What are the dosing guidelines for Laudanum (opium tincture)?

Dosing Guidelines for Laudanum (Opium Tincture)

The recommended dose of deodorized tincture of opium (laudanum) is 10-15 drops in water every 3-4 hours for the treatment of severe diarrhea. 1

Formulation and Concentration

Laudanum (opium tincture) comes in two main formulations that must not be confused:

1. Deodorized tincture of opium: Contains the equivalent of 10 mg/mL morphine

   • Recommended dose: 10-15 drops in water every 3-4 hours 1

2. Paregoric (camphorated tincture): A less concentrated preparation containing the equivalent of 0.4 mg/mL morphine

   • Recommended dose: 5 mL in water every 3-4 hours 1

Clinical Indications

Laudanum is primarily indicated for:

• Severe diarrhea that has not responded to first-line treatments like loperamide 1, 2
• Alternative to loperamide in patients with chronic diarrhea 1
• Management of diarrhea in cancer patients 1

Dosing Algorithm

1. First-line treatment: Begin with loperamide 4 mg followed by 2 mg every 2-4 hours or after every unformed stool (maximum 16 mg daily) 1, 3

2. If loperamide fails:

   • Switch to deodorized tincture of opium: 10-15 drops in water every 3-4 hours 1
   • OR paregoric: 5 mL in water every 3-4 hours 1

3. For persistent diarrhea:

   • Consider low doses of morphine concentrate as a cost-effective alternative to tincture of opium 1
   • For severe cases, consider octreotide (100-150 μg SC/IV three times daily) 1, 3

Special Considerations

Monitoring

• Monitor for signs of opioid-related adverse effects including:
  • Sedation
  • Respiratory depression
  • Constipation
  • Nausea
  • Delirium 1

Contraindications

• Avoid in patients with intestinal obstruction 3
• Use with caution in elderly patients or those with respiratory conditions
• Avoid in patients with grade 3-4 diarrhea from immunotherapy (corticosteroids preferred) 1

Important Precautions

• Do not confuse deodorized tincture of opium with paregoric, as this could result in a 25-fold dosing error 1
• Unlike loperamide, laudanum has significant systemic effects due to its morphine content 1
• Tolerance does not typically develop for the antidiarrheal effect 2
• Monitor for signs of dependence, though recent studies suggest this is uncommon when used appropriately for diarrhea 2

Advantages of Laudanum

• Liquid formulation allows for rapid onset of action 2
• Effective for severe diarrhea resistant to other treatments 2
• Sustained therapeutic effect without development of tolerance to the antidiarrheal properties 2

Laudanum represents an effective option for managing severe diarrhea when first-line agents have failed, but careful attention must be paid to proper dosing and monitoring for adverse effects due to its opioid content.