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analgesic ladder

Discussion in 'Anesthesiology' started by APACHE3, 07.01.06.

  1. APACHE3

    APACHE3 Senior Member

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    Ok, IM intern here..needs some advice. When considering Step 2 analgesics for patients, how would you rank weaker to stronger meds? ie Tylenol #3, percoset, lortab, oxycontin, others?? barring allergies, should I start with T#3 then move on to which one is stronger? Dumb question, sorry :confused:
  2. jetproppilot

    jetproppilot Turboprop Driver

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    Tylenol #3 has codeine, acetaminophen, and caffeine. Kind of a trash drug.

    Percocet and oxycontin have the same opiod, oxycodone ....

    ....percocet (and Tylox)= oxycodone + acetaminophen....very versatile drug with good analgetic properties that you could use as the staple of your pain armamentarium for fractures, minor-moderate burns, post operatively for open appy upon discharge, etc. Percocet is generic, ubiquitous (so patients wont have trouble getting it at a drugstore)...used to be my favorite when writing scripts for stuff in the ER.

    ...oxycontin= sustained release oxycodone. Very powerful with high abuse potential but indicated for severe stuff like cancer pain, etc.

    percocet has tylenol in it, as does tylox (percodan has aspirin) which somewhat limit's its abuse potential. Oxycontin is pure oxycodone, hence its high abuse potential. Keep this in mind if you prescribe oxycontin.

    ............................

    Vicodin and Lortab contain hydrocodone and acetaminophen as well.
    effective about the same as percocet.

    SO,

    Oxycontin> percocet/percodan/vicodin/lortab> tylenol#3.

    Pick one of the drugs in the middle for most pain. Avoid percodan for someone who cant take aspirin. The rest in the middle contain acetaminophen which is safe in most people.

    Good luck.
  3. sdn1977

    sdn1977 Senior Member

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    jet - I gotta disagree a bit. Tylenol No. 3 has only hydrocodone & acetaminophen - no caffeine (that used to be Empirin No 3 - ASA, codeine & caffeine....now I know how old you are ;) )

    IMO: Tylenol #3 = Darvocet = Vicodin....if you use equipotent doses.

    Vicodin, Lortab & Norco are all the same.....just different strengths of the narcotic (hydrocodon) & acetaminophen. Norco is the one which has the least acetaminophen which is an issue in the chronic pain folks (it has 325mg/tab as opposed to 500-750mg/tab) IMO - if you are treating chronic pain....the acetaminophen is the real issue - that is the part which will cause liver problems. Try to stay below 3-4Gm/day if you can (3Gm is preferable chronically)

    Oxycodone is the narcotic in Percodan/Tylox/Percocet. It is more potent than hydrocodone. All are available in different narcotic strengths -2.5mg/5mg/10mg & all are available generically.

    If you use equipotent doses...they'll all do the same thing. The problem is the more codeine you use to equal the same potency of hydrocodone (or hydrocodone vs oxycodone), you get nausea - due not just to the narcotic, but also to the fillers & binders in the tablets themselves.

    Oxycodone is also available by itself - as an immediate release tablet or controlled release tablet. Again...they are more potent than hydrocodone & have the ability to be increased without increasing the acetaminophen portion (which can be dosed separately). The controlled release is a better long term pain relief agent than oxycodin IR because it evens out the peaks & valleys, which diminishes the pain anticipation anxiety, however, the abuse potential is due to the current street pattern of crushing the SR & taking it orally - it gives a fast rush.

    IMO - Vicoprofen is a dog of a drug - it has 750mg hydrocodone & only 200mg ibuprofen. For most issues it is too much narcotic & not enough NSAID.

    There are lots of other options....let me know if you want more.....
  4. bubalus

    bubalus Member

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    I seem to recall having read a study that said darvocet wasn't any better than 800 mg ibuprofen. Although I occasionally got a patient who said darvocet worked for them, most seemed to do better with percocet or vicodin. Percocet was the one I typically used

    SDN, did you really mean to say that vicoprofen has 750 mg hydrocodone? Seems to me that would be one heck of a drug, at least until you stopped breathing.
  5. sdn1977

    sdn1977 Senior Member

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    my bad! sorry - 7.5mg hydrocodone! (gawd....I have worked too long today!)

    Isnt' it funny how percocet is ALWAYS the drug that works????

    I'd agree with the strict analgesia part of your comment.
    Darvocet=ibuprofen 800 (600 in a small person)=tylenol no. 3=vicodn....but, the ibuprofen has the antiinflammatory properties & doesn't work on the opiod receptors. Acetaminophen, by itself, is minor in its pain relief, but seems to augment some of the opiates. Don't forget tramadol, altho folks complain about it making them really "spacey".

    Part of the issue of comparing is the etiology of pain. Back pain from an acute strain, surgical pain, root canal pain, cancer pain, headache, etc...all have drugs which are better for some & not for others. Some need inflammation & analgesia, some need something to work on nerve impluses (ie gabapentin, etc) in addition to analgesia, some just need narcotics to keep from going into withdrawal....... :rolleyes:
  6. SleepIsGood

    SleepIsGood Support the ASA !

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    what does IMO and IMHO stand for? I see ppl use it on here all the time, as in the above posts. I realize it's some shorthand

    cheers :thumbup:
  7. lawdawg

    lawdawg Member

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    In my opinion, In my honest opinion respectively. i think ;)
  8. lawdawg

    lawdawg Member

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  9. sdn1977

    sdn1977 Senior Member

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    Yes......IMO (in my opinion) & IMHO (in my honest opinion)

    AND - I do apologize!!!! As a pharmacist, I am the very last person who should be using acroynms which are not in common usage. My profession rags on prescribers all the time for sigs (which are directions for use) which we can't understand......so I'll try to stop this.

    I blame my kids though :smuggrin: ....they seem to have this whole "internet speak" that has its own language (just like medicine ;) )
  10. Noyac

    Noyac SDN Advisor SDN Advisor

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    Lets consider Ultram. Persoanlly, I think this is a great drug for mild to moderate pain. It isn't all that potent but it does work well for "some" people. It is also combined with tylenol, Ultracet. Its abuse potential is much less and SE's are less as well (I believe).

    SDN, what is it about the tramadol that gives pts a euphoria or antidepressant effect? I remember being told that it had some SSRI properties similar to prozac,etc.

    I say it has less abuse potential but I do know one physician who had a problem with it.
  11. VentdependenT

    VentdependenT You didnt build thaT Moderator Emeritus

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    I really enjoy the folks who are allergic to every opoid except good old demerol.
  12. jetproppilot

    jetproppilot Turboprop Driver

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    Thanks for the reply SDN....

    yeah I think youre right about it not having caffeine...but somebody look up what Tylenol #3 has in it opiod wise...pretty sure its codeine. Anyway, always thought percocet worked better than it regardless.

    Empirin? Hmmmm.... musta been before my time. Never used it.
  13. jetproppilot

    jetproppilot Turboprop Driver

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    in my humble opinion.
  14. stoic

    stoic best served chilled.

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    tylenol #3 is codeine/APAP.

    the newer guidelines don't support the use of tylenol #3, darvocet, or ultram due to lack of proven efficacy. tylenol #3 is especially hard to justify using, as 10% of caucasians can't metabolize the codeine to morphine and as such get no benifit over straight APAP. darvocet and ultram haven't been shown to be more effective than 800mg ibuprofen. that said, the rheum folks use a lot of ultram for fibro/OA pt's who need more than just NSAIDS.

    i can dig the references up if you guys want, but i've looked at them fairly recently and am very confident that i haven't convoluted any findings from the literature.

    generally speaking oxycodone is more potent than hydrocodone. i'm still a student, so i can't write for stuff obviously, but it certainly seems that my attendings write for a lot more vicodon (schedule III) than percocet (schedule II).

    anyway that's what i know.
  15. canjosh

    canjosh

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    Or dilaudid.
  16. Lizard1

    Lizard1 Member

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    One thing I've noticed(not personally of course!) is that there is much more synergistic action with the hydrocodone/APAP mixture vs hydrocodone/ibuprofen mixture. This is unfortunate for those types of pain that are somewhat due to inflammation and would benefit from an anti-inflammatory. I thought I heard a drug rep pushing a new drug that had a higher content of ibuprofen than the 200mg in Vicuprofen but I asked a pharmacist and they had not heard anything???

    Anyone know of a hydrocodone/ibuprofen mixture besides vicuprofen? and is it as efficacious as hydrocodone/APAP concoctions?
  17. stoic

    stoic best served chilled.

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    every since my hospital took demerol off of the formulary, all of the junkies switched from asking for demerol to dilauded. i swear it took about 20 minutes for the word to get out.

    i can't believe the tolerance some people have built up to that stuff. i've seen people who "needed" 4mg's IV to get relief. i honestly think that if you gave that to me, i'd have to ventilated.
  18. stoic

    stoic best served chilled.

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    there is a new oxycodone/ibueprofen mix - combunox (or combinox or something). it's 5mg oxycodone/400mg ibuprofen. actually, it seems like a pretty good combo. but it's probably more expensive than 1 or 2 percocet + some OTC ibuprofen.
  19. seattledoc

    seattledoc Senior Member

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    well the problem with all these newer and different combination drugs is that they won't be on formulary at the hospitals, insurance won't cover them, etc...

    It makes sense to me to stick to the tried and true PO's
    1st tier: t#3, darvocetN-100, (ultram maybe)
    2nd tier: vicodin
    3rd tier: percocet
    if the percs aren't working, then switch to a combination of Oxy IR/oxycontin or MSIR/MScontin.
    If that doesn't work, then they probably need IV opioids

    Keep it simple, learn how to calculate equipotent doses of hydrocodone to oxy and MS and you'll look like a star in most medicine situations.
  20. APACHE3

    APACHE3 Senior Member

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    Wow, I haven't gotten this much response in years!! I guess I should just pick a few drugs and stick with them. But, today (my day 2 as an intern in the ER)!!!, my patient had a crush injury to the foot and my attending asked me, "so what do you want to give him for pain, I said Morphine 10 mg IV, he says, try 100 mcg Fentanyl..and then walks off!! ahhhhh! Now I'm back to square one! I'll ask him tomorrow about "why", .(slower release???)...why not the morphine or dilaudid, etc... :D
  21. stoic

    stoic best served chilled.

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    100mcg fentanyl is a curious choice... it has such a short duration of action that you'd have to be redosing at least every hour. the fentanyl patch takes several hours to begin working and isn't supposed to be used in opioid niave patients... i'm confused as to why the fentanyl would be a better choice that morphine or dilaudid.
  22. seattledoc

    seattledoc Senior Member

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    Your answer makes more sense than your attendings, it might have been one of those situations in residency where the correct answer is always the one you didn't pick...100mcg of fentanyl has a faster onset that's about the only advantage I can think of...
  23. bubalus

    bubalus Member

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    And then they say how bad their allergies are and that they need benadryl, but can't swallow pills, so they have to get it IV.
  24. sdn1977

    sdn1977 Senior Member

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    I gotta apologize again! Yes - Tyl #3 is codeine & apap! (I worked 15 hrs withou eating - how do you do it????)

    Your question about a "new" drug - Combunox - not so new - approved in 2004, marketed in 2005 - its 5m oxycodone & 400mg ibuprofen. I've never seen it. Again....a poor combination for lots of reasons - most of which is because it's dosage form is too fixed. Its cheaper & more flexible to dose each one separately.

    Fentanyl vs MS - if you look at the kinetics alone, they look similar, especially half lives. But..if you look at the lipid solubility. Fentanyl is more lipid soluble than morphine. So...it takes fentanyl longer to get thru the blood brain barrier than morhine. Which means, conversely, it takes morphine longer to get out of the blood brain barrier than morphine. They have similar receptor affinities, so have equianalgesic effects when given in equipotent doses, but fentanyl is a "fast in, fast out" narcotic.

    Clinically, if you have a pt who is a short stay surgery or ER pt...fentanyl is sometimes a better choice because you get a less post discharge side effects - N&V being the most common post discharge effects from MS. You get less of that with fentanyl.

    I'm not sure if that was a choice made with your pts foot injury......

    Dilaudid - not used so much in hospitals anymore unless you have a big cancer population. Mostly due to contractual arrangements than anything else though I think.
  25. jetproppilot

    jetproppilot Turboprop Driver

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    We use Dilaudid for nearly every PCA now.

    Previous gig---> mostly morphine PCAs. Used diaudid as a rescue drug in the PACU.
  26. sdn1977

    sdn1977 Senior Member

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    I'd bet you get a good price on it!. Sometimes, people like to say there is less itching with dilaudid, but my experience is a few days on either one & they both cause itching. Have you noticed a difference?

    Our ER has no dilaudid in their pyxis, so its really not a choice. Its only in OR/PACU/ICU.
  27. Mapleson D

    Mapleson D DBCA

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  28. jetproppilot

    jetproppilot Turboprop Driver

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    I was hesitant to make the transition to using dilaudid as my primary PCA choice...probably from lack of experience with it.....

    but now a cuppla years later I think it is superior to morphine for pca...anecdotally, less itching and superior analgesia with equipotent doses.

    I write for .5mg every 15 minutes, four hour limit 8mg.

    Works better than morphine 2 mg every 10 minutes which is how I write a morphine PCA.
  29. sdn1977

    sdn1977 Senior Member

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    Thanks for the info!

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