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December 21, 1984

Dosage Errors Involving Opium

Author Affiliations

Brigham and Women's Hospital Boston

JAMA. 1984;252(23):3251-3252. doi:10.1001/jama.1984.03350230013013

To the Editor.—  We have recently detected three dosage errors related to the prescribing of deodorized tincture of opium (DTO). The notable factor is that all incidents were traced to identical origins. In each case, the prescriber went to the Physician's Desk Reference for dosage information. The index lists opium tincture and directs the user to the Parepectolin monograph. In all cases, the dosage of Parepectolin (1 to 2 tablespoons) was prescribed for DTO and subsequently administered. A DTO dose is normally 0.6 to 1.5 mL (equivalent to 6 to 15 mg of morphine sulfate), while Parepectolin (2 tablespoons) contains kaolin, 5.5 g; pectin, 162 mg; and paregoric, 3.7 mL (equivalent to approximately 1.48 mg of morphine sulfate). As is common practice,1 controlled substances are stored on the nursing unit and administered from a "stock" supply before pharmacists' review of dosage.The purpose of this letter is two-fold: (1)