Editing Laudanum (section)

== Hazards ==
===Potency of laudanum===
Opium tincture is one of the most [[Potency (pharmacology)|potent]] oral formulations of morphine available by prescription. Accidental or deliberate [[overdose]] is common with opium tincture given the highly concentrated nature of the solution. Overdose and death may occur with a single oral dose of between 100 and 150&nbsp;mg of morphine in a healthy adult who has no tolerance to opiates.<ref name="Morphine Sulfate">{{cite web
|url = http://bulkpharm.mallinckrodt.com/_attachments/msds/MORIN.htm
|title = Material Safety Data Sheet for Morphine Sulfate
|access-date = 2009-01-16
|publisher = [[Mallinckrodt]] Pharmaceuticals
|archive-url = https://web.archive.org/web/20081015043251/http://bulkpharm.mallinckrodt.com/_attachments/msds/MORIN.htm
|archive-date = 2008-10-15
|url-status = dead
}}</ref><ref name="Medical Toxicology">{{cite book
|url = https://books.google.com/books?id=qDf3AO8nILoC&q=opium+tincture+overdose&pg=PA929|title = Medical Toxicology, Toxic Dose of Morphine (p. 929)
|access-date = 2009-03-06
|publisher = Wolter Kluwer Health
|isbn = 9780781728454
|year = 2004
}}</ref> This represents the equivalent of between two and three [[teaspoon]]s ({{convert|10|-|15|mL|mL|disp=out}}) of opium tincture. [[Suicide]] by laudanum was common in the mid-19th century.<ref>The ''Brooklyn'' (New York) ''Daily Eagle'', January 10, 1861, p. 3, reported two unrelated instances in a single day.</ref> Prudent medical judgment necessitates toward dispensing very small quantities of opium tincture in small dropper bottles or in pre-filled syringes to reduce the risk of intentional or accidental overdose.

===Danger of confusion with paregoric===
In the United States, opium tincture contains 10&nbsp;mg per mL of [[anhydrous]] [[morphine]]. By contrast, opium tincture's weaker cousin, [[paregoric]], also confusingly known as "camphorated tincture of opium", is 1/25th the strength of opium tincture, containing only 0.4&nbsp;mg of morphine per mL. A 25-fold morphine overdose may occur if opium tincture is used where paregoric is indicated. Opium tincture is almost always dosed in drops, or fractions of a mL, or less commonly, in [[Minim (unit)|minims]], while paregoric is dosed in teaspoons or tablespoons. Thus, an order for opium tincture containing directions in teaspoons is almost certainly in error. To avoid this potentially fatal outcome, the term "camphorated tincture of opium" is avoided in place of paregoric since the former can easily be mistaken for opium tincture.<ref name="ISMP">{{cite web
|url = http://www.ismp.org/hazardalerts/recruting.asp
|title = Hazard Alert! Recurring Confusion Between Tincture of Opium and Paregoric
|access-date = 2007-10-13
|publisher = Institute for Safe Medication Practices
|archive-url = https://web.archive.org/web/20071015130903/http://ismp.org/hazardalerts/recruting.asp
|archive-date = 2007-10-15
|url-status = dead
}}</ref>

In 2004, the FDA issued a "Patient Safety" news bulletin stating that "To help resolve the confusion [between opium tincture and paregoric], FDA will be working with the manufacturers of these two drugs to clarify the labeling on the containers and in the package inserts."<ref name="FDA Patient Safety News, May 2004">{{cite web
|url = http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/printer.cfm?id=224
|title = Dangerous Mixups Between Opium Tincture and Paregoric
|access-date = 2010-11-30
|publisher = FDA
}}</ref> Indeed, in 2005, labels for opium tincture began to include the concentration of morphine (10&nbsp;mg/mL) in large text beneath the words "Opium Tincture". The FDA has also alerted pharmacists and other medical practitioners about the dangers of confusing these drugs, and has recommended that opium tincture not be stocked as a standard item (i.e., that it should not be "on the shelf"), that opium tincture be dispensed in oral syringes, and that pharmacy software alert the dispenser if unusually large doses of opium tincture appear to be indicated.<ref name="Pharmacy Times, February 2008">{{cite web
|url = http://apha.imirus.com/Mpowered/imirusApp.jsp?volume=pt14&issue=2&page=74
|title = More Confusion Between Opium Tinctures
|access-date = 2009-01-17
|publisher = Institute for Safe Medication Practices
}}{{Dead link|date=February 2020 |bot=InternetArchiveBot |fix-attempted=yes }}</ref>

Despite the FDA's efforts over the past few years, the confusion persists, sometimes with deadly results.<ref name="Pharmacy Times">{{cite web
|url = http://www.pharmacytimes.com/issues/articles/2003-06_492.asp
|title = Recurring Confusion Between Opium Tincture and Paregoric
|access-date = 2009-01-30
|publisher = Pharmacy Times
}}{{Dead link|date=February 2020 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> The [[Institute for Safe Medication Practices]] recommends that opium tincture not be stocked at all in a pharmacy's inventory, and that "It may be time to relegate opium tincture and paregoric to the museum of outmoded opioid therapy."<ref name="ISMP"/> Despite the risk of confusion, opium tincture, like many end-stage medications, is indispensable for intractable diarrhea for terminally ill patients, such as those with AIDS and cancer.<ref name="20 Common Problems in End-of-Life Care"/>

===Misinterpretation of "DTO"===
The abbreviation "DTO," traditionally used to refer to Deodorized Tincture of Opium, is sometimes also erroneously employed to abbreviate "''diluted'' tincture of opium." Diluted tincture of opium, also known as Camphorated Tincture of Opium (Paregoric) is a 1:25 mixture of opium tincture to water prescribed to treat withdrawal symptoms in newborns whose mothers were using [[opioid]]s while pregnant. The [[United States Pharmacopeia]] and FDA recommend that practitioners refrain from using DTO in prescriptions, given this potential for confusion. In cases where pharmacists have misinterpreted DTO, and given "deodorized tincture of opium" when "diluted tincture of opium" was meant, infants have received a massive 25-fold overdose of morphine, sometimes resulting in fatalities.<ref name="ISMP"/>

===Side effects===
Side effects of laudanum are generally the same as with [[morphine]], and include [[euphoria]], [[dysphoria]], [[pruritus]], [[sedation]], [[constipation]], reduced [[tidal volume]], [[respiratory depression]], as well as [[Substance dependence|psychological dependence]], [[Drug tolerance|physical dependence]], [[miosis]], and [[xerostomia]]. Overdose can result in severe respiratory depression or collapse and death. The ethanol component can also induce adverse effects at higher doses; the side effects are the same as with alcohol.
Long-term use of laudanum in nonterminal diseases is discouraged due to the possibility of [[drug tolerance]] and addiction. Long-term use can also lead to abnormal liver function tests; specifically, prolonged morphine use can increase [[Alanine transaminase|ALT]] and [[Aspartate transaminase|AST]] blood serum levels.{{Citation needed|date=December 2022}}

===Treatment for overdose===
{{further|Opioid overdose#Treatments}}
Life-threatening overdose of opium tincture owes to the preparation's morphine content. Morphine produces a dose-dependent depressive effect on the respiratory system, which can lead to profound respiratory depression, hypoxia, coma and finally respiratory arrest and death. If overdose of opium tincture is suspected, rapid professional intervention is required. The primary concern is re-establishing a viable airway and institution of assisted or controlled ventilation if the patient is unable to breathe on their own. Other supportive measures such as the use of [[vasopressors]] and oxygen may be indicated to treat cardiac and/or pulmonary failure. Cardiac arrhythmias or arrest will require advanced life-saving measures.{{Citation needed|date=December 2022}}

Intravenous [[naloxone]] or [[nalmefene]], quick-acting opioid antagonists, are the first-line treatment to reverse respiratory depression caused by an overdose of opium tincture. Gastric lavage may be of some use in certain cases.