How do you select which opiate to use for pain control?

Dilaudid is really potent and is given for breakthrough pain. About 5x more than oxy according to opiate addicts. Morphine sulphate has to be given at an extremely high dose to give the same relief as dilaudid and could put you into resp failure at those doses. This is just by what I've gathered and it makes sense when the drug addicts ask for dilaudid specifically. Its by default more addictive, and dilaudid even has a higher potency formulation, if you can imagine that.

Oh, I didn't read your post sufficiently. Seems that hydromorphone and morphine are confused often enough when dosing that people have died

medicine6 said:

why does my attending not have a problem giving out a few mg's of Morphine but the whole emergency department freaks out when you want to give Dilaudid, even if it were a miniscule dose? From what I've seen, the side effects are the same so I can't see any other reason to choose one over the other.

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?

doesn't make sense cause we love dilaudid down in the ED, it's kind of our speciality..

you're on the right track with understanding equivilancy in narcotic analgesia.

Route also plays a large role. an IV drug will hit harder than PO.

Normally the RN's I work with like dilaudid more than morphine. Let me rephrase; it's easier to give an adequate dose of dilaudid because it comes in 1mg vials. Morphine comes in 2mg vials. So 1mg dilaudid = 5 mg morphine. RN's here will give 2mg diluadid fine but don't like 10 mg of morphine. why? because you have to open 5 vials to give the morphine and it's a PITA.

beyond that fentanyl is used for trauma because it has very rapid onset and is shorter acting so it can be titrated over time more easily.

morphine is traditionally used for acute coronary syndrome and renal stones.. I remember hearing some attending say something about increased smooth muscle relaxation compared to other narcotics, but I don't know of any study to actually confirm that. Recent literature actually suggests an possible increase in mortality in ACS 2/2 NSTEMI (of course this is not validated, etc)

medicine6 said:

Other than differing in their relative strengths, I don't understand the differences between opiates. It seems like they should all be 100% interchangeable assuming you correct for the difference in potency/strength. In other words, why does my attending not have a problem giving out a few mg's of Morphine but the whole emergency department freaks out when you want to give Dilaudid, even if it were a miniscule dose? From what I've seen, the side effects are the same so I can't see any other reason to choose one over the other.

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I can't speak to all the specifics, but in addition to potency, there's other things to consider. For example, fentanyl has a very short half-life, which is good for less stable patients but will be a major strain on your nursing staff to give it frequently for the abdominal pain patient who's sitting in the department for three hours. It also causes slightly less hypotension.

Morphine has long been used in chest pain since it reduces afterload and might reduce the risk of arrhythmia, and so I've seen a lot of attendings who typically treat severe pain with Dilaudid use morphine in this instance. But this, like most of the "MONA" treatment of ACS, is questionable: http://www.emlitofnote.com/2011/10/yes-let-mona-fade-away.html

Pain seems to be frequently undertreated. I've read that even a starting dose of 0.1mg/kg will effectively treat pain in less than 50% of adult patients, and yet it seems fairly rare for a dose this large to be given (in my experience from community hospitals, maybe academic places are more aggressive about it). How many 70 kg. adult males do you see getting 7 mg. first doses of morphine, or even the much bigger people who are more representative of the average patient? Since some people balk at giving that much morphine, they're leery of giving 1-2 of Dilaudid. And that's ignoring the importance of the hospital's routine and culture in what gets prescribed: I remember a few instances where the fresh out of residency physicians from the EM just 15 minutes down the road were met by some very confused nurses when they ordered fentanyl rather than Dilaudid. It just wasn't done at that hospital.

There are a number of things that go into pain medication choice and there are a million scenarios that different docs could come up with on why you'd give one more than another.

For general pain, it's wise as a resident to pick 2 or 3 narcotics (at least one PO and one IV form) of which you're absolutely comfortable with - you know the dosing and frequency cold and can immediately sense when someone has gotten a big or small dose. Likely this will be dictated on where you did residency and what was common there. For example, in my peds residency, the main narcotics were oxycodone PO and morphine and fentanyl IV. We didn't use much codeine, hydrocodone or hydromorphone and even now as a fellow, I'm not particularly comfortable with those medications.


After you get past just standard pain, then knowing particular side effects is helpful for certain situations - ie fentanyl has less effect on cardiac output/blood pressure than morphine (which is why the cardiac anesthesiologists love it). Likewise fentanyl causes less histamine release than morphine so it's beneficial in the patient that morphine causes itching or for the asthmatic who is complaining of severe pain that I'd like to avoid the potential of further bronchospasm.


As for the issue of weight based dosing. I'd be careful how you interpret pain treatment studies - what's the endpoint? Complete resolution of pain or simply improvement? As a pediatrician, weight based dosing is just par for the course, but at some point for every medication, you reach a limit that's the standard adult dose. You can always give more medication if you need to, but until you have a sense of what's going to happen, it's wiser to start lower and titrate up as indicated. The key point is that you should go back and reassess your patient (which sounds pretty simple, but you'd be surprised how infrequently this happens).

very informative thread... been curious about this for a while myself...

thank you!

Re: dilaudid

The reason people hesitate to give it is not potency or worries about mis-dosing it as a result.

Far more than other opioids, dilaudid has a subjective euphoric "high" especially with IV push administration. It is therefore frequently associated with narc-seekers and abuse.

southernIM said:

Re: dilaudid

The reason people hesitate to give it is not potency or worries about mis-dosing it as a result.

Far more than other opioids, dilaudid has a subjective euphoric "high" especially with IV push administration. It is therefore frequently associated with narc-seekers and abuse.

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Put 2mg in 100cc NS & run over 30-60min...same pain relief (like a poor man's PCA basal dose) but no euphoric rush from rapid IV push.

Seekers get cranky, true pain typically gets a little better.

One other thing; it can take a lot to overcome pain, then relatively little to maintain analgesia (analagous to loading/maintenance). As stated above, start low & redose as needed based on frequent reevaluations...

Cheers!
-d

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Ive worked in the ED for a couple years now and I must say, Dilaudid must be one hell of a drug because people will do/say anything to get it. I once saw a pt storm out of the ED after being refused narcotics. The pt went to his car, stabbed himself in the leg with a knife and walked back in so they would be forced to give him some pain meds.

A couple notes on the IV opiates from an ED doc (we have a lot of experience with these, second only to anaesthesiologists): morphine comes in many different dose sizes. my current ED uses 8mg vials. I've seen 2mg and 5mg dosing vials. So what does of morphine you order in your hospital is honestly based on what's easiest to give. If all you've got is 4mg vials, try to use 4, 8, or maybe 6. if you've got 2's and 5's. then you'll be giving 4mg, 7mg, and 10mg doses (unless you don't know proper dosing and give 2mg doses, though there are uses for homeopathic doses of morphine).

Dilaudid 1mg is equivalent to around 7-8mg Morphine. But keep in mind, they will affect people differently. I've had both of those and the morphine really made me feel like crap (which I didn't mind because feeling like crap is better than being in 9/10 pain) and dilaudid made me feel pain free. Both were euphoric long-term, but only morphine was dysphoric short term. That is me, but some patients will let you know they're intolerant of one or the other.

The other thing you need to know is that morphine tends to last longer than dilaudid, and if they're renal insufficient, it will last a helluva lot longer (it's active metabolites are renally excreted). So if you have a patient that tends towards renal failure, don't prescribe PO morphine when discharging them. Because they'll come in in ARF again and opiate overdosed and get labeled a drug abuser when in reality, they're taking it every 6 hours just like you told them to. (seen that twice this year, had to really convince the residents accepting the patients that they weren't drug abusers, just that they needed to be prescribed an alternate narcotic such as hydrocodone).

Lastly, fentanyl is great and cardiac stable with rapid onset, but as has been said, also a rapid offset. I'll use it on my unstable patients, my intubated patients (it makes a good gtt for them), or for ones getting painful procedures such as chest tubes.

Rendar5 said:

If all you've got is 4mg vials, try to use 4, 8, or maybe 6. if you've got 2's and 5's. then you'll be giving 4mg, 7mg, and 10mg doses (unless you don't know proper dosing and give 2mg doses, though there are uses for homeopathic doses of morphine).

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Just curious- what do you mean by "homeopathic doses of morphine"- and what would those uses for under-dosing be?

theshellyb said:

Just curious- what do you mean by "homeopathic doses of morphine"- and what would those uses for under-dosing be?

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I mean 2mg of morphine, and by homeopathic, I just mean simply underdosing. the uses? to shut up opiate seeker by saying i'm giving something, to give mild pain relief to people who are NPO and for whatever reason can't take IV toradol or rectal tylenol, for relief of air hunger. For real pain relief, i find the inpatient services mistakenly give 2mg thinking that's an appropriate dose and that people asking for more are simply seekers.

Of course, that does not apply to my pediatric patients such as my 5-year old appendicitis patient for whom 2mg is an appropriate weight-based dose.

Rendar5 said:

I mean 2mg of morphine, and by homeopathic, I just mean simply underdosing. the uses? to shut up opiate seeker by saying i'm giving something, to give mild pain relief to people who are NPO and for whatever reason can't take IV toradol or rectal tylenol, for relief of air hunger. For real pain relief, i find the inpatient services mistakenly give 2mg thinking that's an appropriate dose and that people asking for more are simply seekers.

Of course, that does not apply to my pediatric patients such as my 5-year old appendicitis patient for whom 2mg is an appropriate weight-based dose.

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Gotcha- thanks for clarifying! Helpful posts, for sure.

Question for any of the EM physicians in this thread: do you have any use for Ofirmev (IV acetaminophen)? Is it even available in the ED?

K31 said:

Question for any of the EM physicians in this thread: do you have any use for Ofirmev (IV acetaminophen)? Is it even available in the ED?

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I've used it before in my old ivory tower when I was a resident. don't use it where I'm at because it's unavailable. seen surgeons use it but honestly...why? rectal works just fine. though I guess if someone doesn't have a rectum...lol (it does happen...).

While dilaudid is a good medicine for pain control it really should be used for breakthrough pain as it has a short duration. When you are prescribing pain medications in the hospital, you want to take into account how bad the pain is. This is a real issue because there is o real objective way to measure pain, it is purely subjective. However, the patient should be asked about the pain using a 1-10 scale. That being said, it would be a good idea to ensure at you are not using a shotgun to kill a fly. You are not going to prescribe dilaudid for a pain level of 2. Start with an NSAID for mild pain, then move to a Percocet for moderate pain and then the IV.narcotic. But again, you are only treating th breakthrough pain here.

In patients who have constant pain, those with a pain syndrome or cancer pain, start with a long acting basilar pain medication. MS Contin is a 12 hour drug. It is a basilar pain med just like levemir for insulin. You can also you a patch that gives continuous medication. Then use the others for breakthrough.

When dosing, remember that you can always give more but you can never take back. Start with the lowest dose and increase it until the patient gets proper relief. We are not talking about drug seekers here as they never get relief. The best dose is the lowest effective dose.

If the patient is complaining of a localized pain such as arthritis, there is no need to always give an opiate. I have had good results with a topical capscacin cream, lidoderm patch, etc. Taylor your meds to the patient, not the patient to the meds.