Posted 31 December 2004 - 08:29 AM
Here's the skinny. It's confusing. But Opium Tincture is 25 times as strong as paregoric. Opium Tincture has 10 milligrams of morphine per milliliter. Paregoric has 0.4mg or morphine per mL. Huge difference! Also, Opium Tincture, is, well, pure opium powder dissolved in alcohol, nothing else. Paregoric is a compound with several ingredients. I use Opium Tincture because it works better and you only have to take a few drops instead of teaspoonfulls. But the drawback is that it's a Schedule II controlled substance (no refills, no phone scripts, no fax scripts, DEA monitors VERY closely, other Schedule II include morphine, Oxycontin, cocaine, etc). Very few doctors will prescribe Opium Tincture because it's a Schedule II controlled substance (it's basically pure morphine). Also, it is really easy to overdose on Opium Tincture-- just 2 or 3 teaspoons is enough to overdose for someone not used to the medication. Further, Opium Tincture has a really high street value, since it's pure opium, unlike paregoric. Opium Tincture can be converted to heroin quite easily, apparently. Pharmacies don't like stocking drugs that are easily diverted by pharmacists, thieves, and even patients or doctors. Paregoric is also known as camphorated tincture of opium; it is not as strong, and it tastes really nasty-- it has camphor (moth balls) in it. The usual dose for Opium Tincture is 10 minims (about 0.6cc) four times a day. The dose can be increased until the D is brought under control; there is no upper dose limit. The amount of morphine (6mg per usual dose) is quite low-- I felt a little groggy for the first couple of days, but fine after that. But the usual dose for pain control is much higher; also, opium has poor oral potency -- that is, along with morphine, it's only about 1/3 to 1/6th as effective taken orally as opposed to being injected. The usual starting ORAL dose for morphine for pain is 20-30mg. You build up a tolerance to the pain killing and drowsiness side effects of the opium, but not its constipating effect. So, there's no need to keep increasing the dose.All that having been said, of course opium tincture is a narcotic, and a powerful one at that. In tincture form, it's easy to abuse if one were so inclined-- there's no Tylenol or Aspirin or Camphor mixed in to prevent abuse. However, I've taken the drug since 2002 off and on for chronic diarrhea and I have found it to be the most effective medication for D. And I have not needed to increase my dose. In fact, I often take just .3cc or .4cc twice a day. It is the "nuclear" option for diarrhea. If nothing else stops your D, Opium Tincture definitely will. Imodium and Lomotil did not work well for me-- I had to take huge doses of each to control the D, so the MD put me on the tincture. Most people will respond to other antidiarrheals -- I would suggest Opium Tincture as a last resort -- not because it doesn't work, but because it works too well and there is a potential for addiction that doesn't exist with Imodium and is unlikely to exist for Lomotil.Also, you may want to try codeine tablets or Tylenol with Codeine before moving up to Opium Tincture. Codeine is quite constipating -- you might find that 15mg (1/4 grain) of codeine 4 times a day will work. Codeine is a Schedule III drug; doctors are much more willing to write for Schedule III than Schedule II. The problem with codeine is that the Schedule III varieties have acetaminophen or aspirin in them. Taking relatively large amounts of Tylenol or Aspirin every day may not be the best thing for your liver or your stomach. Just something to consider. Codeine sulfate and Codeine phosphate are available without added Tylenol or Aspirin, but only as Schedule II -- Are you beginning to see a pattern? The government insists on adding stuff to pure narcotics to prevent "abuse"-- the Tylenol and Aspirin limit the amount of codeine you can take per day. But why take Schedule II codeine when Opium Tincture itself is Schedule II?Finally, I've found that codeine has nasty side effects (itching, feeling 'high', dry mouth, etc.) at relatively low doses -- e.g., 30mg. So the amount of codeine needed to control your diarrhea might bring on unwanted side effects. The benefit of Opium Tincture is that Opium is mostly morphine, and highly concentrated morphine at that. At the low doses of morphine required to control D, I've found that there's very few side effects compared to the amount of codeine required for similar D control.By the way, the Opium Tincture exclusively available in the U.S. now is "deodorized"-- which means the nasty alkaloids like narcotine (which has no therapeutic value) have been removed. There's a online video at FDA that explains the difference. Here's the address: http://www.accessdata.fda.gov/scripts/cdrh...ipt.cfm?show=27
You have to go down the page a ways, and then there's an article, along with a couple of slides illustrating the difference between opium tincture and paregoric, and a link to a video presentation.Here's the article that accompanies the video:[quote]Recent articles have warned health professionals about dangerous mixups between opium tincture and paregoric. Since 1997, FDA has received eight reports of medication errors involving these two drugs. Three were fatal, and three others required medical treatment.The danger stems from the fact that opium tincture is 25 times more concentrated than paregoric. So if the practitioner thinks he or she is ordering paregoric, but is actually ordering opium tincture, the patient can receive a large overdose.Although the two names don't sound alike, these two drugs each have several synonyms, and it�s those synonyms that can easily be confused. Opium tincture is also called deodorized opium tincture, deodorized tincture of opium, tincture of opium, laudanum, opium, and DTO, which is an abbreviation for �deodorized tincture of opium.� Paregoric is also called camphorated tincture of opium and tincture of paregoric. So you can see how this confusion of names can lead to errors. For example, some practitioners have prescribed �DTO� thinking that this abbreviation stands for �diluted tincture of opium,� when it actually means �deodorized tincture of opium.� As a result, patients have been seriously overdosed.To help resolve the confusion, FDA will be working with the manufacturers of these two drugs to clarify the labeling on the containers and in the package inserts. In the meantime, it's important to educate staff members about possible confusion between the two products. One general rule of thumb that can help to prevent errors is to remember that opium tincture is dosed in drops, in other words in fractions of a milliliter, whereas paregoric is dosed in teaspoons. So any order for opium tincture that specifies teaspoonful doses is likely to be in error.Our web site lists a number of additional recommendations to avoid mixups between paregoric and opium tincture that hospital pharmacies might want to consider. Here are a few of them.First of all, determine if there's a need to even stock opium tincture. Check the last time this medication was dispensed, and eliminate it from the inventory if possible. If you're going to stock both products, be sure to keep the terminology clear and consistent. Call paregoric �paregoric,� and not �camphorated tincture of opium.� And call opium tincture �opium tincture,� and not �DTO.� Put poison labels on all containers of opium tincture, as well as a label stating the strength of morphine per mL, and a statement such as "WARNING! Do NOT confuse opium tincture with paregoric." Since accurately measuring opium tincture doses can be difficult, consider dispensing it only in small dropper bottles or oral syringes. Additional Information:Drug Topics (July 7, 2003). FDA Safety Page: Drug errors associated with opium tincture and paregoric. http://www.fda.gov/cder/drug/MedErrors/opi...e_paregoric.pdf
Pharmacy Times Article http://www.pharmacytimes.com/article.cfm?ID=492
Here's the entries for Opium Tincture and Paregoric from Materia Medica:OPIUM TINCTURE/LAUDANUM
SYNONYMS: Laudanum, Tinctura meconii, Tinctura thebaica.Preparation.�"Powdered opium, one hundred grammes (100 Gm.) [3 ozs. av., 231 grs.]; precipitated calcium phosphate, fifty grammes (50 Gm.) [1 oz. av., 334 grs.]; water, four hundred cubic centimeters (400 Cc.) [13 fl, 252]; alcohol, four hundred cubic centimeters (400 Cc.) [13 fl, 252]; diluted alcohol, a sufficient quantity to make one thousand cubic centimeters (1000 Cc.) [33 fl, 391]. Rub the powders, in a mortar, with the water previously heated to the temperature of 90� C. (194� F.), until a smooth mixture is made, and macerate for 12 hours; then add the alcohol, mix thoroughly, and transfer the whole to a cylindrical percolator. Return to the percolator the first portion of the percolate, until it runs through clear, and, when the liquid ceases to drop, gradually pour on diluted alcohol, continuing the percolation slowly, until one thousand cubic centimeters (1000 Cc.) [33 fl, 391] of tincture are obtained"�(U. S. P.).History and Description.�This tincture is universally known in this and other English-speaking countries as laudanum. It has been known throughout Europe as Laudanum Liquidum Simplex, in contradistinction to solid opium preparations, which were also called by the name laudanum, usually with some qualifying term, as Laudanum Antihystericum, etc. Tincture of opium has a deep red-brown color, and the characteristic odor and taste of opium. Lest concentration take place, through evaporation of its alcohol, it should be kept in securely-stoppered bottles. Each fluid drachm represents 5.7 grains of dry opium, or 1 grain of opium in about 10.5 minims of the tincture.In preparing this tincture, it is essential that well-dried opium should be used, to insure a full-strength product, and it should be in a finely-powdered form. The admixture with calcium phosphate aids in its percolation, which could not otherwise be readily accomplished with diluted alcohol. The percolate passes slowly, and about 60 per cent of the opium constituents are obtained in solution by the use of the diluted alcohol. The Pharmacopoeia directs the drug to be macerated 12 hours previous to percolation. Twice that length of time, however, will better insure the complete disintegration of the opium. After completion of the percolation, water should abstract nothing from the dried residue, and only mere traces of alkaloids, or their compounds, should be abstracted by diluted acids.VALUATION.�"If 100 Cc. of tincture of opium be assayed by the process immediately following, it should yield from 1.3 to 1.5 Gm. of crystallized morphine"�(U. S. P.).ASSAY OF TINCTURE OF OPIUM.�"Tincture of opium, one hundred cubic centimeters (100 Cc.) [3 fl, 183] ammonia water, three and five-tenths cubic centimeters (3.5 Cc.) ; alcohol, ether, water, each, a sufficient quantity. Evaporate the tincture to about 20 Cc., add 40 Cc. of water, mix thoroughly, and set the liquid aside for an hour, occasionally stirring, and disintegrate the resinous flakes adhering to the capsule. Then filter, and wash the filter and residue with water, until all soluble matters are extracted, collecting the washings separately. Evaporate in a tared capsule, first, the washings to a small volume, then add the first filtrate, and evaporate the whole to a weight of 14 Gm. Rotate the concentrated solution about in the capsule until the rings of extract are redissolved, pour the liquid into a tared Erlenmeyer flask having a capacity of about 100 Cc., and rinse the capsule with a few drops of water at a time, until the entire solution weighs 20 Gm. Then add 10 Gm. (or 12.2 Cc.) of alcohol, shake well, add 25 Cc. of ether, and shake again. Now add the ammonia water from a graduated pipette or burette, stopper the flask with a sound cork, shake it thoroughly during 10 minutes, and then set it aside, in a moderately cool place, for at least 6 hours, or over night. Remove the stopper carefully, and, should any crystals adhere to it, brush them into the flask. Place in a small funnel 2 rapidly acting filters, of a diameter of 7 Cm., plainly folded, one within the other (the triple fold of the inner filter being laid against the single side of the outer filter), wet them well with ether, and decant the ethereal solution as completely as possible upon the inner filter. Add 10 Cc. of ether to the contents of the flask, rotate it, and again decant the ethereal layer upon the inner filter. Repeat this operation with another portion of 10 Cc. of ether. Then pour into the filter the liquid in the flask, in portions, in such a way as to transfer the greater portion of the crystals to the filter, and, when this has passed through, transfer the remaining crystals to the filter by washing the flask with several portions of water, using not more than about 10 Cc. in all. Allow the double filter to drain, then apply water to the crystals, drop by drop, until they are practically free from mother water, and afterward wash them, drop by drop from a pipette, with alcohol previously saturated with powdered morphine. When this has passed through, displace the remaining alcohol by ether, using about 10 Cc., or more, if necessary. Allow the filter to dry in a moderately warm place, at a temperature not exceeding 60� C. (140� F.), until its weight remains constant, then carefully transfer the crystals to a tared watch-glass and weigh them. The weight found represents the amount of crystallized morphine obtained from 100 Cc. of the tincture"�(U.S. P.).PAREGORIC/CAMPHORATED TINCTURE OF OPIUM
SYNONYMS: Paregoric, Elixir paregoricum, Paregoric elixir.Preparation.�"Powdered opium, four grammes (4 Gm.) [62 grs. benzoic acid, four grammes (4 Gm.) [62 grs.]; camphor (more), four grammes (4 Gm.) [62 grs.]; oil of anise, four cubic centimeters (4 Cc.) ; glycerin, forty cubic centimeters (40 Cc.) [1 fl, 169]; diluted alcohol, a sufficient quantity to make one thousand cubic centimeters (1000 Cc.) [33 fl, 391]. Add nine hundred cubic centimeters (900 Cc.) [30 fl, 208] of diluted alcohol to the other ingredients, contained in a suitable vessel, and macerate for 3 days, shaking frequently; then filter through paper, in a well-covered funnel, and pass enough diluted alcohol through the filter to make the product measure one thousand cubic centimeters (1000 Cc.) [33 fl, 391]"�(U. S. P.). This tincture has a brown-yellow color, a sweetish and somewhat bitter, sharply aromatic taste, and an odor resembling that of camphor and anise combined. In reaction it is acid, and, when added to water, renders the latter milky. It contains, in every 263 minims, 1 grain of opium. True benzoic acid should be preferred to that made from the urine of herbivorous animals.