Precautions

Warnings

Abuse Potential

Possible tolerance, psychologic dependence, and physical dependence. Episodes of abuse associated with all routes of administration, especially nasal administration.

Patients with a history of drug or alcohol dependence or abuse are at risk of habituation or dependence; use only with careful surveillance in such patients.

Respiratory Effects

Possible respiratory depression, especially in patients with impaired respiration caused by other drugs, uremia, severe infection, severely limited respiratory reserve, bronchial asthma, respiratory obstruction, or cyanosis. Use with caution and in lower dosages in these patients.

Routinely discuss availability of the opiate antagonist naloxone with all patients receiving new or reauthorized prescriptions for opiate analgesics, including butorphanol.

Consider prescribing naloxone for patients receiving opiate analgesics who are at increased risk of opiate overdosage (e.g., those receiving concomitant therapy with benzodiazepines or other CNS depressants, those with history of opiate or substance use disorder, those with medical conditions that could increase sensitivity to opiate effects, those who have experienced a prior opiate overdose) or who have household members, including children, or other close contacts who are at risk for accidental ingestion or overdosage. Even if patients are not receiving an opiate analgesic, consider prescribing naloxone if the patient is at increased risk of opiate overdosage (e.g., those with current or past diagnosis of opiate use disorder [OUD], those who have experienced a prior opiate overdose).

Patients Dependent on Opiates

Partial opiate antagonist; not recommended for use in patients physically dependent on opiates because of the potential to precipitate symptoms of withdrawal (e.g., anxiety, agitation, mood changes, hallucinations, dysphoria, weakness, diarrhea).

Use with caution in patients who recently received repeated doses of opiate analgesics; allow an adequate period of withdrawal from opiates before initiation of butorphanol therapy.

Concomitant Use with Benzodiazepines or Other CNS Depressants

Concomitant use of opiate agonists or opiate partial agonists, including butorphanol, and benzodiazepines or other CNS depressants (e.g., anxiolytics, sedatives, hypnotics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opiates, alcohol) may result in profound sedation, respiratory depression, coma, and death. Substantial proportion of fatal opiate overdoses involve concurrent benzodiazepine use.

Reserve concomitant use of butorphanol and other CNS depressants for patients in whom alternative treatment options are inadequate. (See Specific Drugs under Interactions.)

General Precautions

CNS Depression

Performance of activities requiring mental alertness and physical coordination may be impaired.

Concurrent use of other CNS depressants may potentiate CNS depression and may result in profound sedation, respiratory depression, coma, or death. (See Concomitant Use with Benzodiazepines or Other CNS Depressants under Cautions.)

Adrenal Insufficiency

Adrenal insufficiency reported in patients receiving opiate agonists or opiate partial agonists. Manifestations are nonspecific and may include nausea, vomiting, anorexia, fatigue, weakness, dizziness, and hypotension.

If adrenal insufficiency is suspected, perform appropriate laboratory testing promptly and provide physiologic (replacement) dosages of corticosteroids; taper and discontinue the opiate agonist or partial agonist to allow recovery of adrenal function. If the opiate agonist or partial agonist can be discontinued, perform follow-up assessment of adrenal function to determine if corticosteroid replacement therapy can be discontinued. In some patients, switching to a different opiate improved symptoms.

Head Injury and Increased Intracranial Pressure

Adverse effects of opiates may obscure the existence, extent, or course of intracranial pathology. Use in patients with head injury only if the potential benefits justify the possible risks.

Cardiovascular Effects

Possible increased myocardial workload; use in patients with AMI, ventricular dysfunction, or coronary insufficiency only if the potential benefits justify the possible risks.

Severe hypertension reported rarely. If hypertension occurs, discontinue and administer a hypotensive agent as necessary; butorphanol-induced hypertension reportedly has been managed with naloxone in patients who were not opiate dependent.

Use cautiously before surgery or anesthesia in hypertensive patients.

Possible hypotension associated with syncope in patients receiving nasal solution; caution patients against performing activities that may pose risks if hypotension were to occur.

Biliary Tract Surgery

Safe use in patients about to undergo biliary tract surgery has not been established; use with caution.

Hypogonadism

Hypogonadism or androgen deficiency reported in patients receiving long-term opiate agonist or opiate partial agonist therapy; causality not established. Manifestations may include decreased libido, impotence, erectile dysfunction, amenorrhea, or infertility. Perform appropriate laboratory testing in patients with manifestations of hypogonadism.

Specific Populations

Pregnancy

Category C.

Use of intranasal spray not recommended during labor and delivery.

Lactation

Distributed into milk following parenteral administration, but not in clinically important amounts at usual therapeutic dosages.

No experience with use of nasal solution in nursing women; estimated that amount of drug distributed into milk will be similar to that when administered parenterally.

Pediatric Use

Safety and efficacy not established in children <18 years of age.

Geriatric Use

Select dosage with caution. (See Geriatric Patients under Dosage and Administration.)

Possible increased sensitivity to the drug in some geriatric individuals.

Insufficient experience with the nasal solution in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults.

Hepatic Impairment

Use with caution. (See Hepatic Impairment under Dosage and Administration.)

Renal Impairment

Use with caution. (See Renal Impairment under Dosage and Administration.)

Common Adverse Effects

Sedation, dizziness, nausea and/or vomiting.

General

Managing Opiate Therapy for Acute Pain

• Optimize concomitant use of other appropriate therapies.

• When opiate analgesia required, use conventional (immediate-release) opiates in smallest effective dosage and for shortest possible duration, since long-term opiate use often begins with treatment of acute pain.

• Consider prescribing naloxone concomitantly for patients who are at increased risk of opiate overdosage or who have household members, including children, or other close contacts who are at risk for accidental ingestion or overdosage. (See Respiratory Effects under Cautions.)

• When sufficient for pain management, use lower-potency opiate analgesics given in conjunction with acetaminophen or an NSAIA on as-needed (“prn”) basis.

• For acute pain not related to trauma or surgery, limit prescribed quantity to amount needed for expected duration of pain severe enough to require opiate analgesia (generally ≤3 days and rarely >7 days). Do not prescribe larger quantities for use in case pain continues longer than expected; instead, reevaluate patient if severe acute pain does not remit.

• For moderate to severe postoperative pain, provide opiate analgesic as part of a multimodal regimen that also includes acetaminophen and/or NSAIAs and other pharmacologic (e.g., certain anticonvulsants, regional local anesthetic techniques) and nonpharmacologic therapy as appropriate.

• Oral administration of conventional opiate analgesics generally preferred over IV administration in postoperative patients who can tolerate oral therapy.

• Scheduled (around-the-clock) dosing frequently is required during immediate postoperative period or following major surgery. When repeated parenteral administration is required, IV patient-controlled analgesia (PCA) generally is recommended.

Administration

Administer IM, by IV injection, or by nasal inhalation.

Nasal Administration

Assemble the nasal solution spray pump according to the manufacturer’s instructions. Prior to initial use, fully prime the spray pump; reprime pump whenever it has not been used for ≥48 hours.

Consult the manufacturer’s patient instructions regarding use of the nasal solution spray pump.

The nasal solution spray pump is an open delivery system; aim the pump spray away from the patient, other individuals, or animals to minimize environmental exposure.

IV Administration

For drug compatibility information, see Compatibility under Stability.

Dosage

Available as butorphanol tartrate; dosage expressed in terms of the salt.

After initial priming, the nasal solution spray pump delivers about 14–15 metered doses containing 1 mg per spray. If repriming of the pump is necessary, the spray pump will deliver about 8–10 metered doses, depending on the extent of repriming.

Use lowest effective dosage and shortest duration of therapy consistent with treatment goals of the patient.

When used concomitantly with other CNS depressants, use lowest effective dosages and shortest possible duration of concomitant therapy. (See Specific Drugs under Interactions.)

Adults

Pain

IV

Initially, 1 mg; may repeat dose every 3–4 hours as necessary. Usual effective dosage, depending on severity of pain, is 0.5–2 mg repeated every 3–4 hours.

IM

Initially, 2 mg in patients able to remain recumbent; may repeat dose every 3–4 hours as necessary. Usual effective dosage, depending on severity of pain, is 1–4 mg repeated every 3–4 hours.

Intranasal

Initially, 1 mg (1 spray in 1 nostril); if adequate analgesia is not achieved, may give an additional 1-mg dose within 60–90 minutes. May repeat this initial dose sequence in 3–4 hours, if needed.

For management of severe pain: Initially, 2 mg (1 spray in each nostril) in patients who can remain recumbent if drowsiness or dizziness occurs. Do not administer additional 2-mg doses at intervals <3–4 hours, since the incidence of adverse effects may be increased.

Preoperative Sedation and Analgesia

Usual dosage is 2 mg administered 60–90 minutes before surgery.

Supplement to Surgical Anesthesia

2 mg shortly before induction of anesthesia and/or 0.5–1 mg administered during anesthesia in increments up to 0.06 mg/kg (depending on previous administration of sedatives, analgesics, and hypnotic agents). Usual total dose is 4–12.5 mg (approximately 0.06–0.18 mg/kg).

Obstetric Analgesia

1–2 mg administered in patients at full term in early labor; may repeat after 4 hours. Use alternative analgesia if delivery expected within 4 hours.

Prescribing Limits

Adults

Pain

For acute pain not related to trauma or surgery, limit prescribed quantity to amount needed for the expected duration of pain severe enough to require opiate analgesia (generally ≤3 days and rarely >7 days).

Some states have set prescribing limits for opiate analgesics (e.g., maximum daily dosages that can be prescribed, dosage thresholds at which consultation with a specialist is mandated or recommended).

IM

Maximum 4 mg as a single dose.

Special Populations

Hepatic Impairment

Pain

IV

Initially, 0.5 mg. If necessary, repeat dose at an interval of ≥6 hours.

IM

Initially, 1 mg. If necessary, repeat dose at an interval of ≥6 hours.

Intranasal

Initially, 1 mg (1 spray in 1 nostril); may give an additional 1-mg dose within 90–120 minutes, if necessary. May repeat this initial dose sequence at an interval of ≥6 hours.

Renal Impairment

Patients with renal impairment may receive the same IV, IM, or intranasal dosages as patients with hepatic impairment.

Geriatric Patients

Geriatric patients may receive the same IV, IM, or intranasal dosages as patients with hepatic impairment.

Not known whether drugs that affect hepatic microsomal enzymes may interfere with metabolism of butorphanol.

Drugs Associated with Serotonin Syndrome

Risk of serotonin syndrome when used with other serotonergic drugs. May occur at usual dosages. Symptom onset generally occurs within several hours to a few days of concomitant use, but may occur later, particularly after dosage increases. (See Advice to Patients.)

If concomitant use of other serotonergic drugs is warranted, monitor patients for serotonin syndrome, particularly during initiation of therapy and dosage increases.

If serotonin syndrome is suspected, discontinue butorphanol, other opiate therapy, and/or any concurrently administered serotonergic agents.

Specific Drugs