Hazard Alert! Recurring confusion
between tincture of opium and paregoric
From the February 20, 2002 issue of MSA Acute Care Edition Newsletter
ISMP urges hospitals, community pharmacies, and other locations
that use opium tincture and/or paregoric (camphorated tincture
of opium) to take action immediately to minimize the risk
of fatal confusion between these drugs. Last week, a Connecticut
newspaper reported that a 51-year-old woman with chronic diarrhea
died from morphine intoxication after receiving a teaspoonful
of opium tincture (about 50 mg morphine) instead of paregoric.
After a dose, the patient became weak, tired, and achy. Her
son checked on her periodically, but when he tried to wake
her later that day, she did not respond. Paramedics were summoned
but they could not revive the woman.
The patient's physician had prescribed "camphorated
tincture of opium." A recent pharmacy graduate confused
this with opium tincture. Paregoric has been used for many
years to control diarrhea in children and adults. However,
it often is dangerously referred to by its synonym, camphorated
tincture of opium, which can be confused easily with opium
tincture, a compound that contains 25 times the amount of
morphine. Paregoric has just 0.4 mg/mL of morphine while opium
tincture contains 10 mg/mL. This is a potentially dangerous
situation that invites serious medication errors. We've previously
described such confusion in the June 19, 1996; Oct 8, 1997;
September 5, 2001; and October 3, 2001, issues of ISMP Medication Safety Alert!.
To reduce the risk of errors, discuss the following issues
at your next Pharmacy and Therapeutics Committee meeting:
- Consider the need for these products at your practice
site, as there are other more effective medications to treat
pain and control diarrhea. As one of our medical consultants
stated, "It may be time to relegate opium tincture
and paregoric to the museum of outmoded opioid therapy."
- In neonatal abstinence syndrome due to opiate withdrawal,
some pediatricians recommend opium tincture in a 1:25 dilution.
This is similar to the amount of morphine in paregoric.
But paregoric contains 45% alcohol and other potentially
harmful ingredients, so pharmacy should prepare an aqueous
oral solution of morphine from morphine injection.
- In the US, paregoric, the official name for camphorated
tincture of opium, should be the designated nomenclature
used for prescriptions and for listing on formularies, in
computer systems, on labels, etc. Make clinicians aware
that it is dangerous to refer to paregoric as "camphorated
tincture of opium." Likewise, "DTO" should
never be used as an abbreviation for opium tincture (also
known as deodorized tincture of opium) because 1:25
dilution has also been referred to as DTO (diluted
tincture of opium).
- Because all who have access to opium tincture may not
be familiar with its dangerous properties, place poison
labels on all containers as well as a label stating the
strength of morphine per mL (10 mg/mL) and a statement,
"WARNING! Do NOT use opium tincture in place of paregoric."
- Build alerts in the computer system to warn staff about
the differences between these products. Include appropriate
dose ranges by weight and volume, and if possible, an alert
for exceeding a maximum dose.
- Place auxiliary labels in pharmacy storage locations
as a constant reminder.
- Only dispense opium tincture in a small dropper bottle
or unit dose packaging. Recognize that measuring opium tincture
doses accurately may prove challenging. For institutional
use, dispense opium tincture for individual patients only.
Do not store as a floor stock item, including in automated
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