pain meds

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

jok200

Full Member
10+ Year Member
Joined
Feb 9, 2009
Messages
175
Reaction score
4
looking for something that helps give me a frame of reference for pain meds.?? I know morphine is serious pain med relief but how do I gauge that, in comparison to what??? I know diluadid is for serious pain like osteosarcoma or something, but how do I compare it to something else?? Sorry if this question has been asked before I know what to give on the floor with my patients, just trying to get some more understanding behind it.

thanks-

Members don't see this ad.
 
I would encourage you to look at an equianalgesic table. It will list various opioids and relative potency.
For instance, many people (even physicians) think that hydrocodone is not as strong as morphine. Perhaps this is because hydrocodone is DEA Schedule III and morphine is DEA Schedule II. In truth, they are equally potent (30 mg of oral morphine is roughly equivalent to 30 mg of oral hydrocodone).
An equianalgesic table is a good place to start.

I hope that helps.
 
Hydromorphone (Dilaudid) is stronger on a dose-basis, but you can calculate equivalent doses among other opioids. Other issues come into play as likely more important than "strength," e.g., route, active-metabolite production and clearance, as well as cost.

You could try this one to start with. http://clincalc.com/Opioids/
There is variance out there among equianalgesic charts, depending on the data sets used.

Beware conversions to methadone!
Initial dosing is very complicated, due to opioid tolerance, opioid-opioid cross-tolerance, renal (pH-dependent urinary excretion) and hepatic function (chronic dosing induces its own CYP450 metabolism), and non-opioid, drug-drug interactions (many), and thus a very subject-dependent variation in 1/2-life. There is surprisingly little hard data on which to base this consequential decision. But, from the available data it is clear the methadone equianalgesia is very non-linear, which adds to the danger of overdosing a patient. http://paindr.com/methadone-dose-conversion/

Analgesic effects of methadone are short-lived, so analgesic dosing is generally in divided doses TID-QID, whereas methadone maintenance dosing is once daily. Dosing changes should be very conservative, and because of the variable, but likely long 1/2-life (8-59 hours), be very, very patient, e.g., 10%-increases, closely monitored over 5-7 days for pharmacokinetic equilibration. Psychosocial functioning and support in patient-selection is key for these safety reasons.

The deaths of patients placed on methadone for analgesia are likely due to clinicians in busy practices, who are lacking training and experience with this useful, but tricky drug, prescribing it in cursory fashion.

So, kids don't try this at home! Get training, read about all the pitfalls, make time for appropriate and careful calculations, double-check yourself, shoot low (choose the conservatively low figure in the range), go very, very slowly. Only use methadone for chronic pain that is not going anywhere, so there's no rush to control the pain with methadone alone, depend on a range of dosing of short-acting opiates to control pain in the interim, as serum levels of methadone are glacially coasting up over a period of days. Continue to monitor them looking for metabolic changes in pharmacokinetics, for all the above reasons. Plus, there's likely going to be some QT/QTc-prolongation, so, baseline EKG, and at 6-months intervals thereafter.

If you cannot do all these things in managing methadone, then leave it to the professionals, and refer the patient to a subspecialist who manages chronic pain.
 
Last edited:
Members don't see this ad :)
Keep in mind something else when talking about equivalent doses. There is some receptor specific tolerance that develops when one is on a given opoid for long term. So you can't just do the math and switch over to a different drug. You have to cut the dose down, switch over, and titrate back up. There are equivalency tables, and there are conversion tables. The conversion tables suggest the safe starting dose of the new opoid, which is lower than the equivalent dose of the old opoid. Yes, its a pain in the ass to switch opoids, but to do it safely this is how it must be done.
 
http://www.dom.pitt.edu/dgim/spc/downloads/paincard2011.pdf
As pointed out supra by VentJocky, NB, from page 4:
"When converting from one opioid to another, you should use 50–75% of the equivalent dose. Allow for incomplete cross-tolerance between different opioids (may need to titrate up rapidly and use PRN dose to ensure effective analgesia for the first 24 hours)."
 
Top