What narcotics can be given with Exparel (bupivacaine liposome injectable suspension)?

Narcotics That Can Be Used with Exparel (Bupivacaine Liposome Injectable Suspension)

Most opioids can be safely administered with Exparel (bupivacaine liposome injectable suspension) as there are no specific contraindications for combining them, but careful monitoring for combined effects on respiratory depression is essential. 1

Compatible Opioid Options

• Full mu-opioid agonists can be safely used with Exparel, including:

  • Morphine (oral, intravenous, or subcutaneous) 1
  • Fentanyl (intravenous, transdermal) 1
  • Oxycodone (oral) 1
  • Hydromorphone 1
  • Tramadol 1

• Opioid agonist-antagonists that can be used with Exparel include:

  • Butorphanol 1
  • Nalbuphine 1

Clinical Considerations

• When using Exparel with opioids, consider the additive effects on pain control which may allow for reduced opioid dosing. Studies show that patients receiving Exparel may require fewer opioids postoperatively 2

• Careful monitoring is required when combining Exparel with opioids due to potential additive effects on:

  • Respiratory depression
  • Sedation
  • Central nervous system effects 1

• For breakthrough pain while using Exparel, immediate-release formulations of opioids are appropriate 1

Opioids to Use with Caution

• Meperidine should be avoided or used with extreme caution due to its poor efficacy profile, multiple drug interactions, and increased risk of toxicity 1

• Methadone requires careful consideration due to its long half-life and complex pharmacokinetics 1

• Buprenorphine may be used but requires individualization based on the patient's clinical circumstances 1

Dosing Considerations

• Initial opioid dosing with Exparel should be reduced by 25-50% compared to standard dosing due to the local anesthetic effects of Exparel 1

• Rescue doses of short-acting opioids should be approximately 10-20% of the 24-hour oral dose when needed for breakthrough pain 1

• Titrate opioid doses based on pain assessment using validated pain scales (VAS, VRS, or NRS) 1

Important Caveats

• Despite theoretical benefits, some studies suggest that Exparel may not significantly reduce opioid consumption compared to standard local anesthetics 3, 4

• A systematic review found that in 85.71% of randomized clinical trials, liposomal bupivacaine did not show a reduction in opioid consumption 4

• For endodontic procedures, liposomal bupivacaine did not significantly reduce the need for rescue narcotic medication compared to standard bupivacaine 5, 6

• Be aware that financial conflicts of interest may influence reported outcomes in studies of liposomal bupivacaine efficacy 4

Remember that while most opioids can be safely administered with Exparel, the goal should be to minimize opioid use while maintaining adequate pain control through multimodal analgesia.