The Dilaudid Poll

[turkeyjerky]

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that doesn't really make sense to me...
dilaudid, morphine + benadryl, or morphine + cromolyn all seem to make more sense

No, it's true that low dose narcan infusions can be used to combat pruritis. See here. I don't think this has much role in the ED though.

 

[Rendar5]

i dunno, i've had dilaudid before and did not get that euphoric from the push. Not sure how a single push can make you addicted, though I can see why people would ask for it in place of morphine, which gave me the 10 second feeling of "i'm gonna die/hurl".

After my own experiences with biliary colic, I'm more likely to give dilaudid to a patient I find to be in true 10/10 pain like my MVC victims.

 

[leviathan]

I had an abnormally severe reaction to having my wisdom teeth yanked and was in pretty ongoing excruciating pain, like 7/10, for about a week. I normally have a very high tolerance to pain so I did not expect this to happen.

I wasn't given narcotics even after calling the dentist and explaining I was taking tylenol and motrin around the clock with little relief. I don't know what her reservation was about giving narcotics, but I have a feeling I can blame drug addicts.

 

[Venko]

I guess I dont see dilaudid as a real problem. I think the big reason that most people say it helps them and it is the only thing that helps them is because most physicians vastly under dose morphine and fentanyl. Morphine should be dosed at 0.1 mg / kg and so a typical patient these days who is at least 80 kg should be getting 8 mg of morphine (fentanyl which is 1 mcg / kg should be 80 mcg). Since Dilaudid is roughly equivalent to 8 mg of morphine, it would make sense then that most people say dilaudid helps their pain and morphine does not.

When I have begun weight based morphine and fentanyl dosing I have had very little need for dilaudid. The biggest reason I have used it now is for the very large people who need 10 - 12 mg of morphine and the nursing staff dont feel comfortable pushing it, so I add 4 mg morhpine and 1 mg of dilaudid and they feel fine doing that...

I could be just naive to the struggles that most others are facing, but these are my thoughts.

TL

 

[sanityonleave]

I guess I dont see dilaudid as a real problem. I think the big reason that most people say it helps them and it is the only thing that helps them is because most physicians vastly under dose morphine and fentanyl. Morphine should be dosed at 0.1 mg / kg and so a typical patient these days who is at least 80 kg should be getting 8 mg of morphine (fentanyl which is 1 mcg / kg should be 80 mcg). Since Dilaudid is roughly equivalent to 8 mg of morphine, it would make sense then that most people say dilaudid helps their pain and morphine does not.

When I have begun weight based morphine and fentanyl dosing I have had very little need for dilaudid. The biggest reason I have used it now is for the very large people who need 10 - 12 mg of morphine and the nursing staff dont feel comfortable pushing it, so I add 4 mg morhpine and 1 mg of dilaudid and they feel fine doing that...

I could be just naive to the struggles that most others are facing, but these are my thoughts.

TL

Forgive the dumb question (I'm a med student) but are these in opiate-naive patients? These doses are at least double a starting dose in our department, so I'm just surprised there's such a large disconnect.

 

[Venko]

Forgive the dumb question (I'm a med student) but are these in opiate-naive patients? These doses are at least double a starting dose in our department, so I'm just surprised there's such a large disconnect.

yup these are for opiate naive individuals. Great question, and truly my belief why many individuals say dilaudid works for them...for most people its just about proper dosing.

tl

 

[Rendar5]

Forgive the dumb question (I'm a med student) but are these in opiate-naive patients? These doses are at least double a starting dose in our department, so I'm just surprised there's such a large disconnect.

My MICU regularly uses 2mg morphine on pt's in pain. It's laughable. It's a homeopathic dose. May as well just give them tylenol or motrin. They might work better. If you want to start slow and add on morphine to titrate to pain, you can start with a 0.05mg/kg dose, but you'll need to keep giving it every 15-20 minutes to titrate to full effect. Just be cautious in that strat for ESRD patients. the analgesia lingers a lot longer than on normal pt's.

 

[chimichanga]

...because of the idea that it's the IV push and the resultant euphoria that keeps the seekers coming back. If it's given in 50cc of IVF and goes in over 10 to 15 minutes it has the same analgesic effect without the euphoria and without some of the histamine release. Since it's still Dilaudid you have sidestepped the whole morphine "allergy" thing.

As with a lot of nursing-related issues nurses like IV push because it's quick, and easy for them. The fact that it leads to drug euphoria and addiction doesn't seem to matter to many of them.

I will now only give IV narcotics for acute pain (and not the "my stomach hurts again just like it does every week" patients).

Long time RN...I noticed 20 years ago the effects of phenothiazines (and Reglan) given IV push too 'quickly' by myself and other nurses. So I started putting those in piggybacks myself (to the confusing look of nurses and docs alike) and noticed that the incidence of EPS went to basically nil (again, just my own practice)
so i have always (since) done phoenos/dilaudid/morphine that way...never a problem with negative side effects.

And honestly GV, I have always preferred giving these meds IM over IV...I disagree that IV is 'quick and easy' as you put it, and the incidence of EPS in the phenos seems next to nothing with the IM route.( again, anectodal, but have been doing ED for 20+ years)

And for the Dilaudid/Morphine histamine release, it happened to me firsthand, when I awoke from surgery with a dilaudid PCA. After 24 hours, I had a huge rash on my chest that I was (unknowingly) itching, until it bled. Night RN noticed it, I asked for toradol, which worked great for the pain.
And I don't consider myself allergic to dilaudid, just, over time, got mild, itchy hives, that the dilaudid effects seemed to prevent me from noticing that I was constantly itching.

 

[logos]

Quite a few people were starting to do the slow infusion dilaudid at our place instead of pushes. Pharmacy came out with a policy that stopped the practice. They were vary reasonable about it. They essentially said that if we could show any evidence that slow administration was less euphoric they would be happy to keep mixing it up that way. None of the proponents of the piggyback dilaudid were able to find any evidence to support it. It is all anecdotal.

 

[telenurse]

It is frustrating from a nursing standpoint, no one ever seems to order a dose of morphine greater then 4 mg, even on pt's that weigh close to 100kg. I always say that 2-4mg of morphine on a pt that large, I might as well be shooting it on the med room floor. Then the order gets changed to dilaudid 1 mg, and all of a sudden the pain is better...well yeah that's like 8-10mg of morphine. I've been made to seem like I'm insane for suggesting larger doses of morphine than 6mg, but it's okay for me to give 2 mg of dilaudid. 😕

I have had morphine in the ED and after I broke out in hives, they gave me benadryl, and switched to dilaudid. I would much rather have been able to continue getting the morphine. Maybe it was the IV benadryl making me sedated, or the dilaudid making me drunk, but I did not like the feeling, the pain was better but it was like I was underwater. There were things I needed to say, and I could not for the life of me form a coherent thought, or stay awake.

 

[southerndoc]

telenurse, you're in the minority. When I write for 10 mg of morphine, I almost always get second looks and questions from the nurses.

 

[Hawkeye Kid]

telenurse, you're in the minority. When I write for 10 mg of morphine, I almost always get second looks and questions from the nurses.

I have had the same experience as southerndoc. Multiple times I've had nurses uncomfortable with morphine doses >8mg but perfectly comfortable with 2mg dilaudid, even after the discussion about the relative potencies. I think it's just a general "that's too big of a number" thing...

 

[GeneralVeers]

Quite a few people were starting to do the slow infusion dilaudid at our place instead of pushes. Pharmacy came out with a policy that stopped the practice. They were vary reasonable about it. They essentially said that if we could show any evidence that slow administration was less euphoric they would be happy to keep mixing it up that way. None of the proponents of the piggyback dilaudid were able to find any evidence to support it. It is all anecdotal.

I just like the infusion because the drug-seekers hate it. If I order a dilaudid infusion over 15 minutes instead of IVP, many of them will get up, rip everything off and walk out. Anecdotal only? Possibly. Effective? Yes.

 

[deleted109597]

Here I can't do it as an infusion, it has to be push. Comically, at my last hospital, 8mg of Zofran had to come in a piggyback of 50mL NS. I'm not sure how much QT prolongation they prevented with that, but I bet it's almost zero.

What's funny is that the nursing staff (except for telenurse, apparently) will not give large doses of things they know about (morphine, tylenol), but will give large doses of things they don't know about (decadron, fentanyl, dilaudid, droperidol.) Somewhere in nursing school they were taught that more than 4 of morphine was bad. Also, the people who make morphine packaged it that way (2 and 4mg vials) for so long that it is nature. Now you can get it in 10mg vials, but you still can't get an average nurse to give it.

 

[gutonc]

What's funny is that the nursing staff (except for telenurse, apparently) will not give large doses of things they know about (morphine, tylenol), but will give large doses of things they don't know about (decadron, fentanyl, dilaudid, droperidol.) Somewhere in nursing school they were taught that more than 4 of morphine was bad. Also, the people who make morphine packaged it that way (2 and 4mg vials) for so long that it is nature. Now you can get it in 10mg vials, but you still can't get an average nurse to give it.

I'm fairly certain that about half of the "pain crisis" admits I take on my oncology service could be sent home if the ED nurses were willing/able to give the appropriate doses of narcs to our very opiate tolerant patients.

 

[Groove]

IV infusion with no IV push and to hell with the PG, most of them have been there within 90d anyway. Make it ED policy, that way they can't make a scene when they were there 2 days ago and had push where now they're pain isn't being treated because they are getting it through the drip.

 

[Groove]

I mean, when do we really need to slam a pain crisis/ drug seeker with IV push dilaudid other than to get them the hell out of the ED faster and tee them up to sign the d/c papers 10-20 mins later? How many of you are filling out the d/c paperwork and bringing it in not too long after that IV push was given? Come clean, now...

 

[deleted109597]

Quite a few people were starting to do the slow infusion dilaudid at our place instead of pushes. Pharmacy came out with a policy that stopped the practice. They were vary reasonable about it. They essentially said that if we could show any evidence that slow administration was less euphoric they would be happy to keep mixing it up that way. None of the proponents of the piggyback dilaudid were able to find any evidence to support it. It is all anecdotal.

Take pharmacy out of the loop then. Put it in your own bags. It isn't hard.

 

[telenurse]

telenurse, you're in the minority. When I write for 10 mg of morphine, I almost always get second looks and questions from the nurses.

I used to work in hospice...I'm used to giving lot more than 10mg of morphine. I remember equianalagisic dosing....most nurses forget that chapter of pharmacology. I think it is because nursing is taught by nurses...including pharmacology. Which I think is idiotic beyond compare. I think the pharmacology classes of nursing school should be taught by pharmacologists, this is why nurses come out under the curve. (I freely admit that my handle of antibiotics is very shaky.) Nurses are uncomfortable given 8-10mg IV morphine, yet will easily give 1-2 mg IV dilaudid, or 15-30mg morphine po..makes no sense at all when it is ALL the same.

 

[logos]

I don't think its the nurses fault that they are afraid of opioids. At our place the usual dose of morphine ordered on the floor by the IM residents is 2mg. I've never had any trouble giving large doses after explaining the situation to the nurse and that the patient is opioid tolerant and that I calculated the dose based on their home regimen.

The other trick that works is to change to meds they don't know as well or are appropriate to their concerns. They are woried about hypotension in the young female with a BP in the low 100s systolic? Instead of saying just give the morphine say good point instead of 6 of morphine give her one of dilaudid.

 

[docB]

Unit dosing is also a HUGE concern with nurses. Morphine comes in 5 mg vials and 4 mg tubexes. Some places only have one or the other. If you order a dose that doesn't add up, i.e. isn't in a multiple of 4 or 5 depending on which you have, the nurses will badger you until you change it. I've seen whole pain protocols fail because of this issue.

This is not laziness. A partial dose is much more complex to administer. It has to be checked more thoroughly to avoid messing it up. The left overs have to be wasted which requires another nurse witnessing the waste. Ordering a non unit dose triples the work involved.

My point is that a lot of the time when nurses push back on some higher it may be more due to this issue than being uncomfortable with higher doses.

 

[WilcoWorld]

I guess I dont see dilaudid as a real problem. I think the big reason that most people say it helps them and it is the only thing that helps them is because most physicians vastly under dose morphine and fentanyl. Morphine should be dosed at 0.1 mg / kg and so a typical patient these days who is at least 80 kg should be getting 8 mg of morphine (fentanyl which is 1 mcg / kg should be 80 mcg). Since Dilaudid is roughly equivalent to 8 mg of morphine, it would make sense then that most people say dilaudid helps their pain and morphine does not.

When I have begun weight based morphine and fentanyl dosing I have had very little need for dilaudid. The biggest reason I have used it now is for the very large people who need 10 - 12 mg of morphine and the nursing staff dont feel comfortable pushing it, so I add 4 mg morhpine and 1 mg of dilaudid and they feel fine doing that...

I could be just naive to the struggles that most others are facing, but these are my thoughts.

TL

This has been my experience as well.

 

[chimichanga]

Unit dosing is also a HUGE concern with nurses. Morphine comes in 5 mg vials and 4 mg tubexes. Some places only have one or the other. If you order a dose that doesn't add up, i.e. isn't in a multiple of 4 or 5 depending on which you have, the nurses will badger you until you change it. I've seen whole pain protocols fail because of this issue.

This is not laziness. A partial dose is much more complex to administer. It has to be checked more thoroughly to avoid messing it up. The left overs have to be wasted which requires another nurse witnessing the waste. Ordering a non unit dose triples the work involved.

My point is that a lot of the time when nurses push back on some higher it may be more due to this issue than being uncomfortable with higher doses.

👍

 

[telenurse]

Unit dosing is also a HUGE concern with nurses. Morphine comes in 5 mg vials and 4 mg tubexes. Some places only have one or the other. If you order a dose that doesn't add up, i.e. isn't in a multiple of 4 or 5 depending on which you have, the nurses will badger you until you change it. I've seen whole pain protocols fail because of this issue.

This is not laziness. A partial dose is much more complex to administer. It has to be checked more thoroughly to avoid messing it up. The left overs have to be wasted which requires another nurse witnessing the waste. Ordering a non unit dose triples the work involved.

My point is that a lot of the time when nurses push back on some higher it may be more due to this issue than being uncomfortable with higher doses.

True...we got in trouble not too long ago...

Nurses were not witnessing wastage properly, and a patient used a disposable stethoscope and medipore tape to "fish" the used vials out of the sharps container. The vials still had some narcotics in them. The pt then shot himself up. After an incident which involved security, the police, psych, and a thorough inspection of the pt's entire belongings...nurses were drug tested, written up, and now there is a security camera in the med room to record whether we are actually wasting the narcotics appropriately.

Yes it is a hassle, but it is not the patients fault, it is not the doctor's fault for ordering a dose that doesn't fall in what the med vial/ tubex comes in. I think a lot falls on cost cutting measures,and short staffing of nurses. Walk on an acute care floor during med pass time, and watch for frazzled nurse sticking her head out of the med room yelling..."I need a witness...anyone...anyone...witness..." Happens to me all the time.

 

[Apollyon]

"I need a witness...anyone...anyone...witness..."

Well, my baby, she's all right. My baby, she's clean out of sight. Don't you know that she's, she's some kind of wonderful?

[YOUTUBE]O7B5jXYRy3Q[/YOUTUBE]

 

[ERIsme]

Hi, I am a nurse and I was reading this board to learn more about the doctor's perspective on prescribing to people who appear to be seekers. Let me tell you, I would love to never ever give IV push Dilaudid. If they quit making Dilaudid tomorrow I would do a little dance. I am actually going to see if they will let us do the slow drip, love that idea. So tired of feeling like a drug pusher.

 

[Arcan57]

I think it's multifactorial, almost all of which have been covered in the above discussion and all of which create a feedback loop.

1) Residents aren't taught pain management well. My old shop had IM residents rotate through (3-4/mo for the 3 years I was there), and only 2 residents started the month giving at least 4mg of morphine for severe acute pain. The most common order was 2mg morphine, which would always lead into a discussion of whether they were treating a toddler.

2) Nurses give push-back for ordering more than 1 vial of a narcotic at a time (try ordering 3mg of morphine or 150mg of fentanyl). They also fall-back on the "we can always give more" which is true, but unless the patient is critical it is unlikely they will be back in the room within an hour or so. Any pain protocol that's not for major trauma is going to fall apart if it includes q15min dosing.

3) Opioid tolerance varies widely, with the extremely intolerant being used as anectdotes for not giving more opioids and the extremely tolerant being used as examples of drug-seeking trolls.

 

[AlmostJesus]

I used to work in hospice...I'm used to giving lot more than 10mg of morphine. I remember equianalagisic dosing....most nurses forget that chapter of pharmacology. I think it is because nursing is taught by nurses...including pharmacology. Which I think is idiotic beyond compare. I think the pharmacology classes of nursing school should be taught by pharmacologists, this is why nurses come out under the curve. (I freely admit that my handle of antibiotics is very shaky.) Nurses are uncomfortable given 8-10mg IV morphine, yet will easily give 1-2 mg IV dilaudid, or 15-30mg morphine po..makes no sense at all when it is ALL the same.

I think that brings up the idea of those that cant do, teach.

I have little experience with dilaudid, but from what Ive gathered about it, it may not be the best choice for pain control in the ED. Has anyone went to a pain protocol like this? http://emcrit.org/podcasts/gentile-pain/

I know many non EM docs that are horrible about treating pain. One doc I can think of in particular just got out of residency 2 years ago, I think hes a great doctor, but it kills me when I have a patient in obvious pain and he orders 2mg of morphine no matter what. There are times I wish the patient would have called the ambulance so I could have properly controlled their pain prior to arrival.

 

[Rendar5]

Just to be a devil's advocate, from personal experience I would rather give dilaudid than morphine to most of my real acute pain patients.

I had 2 ED visits during residency for biliary colic. First time I refused an offer of dilaudid and got 5mg Morphine + 2mg more 20 minutes later. Second time I got 1mg dilaudid. Both relieved my pain, but the morphine made me feel awful for about an hour (awful was much better than my pain mind you). Dilaudid seemed to me to be a much cleaner drug. And while I would've been fine with a 15min drip, for that agonizing amount of pain I'd much rather get an IV push.

 

[logos]

Just to be a devil's advocate, from personal experience I would rather give dilaudid than morphine to most of my real acute pain patients.

I actually agree. Less histamine release means less chance of hypotension or pruritis.

 

[med2UCC]

I think that brings up the idea of those that cant do, teach.

I have little experience with dilaudid, but from what Ive gathered about it, it may not be the best choice for pain control in the ED. Has anyone went to a pain protocol like this? http://emcrit.org/podcasts/gentile-pain/

I know many non EM docs that are horrible about treating pain. One doc I can think of in particular just got out of residency 2 years ago, I think hes a great doctor, but it kills me when I have a patient in obvious pain and he orders 2mg of morphine no matter what. There are times I wish the patient would have called the ambulance so I could have properly controlled their pain prior to arrival.

I've been finding this fascinating. Where I work, the standard starting dose for morphine is 5 mg IV and we have a nurse initiated analgesia protocol that authorises them to give 5mg doses Q 15 minutes to anyone they think warrants it to a maximum of 20 mg, all without the patient seeing a doctor. If that fails when the ERP has assessed the patient and thinks they need better pain management then we either move on to dilaudid or, in the case of kidney stones, on to buscopan and toradol. As a resident I was taught to write the morphine that way in the orders as well, so the nurses didn't have to hunt me down every 15 minutes to tell me that the patient was still writhing and ask for authorization for more narcs. We have quite a substantial population of drug seekers, but because it is a small place the nurses usually know them by names and don't feed the bears when they come in. It all works surprisingly well, and we don't have people using homeopathic doses of narcs, usually.
I should add the nurses are all also well trained not to start migraines on the NIA protocol. They put them as far up the line as they can and we order the migraine protocol for that (stemetil or maxeran 10 mg IV, 250 mls NS as a bolus and 25 mg benadryl - works like a charm about 95% of the time). Cheers,
M

 

[AlmostJesus]

I've been finding this fascinating. Where I work, the standard starting dose for morphine is 5 mg IV and we have a nurse initiated analgesia protocol that authorises them to give 5mg doses Q 15 minutes to anyone they think warrants it to a maximum of 20 mg, all without the patient seeing a doctor. If that fails when the ERP has assessed the patient and thinks they need better pain management then we either move on to dilaudid or, in the case of kidney stones, on to buscopan and toradol. As a resident I was taught to write the morphine that way in the orders as well, so the nurses didn't have to hunt me down every 15 minutes to tell me that the patient was still writhing and ask for authorization for more narcs. We have quite a substantial population of drug seekers, but because it is a small place the nurses usually know them by names and don't feed the bears when they come in. It all works surprisingly well, and we don't have people using homeopathic doses of narcs, usually.
I should add the nurses are all also well trained not to start migraines on the NIA protocol. They put them as far up the line as they can and we order the migraine protocol for that (stemetil or maxeran 10 mg IV, 250 mls NS as a bolus and 25 mg benadryl - works like a charm about 95% of the time). Cheers,
M

As it should be.
I feel as though we are stepping back in time when I walk through the ED doors. In the field, my protocols allow me to give 4mg of morphine every 5 minutes or 50mcg of fentanyl up to 100mcg along with the option of benzos as needed.
When I walk into the ED, I am suddenly handcuffed. It is frustrating in that respect, especially being in a critical access hospital where the doctor has 20 minutes to come in for a patient and often times wont give us orders for meds over the phone. It would be nice if it was much more protocol driven. (I work in a small town where the paramedics work in the ER when they are not on calls)

 

[fahimaz7]

We had a guy forge a script for 1 pound of Dilaudid. It was an epic fail. Pharmacist called the prescriber and was laughing before he even started to ask.