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LETTER TO THE EDITOR

Pain Reduction by IV Butorphanol Prior to Propofol

Department of Anesthesiology; Harbor-UCLA Medical Center; Torrance, CA; ckakazu{at}msn.com

To the Editor:

We read with great interest the article written by Agarwal et al. (1) regarding pain attenuation of propofol injection with prior administration of IV butorphanol.

After reading the authors’ discussion, we would like to make several suggestions and corrections regarding IV butorphanol. Indeed, IV butorphanol’s onset time and peak effect is 1–2 min and 4–5 min, respectively’ however, the reference for this information is incorrect. After reading in Miller’s Anesthesia (5th edition), Bailey et al. (2) mentions only butorphanol’s effect upon IM administration. The original studies on IV butorphanol’s pharmacokinetics were published in 1977 by Lippmann et al. (3). In that double-blind placebo-controlled study, we found that IV butorphanol 2 mg was significantly better than placebo at the 1-min observation period with respect to pain intensity (P < 0.02), pain intensity difference (P < 0.02), and pain relief (P < 0.01). Butorphanol was also significantly better (P < 0.01) than placebo according to these same parameters for the remainder of the study (2-,3-,4-,5-,10-,15-,30-, and 60-min observation periods). While a high level of analgesic activity was maintained with butorphanol over the entire 60-min observation period, the peak effect was achieved in 4–5 min.

Butorphanol has excellent sedative effects alone and especially in combination with other agents such as promethazine (4). One must be careful in administering 2 mg butorphanol before administering propofol. The combination may lead to profound sedation, especially when also receiving fentanyl. Prolong awakening is undesirable when surgery is performed on an outpatient basis.

Finally, Dr. Agarwal also states that butorphanol is not a restricted drug like other narcotics. Here in the United States, it is designated as a Class IV drug by the Drug Enforcement Agency, because of its habit-forming potential. Therefore, it is considered a "controlled substance."

Butorphanol exerts its action mainly on the central nervous system rather than on the periphery. Because of its excellent analgesic effect along with its sedative action, the pain derived from the administration of IV propofol would indeed be markedly reduced.

References

1. Agarwal A, Raza M, Dhiraaj S, et al. Pain during injection of propofol: the effect of prior administration of butorphanol. Anesth Analg 2004;99:117–9.[Abstract/Free Full Text]
2. Bailey PL, Egan TD, Stanley TH. Intravenous opioid anesthetics. In: Miller RD, ed. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone, 2000;273–376.
3. Lippmann M, Mok MS, Steen SN. Analgesic onset time of intravenous butorphanol in postsurgical patients: a placebo-controlled study. Curr Ther Res 1977;22:276–83.
4. Lippmann M, Mok MS, Steen SN. Butorphanol and promethazine as pre-anaesthetic medication. J Intern Med Res 1978;6:455–9.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Lippmann, M. Articles by Kakazu, C. Z. Search for Related Content PubMed PubMed Citation Articles by Lippmann, M. Articles by Kakazu, C. Z.