Disadvantages of Demerol (Meperidine) for Pain Management
Demerol (meperidine) should be avoided for pain management due to its poor efficacy, multiple drug interactions, increased risk of toxicity, and accumulation of neurotoxic metabolites. 1
Major Clinical Disadvantages
- Poor analgesic efficacy compared to alternative opioid medications, making it a second-line agent at best 2
- Neurotoxicity risk due to accumulation of normeperidine (active metabolite), which can cause tremors, myoclonus, and seizures, particularly with repeated dosing or in patients with renal impairment 3, 2
- Contraindicated in renal insufficiency (GFR <30 mL/min/1.73 m²) and end-stage renal disease due to accumulation of active metabolites 1
- Serotonergic effects that increase the likelihood of toxicity when combined with other medications that increase serotonergic activity 1, 4
- Short duration of action (3-4 hours) requiring frequent dosing, which increases risk of metabolite accumulation 2
- Poor oral bioavailability necessitating parenteral administration in most cases 2
Adverse Effects Profile
- Central Nervous System effects: euphoria, dysphoria, weakness, headache, agitation, tremor, uncoordinated muscle movements, severe convulsions, transient hallucinations, disorientation, and visual disturbances 3
- Cardiovascular effects: flushing of the face, tachycardia, bradycardia, palpitation, hypotension, and syncope 3
- Gastrointestinal effects: dry mouth, constipation, biliary tract spasm, nausea, and vomiting 3
- Genitourinary effects: urinary retention 3
- Allergic reactions: pruritus, urticaria, and other skin rashes 3
Special Population Considerations
- Patients with renal impairment: Meperidine is specifically contraindicated due to accumulation of normeperidine, which can cause seizures 1
- Patients on MAOIs: Can precipitate dangerous monoamine oxidase inhibitor reactions 2
- Elderly patients: Higher risk of adverse effects due to decreased clearance 3
- Patients with hepatic impairment: Increased risk of toxicity due to extensive hepatic metabolism 3
Drug Interactions
- CNS depressants: Increased risk of respiratory depression, hypotension, profound sedation, or coma when combined with sedatives, hypnotics, general anesthetics, phenothiazines, tranquilizers, or alcohol 3
- Serotonergic medications: Increased risk of serotonin syndrome when combined with medications that increase serotonergic activity 1, 4
- Acyclovir: May increase plasma concentrations of meperidine and normeperidine 3
- Mixed agonist/antagonist opioids: May reduce analgesic effect and/or precipitate withdrawal symptoms 3
Superior Alternatives
- For moderate to severe pain: Morphine, hydromorphone, oxycodone, or fentanyl provide more reliable analgesia with better safety profiles 1
- For patients with renal impairment: Fentanyl, sufentanil, or methadone (under experienced supervision) are preferred as they have no active metabolites 1
- For perioperative pain management: Other opioids with fewer drug interactions and better safety profiles are recommended 1
Historical Context
Despite being one of the first synthetic opioids and having been widely used since the 1930s, meperidine is no longer considered a first-line analgesic due to its unfavorable risk-benefit profile 5. Many healthcare systems have removed it from formularies or severely restricted its use 5.
The Society for Perioperative Assessment and Quality Improvement (SPAQI) specifically recommends using the perioperative encounter as an opportunity to optimize pain management strategies away from meperidine due to its poor efficacy, multiple drug interactions, and increased risk of toxicity 1.