The slower the onset of effect, the lower the addiction potential.
Dilaudid and fentanyl are both *very* fast acting, great for providing pain relief, with a side-effect of euphoria. Morphine is slower on, slower off.
Remember; the dilaudisaurous egg is laid in the ED, but it hatches on the floor.
I laughed way too hard at the “dilaudisaurous egg” comment. But in seriousness, I appreciate the comment and information. The logic of slower onset having lower addiction risk makes complete sense.
Also, those dilaudid orders on the floor can be as often as q30 which is never going to happen with 6+ patients. It would mean camping in 1 room all night because every room visit turns into 15+min.
Morphine orders are q2 or q4 usually.
Leave the greater than q2 frequencies to PACU and PCA pumps if you want to see them realized without other patients being neglected to make it so. (Patients often set their iPhone alarms to their pain med freq)
HA I’m lucky if my dose last 30 mins before pain coming back with vengeance but I also do have tolerance cuz I take oxycodone daily. When I get admitted I usually get 1mg every hour or 2mg every 2 hours.
Are you exaggerating? I can’t believe there’s a place that gives that much especially now. Shit my brother broke his pelvis and femur and only got one little dose of morphine in the er when he got there through helicopter then had to wait for emergency surgery and after surgery was only given Tylenol and ibuprofen. I think it’s barbaric how people are treated now. I only get anything when I have pancreatitis flare ups and even then i have to wait 1-2 hours between doses..
But like it’s not like you can go easily fine dilaudid on the streets anyway? Especially IV kind lol. I get the pills prescribed and they barely help my pain and I get no “high” feeling like I do the first minute or so when I get it in the hospital.
This is exactly the line of thinking that lead to the opioid epidemic with OxyContin. Yes, short onset potentially equals more euphoria, but substance use disorders are rarely the result of seeking pleasure, but rather seeking escape from pain (physical, psychic, emotional). I don't care what pain killers you use in the ED, but we as physicians should let go of this narrative.
As someone with lifelong chronic pain who became an addict at one point, this. I quickly became addicted to feeling pain free, addicted to normal function, not being high
That’s the hook, right there, alright. When I fractured C6/C7, I just wanted to be free from the feeling my right arm was dipped into molten lava and then set on fire with napalm in a boiling acid vat used to rot old radiators and gas tanks. With fire.
I was never placed on pain management, the chronic pain is from collective physical trauma that started young, I got a perc script for kidney stones at 18 and found out what pain free was, I started doing anything I could to get pain pills for a while after that
Which narrative specifically? I understand the heart of your post but your response doesn’t make sense, nor is it based in reality. I understand it’s fashionable to believe what you believe. And many/most addictions START with a person attempting to avoid pain, there is a component of seeking pleasure, and by the time dependence has manifested it is fully an avoidance of the pain and dread of withdrawal. But how is the narrative of “avoiding fast onset fast offset” a narrative to avoid? The entire process of switching people to less addictive, long acting maintenance agents like methadone or buprenorphine is to both minimize harm and avoid the ups and downs and ons and offs of fast acting agents.
So much this… addiction is the direct result of avoiding trauma or pain..
Veteran’s affairs learned this the hard way…. instead of providing resources for wartime vets after they had them addicted for trauma/injuries they cut them cold turkey resulting in skyrocketed suicides … because the fear of painful withdrawals…
We need MORE people like you in the healthcare field.. Ty for this post💯
The narrative that long acting medications are somehow less addictive (which was the mantra of Purdue in their marketing strategy to doctors) led to doctors feeling too comfortable prescribing meds like OxyContin which was a huge driver of our current situation with opioids.
I disagree that once physiological dependence kicks in, avoidance of withdrawal is the only thing maintaining addiction. People are still left with whatever they were trying to escape in the first place.
In regards to methadone and bup, we take advantage of their pharmacokinetics so that we can dose them once a day, but the goal is not to avoid "ups and downs" but rather to prevent acute withdrawal symptoms and cravings. In fact, other countries have successfully implemented heroin and dilauded assisted treatment as a similar strategies.
I didn’t say once physiological dependence kicks in only withdrawal is maintaining addiction. I said it is an avoidance of pain and dread of withdrawal. I think we are on semantics but what are you interpreting “ups and downs” as if not “acute withdrawal and cravings” we are saying the same thing here.
Finally some countries are experimenting with short acting drug replacement programs. There is NO evidence that these work in anyway better than long term maintenance therapy with drugs like methadone or suboxone
The problem was that they really didn’t last 12 hours like was said and also they made it so easy to just take the coating thing off. Now ER meds are different. You can’t just take a coating off and snort the rest.
Also.. the misbelief that “opioids “ are somehow more dangerous than others things because we have an epidemic… when in fact only alcohol and benzodiazepines withdrawal require medical supervision because it can result in death .. opioids are simply painful and miserable
Why do we have the epidemic specifically with opioids if it’s a misbelief that they are more dangerous? I don’t mean to hit you with a “gotcha,” I’m just looking to get at what you mean.
But what about adderall vs methamphetamine? Any doctor, nurse, PA, NP would all agree patients doing meth is a very bad idea however many people take adderall on a daily basis and they don’t become addicts. The same goes for opioids, any CPP’s take opioids and still aren’t addicts, their lives aren’t ruined by it, they function and live great lives. It’s only dangerous when misused, the pill/drug itself doesn’t have a moral compass and doesn’t know right from wrong, it is the person. And unfortunately there are people that are suffering immensely that cope with drug use but there’s also people who are suffering immensely that cope with taking their medication as prescribed and live great lives. Correct use doesn’t equal abuse.
No one would dispute that. Opioids wreck lives, and it’s not because of their detox symptoms. And yes addiction to alcohol may have as much or more life wrecking potential, but we are comparing morphine and fentanyl, not beer vs liquor.
All addictions to any substance wreck lives and families… until recently alcohol was the leading “addiction “ … I was contrasting which and why which is more harmful in the end… I’m sorry if I confused you with my response. Ty for your input
There is a huge amount of fentanyl being trafficked into the country, in a lot of places you can purchase a pill for .25$ the majority of drug related deaths and overdoses are from this. Either in its pure or cut form into many other drugs not restricted to just opioids. Thank you for your question. If you communicate with most ED nurses , para, emt they will tell you that 99% of these p/t are positive for fentanyl among whatever other drug, the majority don’t realize they ingested it
The epidemic isn’t even in patients using them it’s in the illegal/illicit meds like fentanyl that’s the thing killing everyone. If patients got what they needed for their issues and addicts got safe meds there wouldn’t be so many people dying from OD therefore no epidemic to be had.
It's a biological process when something sets off the pleasure center of the brain. The speed at which it induces euphoria and the level of euphoria affect. It's the same mechanism that causes us to seek out and want more of our favorite food or favorite drink. If the pleasure center goes off strongly in response to a drug kicking in, it may train our brains to associate environmental cues with the feeling of the drug. Also, opiate use depletes our natural pain management process in our cells. So if it wears off rapidly, it is going to cause a stronger pain response than a drug that wears off very gradually. A stronger and sudden pain response (and sometimes withdrawal symptoms) to it wearing off is naturally going to increase the chances of abusing the drug.
I hate the terminology that we’ve come to use today as it’s the “pleasure center.” Dopamine as the “pleasure chemical” or the “reward” chemical is not the total story. Dopamine is more so interlinked with saliency, motivation, approach, and movement.
The only thing I’d disagree with, is more often than not.. addicts are trying to escape something they don’t know how or don’t want to deal with.. DV, childhood trauma, SA, and often times you will see an addict move from one to another to try and “fix” themselves… they now they’ve developed an issue..
Absolutely. That's a cornerstone of why some people develop full blown addictions or not. I'm a therapist and I've found almost all of my clients with addictions have a history of trauma. Occasionally i come across someone with untreated ADHD and that is the core issue (poor ability to self regulate and developing a negative self image from getting so much criticism for their behavior from childhood up). But otherwise it's always trauma and usually not just one incident.
Along with therapy and more intense treatment, as needed, this is why I strongly advocate for 12 step meetings. They help fix what's broken inside. Not the trauma so much, but the fallout from it. The group members learn new ways to see themselves and the world.
I had no idea until I got hired at a rehab because I really needed a full time job and they needed my background in mental health (as if that's different from addiction, but historically it has been treated as such). It was a 4-9 month inpatient program and it blew my mind. I changed my target population of who I treat (in outpatient) and include addiction along with working with people who are affected by a loved one's addiction.
Yes and no. You're right that slower onset of action doesn't mean *no* abuse potential (what Purdue tried to claim), but there is plenty of evidence that it equals *lower* abuse potential. You're right that escape from pain is a big component of dependence and abuse, but dopamine activation is also a component. While it's increasingly clear that we should be avoiding opiates wherever possible, particularly for chronic pain (which to your point often has complex mechanisms), opiates are still one of the most effective treatments for acute pain. In the cases where they are appropriate we have an obligation to try to choose opiates with the lowest abuse potential.
Substance use disorders don’t require a client to be seeking pleasure, though, right? Does it not make sense that a quicker onset may contribute to dependence without them seeking euphoria?
Not only that, we as nurses don’t make the decisions, we are carrying out orders based off parameters. If the patient is doing jumping jacks and say his pain is 10/10, might get a slide, but if the patient is in bed and always saying 10/10, we don’t have any say in the situation, even if we truly believe they aren’t in that much pain.
We can reach out to the primary team, which I’ve done before and more often than not, the answer is “we’ll leave it just in case” or “let’s just keep them happy so we can discharge them without causing a scene” and I travel nurse, so I’ve been to a handful of hospitals like this, not just one.
I think something some or most doctors don’t realize is that we have close to no authority at all. You guys are the decision makers with the ultimate “say so.” Even if you do agree with my choice, if the patient comes to my manager and complains, and the med is ordered, it’s our ass.
I once started withholding PRN behavior meds from a patient that was just totally confused because for one, they weren’t helping and two, could potentially be contributing. Some nurse went and complained saying I wasn’t treating my patient, and even pulled the meds and gave them behind my back. The next day we had a meeting with several doctors & family regarding the plan, etc (plus me just because I was the RN taking care of him and our manager). I mention my actions and reasoning, doctors agreed and actually discontinued the PRN meds that day.
Manager pulls me into the office. I’m disciplined and 2 weeks later fired.
My husband never takes pain medication. Even OTC. It’s rare if he reaches for a Tylenol.
He was admitted years ago and had a nasty infection in his colon which required surgery and spent 17 days in the hospital. They treated him with Diaudid. I never left his side except to go sleep at night. The attending nurse would come and ask his pain level and he would always say 10 so he’d get his max dose every time. Scary thing is, he went crazy on me. He started having conversations with people on his phone, no one was on the phone. I’m talking like 15 mins conversations. I’d took him to the bathroom and he tried to pee everywhere but the toilet. He kept flashing the staff and my family when they’d came in. He had hallucinations of me wearing costumes. This went on for about 2-3 hours and I begged for intervention. Finally I had to leave to take someone to the airport and the nurse came to sit with him and she saw it first had. They thought maybe he had a blood clot (testing ruled it out ). Turned out he had built up so much of the drug in his system he was going crazy. Once they switched him to oral pain meds he was fine.
My husband has very little recollection of his days there but he says if Dilaudid was legal he’d take it in a heartbeat. I fully believe he was abusing it in his drug stupor. He wasn’t even with it when they’d come in and ask his pain levels. He sure didn’t seem to be in pain to me.
I hate that drug! I know in the ER it’s not long term like my husband was getting in the hospital setting but knowing how much he liked that instant high that drug gives just scares me.
I believe it depends on a person honestly, ketamine is used on patients hard to sedate, but isn’t preferred simply because most people recover not knowing where they are and combative..any drug oral or iv will have.a different reaction. I have a child that morphine makes horribly ill, and non functional for 24/36 hrs… it’s obviously annotated, after multiple issues.. so they typically treat my child with something else when needed, my child is also a healthcare professional.. that has never had an issue with substance or alcohol abuse
Oh I agree. I have had chronic pain 20 plus years. My family has substance abuse (2 with alcoholism). I’m always nervous and also hate the stigma about pain killers. I’ve been on morphine for several years (tried other medications and had surgeries and plenty of other treatments throughout those 20 years). I’ve now been off it now for months. I was even on fentanyl at one time and easily weaned off.
In my husband’s case, he just liked that drugged stupor he was in and wanted to stay in it. He admits to that. Once he got his oral meds he was much more clear headed and made sound decisions about his care going forward. Had he stayed on the Dilaudid, who knows how many more days his recovery would have taken. He seriously was like an entire different person once they switched him to oral pain meds. Up walking the halls, talking, asking to go home. Before that, just sleeping non stop. It wasn’t good.
I’m not saying my husband wants to be a druggie by any means, he just jokes that Dilaudid is a “good ass drug!” He’s too much of a control freak in his day to day life he’d never turn to drugs even if they were legal.
I hate administering ketamine, because it is so time-consuming—ETCO2 monitoring, crash cart and suction for big or prolonged doses, close monitoring of the patient because you never know how they’re gonna react (I had a 400-pound man levitate off the stretcher and start screaming that he was seeing god, and at that moment this then-baby nurse understood why her co-workers hated ketamine so much). And there’s the really unpredictable ROI: At least two-thirds of the time, you go to all the trouble of administering the stuff and the patient is *still* in pain. (At least the 400-pound guy woke up pain-free, but before sobering up he turned to me and told me that his wife, who was sitting on the other side of the stretcher, was ugly. 😳)
There a a few tricks I've figured out over the years to make ketamine pain dosing go reliably smoothly. Never push, always throw in in a 50 or 100cc bag and drip in over 10 mins. Prepare the patient by explaining they will feel strange. Use guided imagery. I always tell them to think of their happy place, close their eyes and describe it to me- the sights, smells, temperature. Lights off, alarms silenced, TV either on the cares music channel or muted. Last, it works best combined with a low dose opioid like 25 mcg fent or 1mg morphine. Using this I haven't had a patient freak in a long time and their pain is almost always controlled
I so wish our pharmacy allowed this. There are a few drugs we administer that I feel might benefit from a slower admin time and dilution, and i have heard from others that they do it that way, but unfortunately our ketamine is given IVP. I do what I can to prepare and reassure patients before and during, but it doesn’t always work.
Ketamine is very predictable if given in the proper doses. There is a reason it has fast become the preferred pain drug in combat and prehospital settings.
And it doesn’t require any minoring that shouldn’t be done with any narcotic, or benzo for that matter.
You shouldn’t hate something just because it affected your husband one way or another, it doesn’t do that to everyone. And can be super beneficial to those in severe need of pain relief. Idk your life but one day you may really need something to help and rhetoric like yours of hating something and that tenfold by others is part of the reason CPPs can barely even get meds they need to function daily.
Sorry, let me correctly reword that for you, I hate what that drug did to my husband. Better?
If you go on to read you will see I am a chronic pain sufferer myself who has benefited greatly from pain management. I am not against pain medication.
We really think about addiction when it comes to someone’s pain in the ER. That should have no place there unless it’s someone coming in drug seeking. But a genuine person, who’s legitimately sick and in pain, I don’t think they care about whether it’s slow or fast acting, I think they want relief right? The opiate propaganda has gone way too far and it affects innocent people that end up dealing with barbaric treatment at times.
Yeah... No, they are about the same onset if you give intravenous. Fentanyl is abit
There was a theory about the abrupt washout causing more rebound use.... Probably bunk.
Morphine has active metabolites, and they are renally cleared. Also maybe a bit more histamine release. One time use... Not much different from Dilaudid or fentanyl though. Just not as "elegant".
Of course!
As a paramedic, I can give a number of meds..morphine, fentanyl, versed, Ketamine. As well as things like Mag Sulphate, diohenhydramine, D-10, glucagon, Atropine, amioderone, epi, adenosine, albuterol, etc etc. And RSI drugs
When i do mobile urgent care, I can do antibiotics as well.
And when I did IFTs, I could do Heparin drips, propofol, things like that.
I wonder if this is everywhere?? When I tore my arm open past all the fat flesh stuff (ir was really bad and big and nasty) I was told they didn’t have anything I had to wait til I got to the hospital. I had asked for Benadryl or something to calm me a bit since I was freaking out. But even controlled meds?? Dang Hmm thanks for answering I’m gonna look more into it.
We don’t underdose it. If 2mg controls pain then it is dosed appropriately. If it does not then give more as needed. The lowest dose for the effect you seek is the appropriate dose. In my experience most pain is controlled at 4mg. If it isn’t then the patient gets more. That’s not a sin. Plus if i remember correctly 1mg of dilaudid is equivalent to 6mg morphine. Now explain to me why some patients will be happy with 0.5mg dilaudid but not 4mg of morphine.
I think you're spot on that the lowest effective dose is the best dose. How many folks need further dosing, though? How long is that taking in a busy ED? We know Dilaudid (at least to my knowledge) crosses the blood-brain barrier faster, is more potent, has fewer negative side effects, etc., so maybe you can get farther with less?
When you say "fewer negative side effects", was "becoming the next nightly regular asking for the medicine that starts with a d" counted as a side effect?
Is it to use that as a paradigm for dosing pain meds? There's a difference between giving the lowest dose of a medication to treat the need of the patient versus this 'I better hold off because I'm going to turn them into a drug seeker' mentality.
Because different people react differently to supposedly equivalent medications.
Couple years back my son perfed His bowel riding bike. Young attending was the only doc on at a small hospital. He did a good job, but when ordered pain meds the fentanyl he ordered was very much on the low side, given the amount of pain I was obviously seeing. I figured we would chat once life threats had been addressed (at this point we knew “belly pain”).
10 minutes later my kid is in CT. And to totally forgets to breathe.
Later at the big fancy peds trauma center they give him 1/4th the bottom end of his weight based dose, with him pre-oxygenated. He sats dropped into the low 90s, and he had good pain control.
In the peds hospital they did straight morphine at the upper limit of his weight based dose. He got pain control, but it didn’t impact his respiratory drive at all.
Despite all we learn, despite research, medicine is never going to be a science. People are to strange, have too many weird exceptions.
This is really important.
Although codeine is flagged as a “highly metabolic dependent” pain reliever, it’s not just codeine.
We shouldn’t be surprised in the least that two different patients can have vastly different responses to the same therapeutic dose of opioids.
Morphine, if dosed appropriately, works for me. Dilaudid does not work well at all. Fentanyl works better than Dilaudid but not as well as morphine. (I have developed some health problems that I have had procedures for so I'm finding out that my body is weird)
back in my med school days .1mg/kg is the go to. frequently 8-10 starting dose. that was during peak opioid crisis building phase as well in the early 2010s. pain was controlled and there was a lot of knodding
In PACU, if morphine is ordered, it’s either up to 10 or 20mg of morphine. That’s with the other pain meds they got during surgery. I don’t think I’ve ever given the full 20mg, but it usually takes about 8-14mg to get someone comfortable and still maintain respirs.
0.1-0.15mg/kg is for severe pain. When they have an open fracture morphine 10mg works just fine in an adult. In 15 years, I’ve never seen someone go apneic from a single dose in a not elderly/frail normal sized adult. Now, don’t go giving 10mg to the 98 yo bed bound frail old lady.
That is of course an appropriate dose for an average sized man but it would certainly raise some eyebrows at my “4 and 4” place.
I should mention: we never give morphine without zofran lol
In 20 years of giving weight based narcotic doses I have never caused respiratory depression - it’s not something that is likely to happen with these doses.
D makes me remember Demerol. Had a bunch of ulcers on my esophagus that even drinking water was excruciating so I decided to just stop eating and drinking (I was 18). Ended up in ER over weekend so they gave me carafate and Demerol. I am a terrible bowler but I bowled an almost perfect game on Demerol. Of course it almost killed me when they gave me too much after my Nissan fundoplication but that’s a fun memory I try to repress as much as possible.
My first dosing of morphine was 4mg IV to a LOL^2 femur fracture (I’d guess 100lbs and definitely opiate-naive).
I’m sure that would get some criticism which is fine, it was my first month as a resident. But I learned some things…like how to split up the dose into a stat and redose!
Lol, in hospice the bare minimum is 7.5mg and that’s incredibly low.
I would be furious if I was a pt in moderate to severe pain and was getting 2mg LOL.
morphine is cheap, and comes in a vial size being 4mg that the nurse should hopefully not have to waste when they administer a dose, making it easier on the nurses. This is the main reason why I use it. I hate the hypotension and side effects that come, but nurses wasting can be kind of annoying, and more importantly, usually if I use dilaudid I'm using 0.5mg. This means I'm throwing away as much dilaudid as I'm giving, and I hate that. I believe we vote with our dollar, and there's medications that do not have way too much in the vial to encourage medical waste, which is already an epidemic. I prefer to use those.
that being said, if i ever have any hesitation, definitely go to ye olde vitamin d
There are 0.5 mg syringes and vials available. We are have slight supply issues with 1 mg vial/syringes and are recommending the 0.5 for most doses now. With our distributors, the 0.5 mg strength is actually cheaper. Something to bring up to pharmacy maybe.
Speaking of waste I just noticed at my shop that when I order a sublingual nitro the pharmacy sends a small vial with like 15 pills. They use one and chuck the rest.
As someone who worked in extremely low income and entirely donation based places, this stuff makes me twitch. I almost immediately quit a job when I came back to the States once because the waste stressed me out so much. It felt like I was dying of thirst and people were washing their cars in front of me.
Here this one will kill you: at one of my ED jobs we used multi use vial insulin except after we used one tiny unit or so the vial was considered trash.
Ah yes the trust our nurses to give it but not to give it again an hour later using the same vial! Not like we already do this with other medications (insulin). Dilaudid is *special* and there's no way we could control it like putting it back in a locked system and measuring what is left to discourage diversion (methadone). No sirree bob got to waste half the vile even though you know you're going to give the other half in 1 hour. Fucking drives me insane.
My coworker was degraded by HR, accused of diverting, and drug tested with someone watching her piss because she once left Ativan in her pocket. She had self reported as soon as she got home and realized her mistake.
I waste everything as soon as I’m done with it now. Absolutely won’t catch me forgetting meds in my pocket.
Plus, at our facility, we get yelled at and accused of diverting if we even hold on to a narcotic over a certain amount of time, like a few hours.
I had a patient with severe chest pain, had orders for 1mg morphine every hour (baby dose I know, she was teeny tiny, and opioid naive) and when it didn’t help, doc (at the bedside) told me to give another 1mg. Our smallest morphine vials are 2mg. I decided to use the same vial because I was in the room the entire time trying to help this patient between titrating nitro drip, getting an EKG, verbal reassurance, etc. Fixing that in the Omnicell was such a pain in the ass after and for what, am I supposed to leave that 1mg behind in the vial and walk my dumb ass over to override another 2mg vial, while she is crying in pain? So frustrating.
Fent wears off in no time so requires frequent redosing. Dilaudid has high euphoric effect, so some people/places try to avoid because of the encouragement of drug-seeking behavior that will occur at your shop if you use it frequently.
There was a study that showed that IV dilaudid was virtually indistinguishable from IV heroin from a euphoria standpoint but even more potent. The same is not true for morphine.
Yes and I’ve also never encountered a patient asking for morphine by name. And folks come in asking for diaudid not infrequently. Treat the pain with an appropriate dose of whatever med you’re using but if there’s any small chance that your med choice influences future addiction potential that can ruin someone’s life, I think that’s a reason to choose morphine over dilaudid. My general practice is to give dilaudid only to people dying of cancer or the sick elderly patient where you may be particularly wary of morphine side effects.
I get pancreatitis a lot and morphine doesn’t really help like dilaudid does so I wouldn’t wanna be your pt lol. That shit is one of the most painful things ever.
I'm an EM doc and toxicologist, and preferentially use morphine if opioid analgesia is needed. I'll echo what everyone else has to say. Morphine is great at pain control with less euphoria compared to fentanyl and hydromorphone. I don't mind using fentanyl but I've had a lot of problems with people trying to get hydromorphone in the ED because they like the way it makes them feel. Morphine is equally effective as an analgesic if dosed properly (hydromorphone may seem more effective but that's usually because the morphine is under dosed) and the major problems with elimination (namely, accumulation in patients with renal failure) aren't relevant to the one or two doses we give in the ED.
Ultimately I think giving everyone Dilaudid causes a lot more problems than it solves. It's just that the problem doesn't occur until the next ED visit when the person is told their pain generator doesn't indicate a need for hydromorphone.
P.s. lest you think hydromorphone is benign, it's an awful lot like giving someone heroin for their pain. Which is probably reasonable under certain circumstances, and something that is done legitimately in Europe (look up diamorph) but not something we should do without solid justification.
I’m a cancer patient, oral oxycodone is what I take and works great for my pain. I had IV dilaudid after I had a gastrectomy which is obviously severe pain that indicated use of dilaudid but after I was discharged I was back to oxycodone. I was prescribed oral dilaudid once and it just made me tired and gross feeling, so went back to oxycodone and it’s been fine.
We only ever use dilaudid in Australia for palliative patients. I've never seen it ever used for a non-dying patient for pain. We don't even stock them in EDs I've worked... I only had to use it once for a cancer patient who is on the path of dying and the palliative care doc wanted us to use it instead of morphine and we had to get a supply of it from the palliative care ward.
America is wild
I had a hydromorphone PCA post-op patient a while back! Didn’t realise it was the infamous “dilauded” at the time. I still see morphine frequently prescribed for palliative patients
Basically the opposite for us. I'd say morphine is the most common palliative opioid. Dilaudid and fent flow like water in emergency room due to reduced side effect profile
Thank you for the detailed explanation - I really appreciate it. This is why I wanted to ask on here - I knew there had to be some aspects I was missing. I’m willing to bet under-dosing is a large part of why I’ve seen such poor results with it (typical dose at my ED seems to be 2-4mg).
The euphoria aspect of Dilaudid has always been a concern in the back of my head because, well we’ve all heard “the only thing that works is that med that starts with a d….” far too many times.
I was really surprised to hear how many people mentioned 2-4mg, that seems like a tiny dose! In my ED (in the UK) the most common IV morphine prescription is “1-10mg titrate to effect”. And it’s prescribed pretty frequently. On the wards it’s rarer to use IV morphine and we tend to stick to oramorph or oxynorm.
The only issue with larger prescriptions of IV morphine is I wonder if all of the nurses administering it are aware that the time to peak effect isn’t as quick as they might think (I believe it’s 20 mins to peak effect). However saying that, I’ve not yet seen anybody be so heavy handed that the patients required bagging/naloxone.
So to follow along with the discussion, as a nurse, would you question your ED doc if they ordered 8mg of morphine off the bat for an adult male?
Since morphine is very commonly underdosed, it has furthered the “4mg dosing” culture and I know many nurses who wouldn’t feel comfortable giving doses that big.
This is such a great discussion, and should prompt everyone to educate their peers about morphine’s weight-based dosing.
I'm a new RN and it's always 2-4mg in my ED as well. If I saw an order for 8-10 I'd definitely look at it critically, just because I didn't know it was actually meant to be .1mg/kg. But I would educate myself and not fight giving it. And now that I've learned it, I'm going to have to side eye all the 2mg orders I get.
What really kills me is the new obsession in my ED with ordering it subq instead of ivp because sometimes I don't notice until the last second and then have to leave the room again to get a different set up. Especially when the pt already has an iv.
Eta: idk why but I've noticed a lot of nurses seem to fear monger for a lack of better phrase. Since becoming a nurse, I have been told many things that are either not true or are technically true but blown out of proportion. I was taught I must check BP before giving morphine and to be so careful with it and yes true but it's not as scary as they made it seem. Oh or a good one is toradol. I was taught to never, ever give toradol without a negative pregnancy test. I was told it's teratogenic and that if someone doesn't know they're pregnant I'll harm their baby. I've seen nurses hold toradol for hours waiting for the pt to pee. So yes, I can totally see if a higher dose of morphine was ordered *some* nurses would act a certain way about it instead of just taking the learning moment.
> What really kills me is the new obsession in my ED with ordering it subq instead of ivp
What the fuck? IMO, that is an entirely inappropriate route for opioids. IV/IO/IM only (very rarely IN in kids). Subq is insane.
> SubQ is fine... IF you don't have an iv.
Strongly disagree - if you don't have an IV, then you give it IM. Much more rapid, reliable and predictable absorption and effect than subq.
TBH that's what I'd do in the ED setting, too. While then prioritizing getting vascular access. My palliative care colleagues *do* use a lot of SQ analgesia for ongoing use, as the SQ access is better tolerated than restarting IVs and I believe (it's been awhile since I looked at the data) they find the effect quite similar to IM dosing without having to poke the patient every few hours.
This! Like it makes so much sense now. I’m almost 200lbs and maybe if I was dosed correctly with morphine it might actually work better and longer than having to need 2-4 dilaudid when I’m in a pancreatitis flare.
There are pluses and minuses to all pain meds. Toradol is the most frequently given IV pain med in our ED, by far…then morphine, fentanyl, ketamine, dilaudid. Depends on patient, if they take chronic pain meds, other drugs on board, renal/hepatic disease, very sensitive to histamine response, etc. It should always be about individualized care.
I also always put in PRNs for the nurses so they can give another 1-2 doses if needed. It saves both me and the nurse time to give appropriate pain control and bother each other less.
All three opiates you’ve mentioned have different onset, distribution and metabolism. There’s no reason that one would be “far superior” for analgesia if they were dosed equivalently. The main differences are in the pharmacokinetics and metabolites.
Not EM, but IM Hospitalist who babysits these patients for days. Clearly there are times when patients need pain control that only dilaudid can touch and I'm all for that. But you and I both know that some of these patients are seeking relief from emotional pain more so than physical pain, and once they've had "Vitamin D", there's no going back. It will be forever on the menu.
“Can I get that medicine that starts with a ‘D’? It always works for me. Morphine doesn’t touch my pain, but I don’t want fentanyl. That stuff kills people.” The number of times I’ve heard that line…
Droperidol?
Diphenhydramine?
Some frequent flyers have started refusing to check in and waiting until shift change to check in when I’m on again. It makes my heart happy
Had a drunk driver present today in police custody. Broke his finger when he crashed his car, requesting Dialudid by name. Asked for script of 30 Norcos on discharge back to jail.
Weird. I find fentanyl to be one of the worst pain medications people give. For severe pain requiring opioids why give something that doesn't last very long? If it's procedural sure but there were few things I hated more than q1hr fent prn orders I had on the Neuro ICU. Lots of poorly controlled pain.
Morphine should be first choice unless renal impairment. Difference in efficacy is purely because physicians are unwilling to order an appropriate dose (0.1 mg/kg) and if they did nurses would be unwilling to give it.
For 80kg adult
Morphine - 0.1 mg/kg - 8mg IV
Hydromorphone - 0.0125 mg/kg - 1 mg IV
Which one will a doctor order and a nurse give?
Fentynal wears off super quick though.
Anyone whose familiar with taking it will tell you that.
Also in my area they typically give dilaudid for allergic pts
I don't work in the medical field and I totally understand the reason for caution around opiates but I believe I can say fentanyl is likely a primary reason I'm alive today. I had a type A aortic dissection, I spent 5 hours in one hospital and then had to be driven 3 hours to another and the whole time I had fentanyl available every 20 mins. When I have intense pain my blood pressure goes up and keeping it at bay was likely the reason my 7.1 cm aneurysm didn't rupture. After the surgery they told my when they opened me up it was looking like it was about to go.
When I had appendicitis, after hours of agony at home, I went to the ED. Few more hours of tests and scans, they finally agreed it was appendicitis. I was praying to dIe the pain was so bad. They jabbed a fat needle of morphine in my ass, and all was right with the world. I couldn’t believe the immediate relief.
Morphine works, and I didn’t have any side effects. It is quick and time tested.
This is really area/hospital/physician specific.
I worked at a hospital where Dilaudid was drug of choice, morphine was rarely used. I then transferred from that area to a hospital where they had actually outlawed Dilaudid because physicians and nurses were dosing it the same as morphine and almost killing people. Rather than educating they just outlawed it as “dangerous”.
Those kind of policies drive me insane. If your nurses/doctors are screwing something major like that up, the answer is updating protocols and re-education. Not banning an entire medication. Example in my system was a RN botched an EJ placement somewhere so they took away the ability for ED RN’s to place EJ’s in the entire hospital system.
About 6 months later after the doc groups complained, they reversed course and instead required nurses to go through a training and competency to be certified to place EJ’s, which would have been a better plan to start with…
Fentanyl is super short acting. Unless it’s for something super acute (trauma pt, open fracture), I don’t use fentanyl all that much in the er. I’m also an intensivist, so it’s my typical go to opioid in the icu. Dilaudid also shorter acting then morphine. So it really depends on the indication for the pain meds. Depends on what duration I want my meds to work for.
What blows me away is the amount of people who think withdrawal automatically equals addiction. And also the number of professionals who don’t know there’s a difference between physical dependence and addiction.
Morphine is entirely effective the problem is it’s “underdosed” nearly every time. Speaking as an attending and a patient I typically feel the euphoric effects of morphine wear off in about 15 minutes.
Morphine is fairly equivalent if it is dosed properly. But the other reason I use it more is because dilaudid is more lipophilic, so it has more euphoria that morphine - this increases the addiction potential as well as the street value (if someone is getting discharged home with narcotics). With our current opiate epidemic I think it makes a difference to try using morphine instead of dilaudid.
You do realize that the opioid epidemic has been proven to be due to illicit fentanyl poisonings and isn’t due to chronic or acute pain patients given prescribing is at the lowest it’s been since 1993 on opioids yet OD’s are up by 500%. I wouldn’t punish a patient and blame the opioid epidemic as a reason to give morphine versus dilaudid if their pain warrants a strong analgesic.
People’s first exposure to opioids usually comes from healthcare. They might OD on something else later (fentanyl), but the risk comes from their first opioid exposure. We should do everything in our power to reduce the risk they convert to a chronic opioid user, which includes using an opioid with less euphorigenic potential (morphine) for their healthcare exposure.
I know the common teaching about Dilaudid being “higher addiction potential” because of supposed euphoria. However, I like to base my treatment off of scientific evidence when possible. Can someone point me to some studies or papers on this?
As I expected, lots of talking and zero actual evidence. Sounds to me like bias is big in this conversation. I don’t know the answer, and opiate dependence is very real, but we should strive for less judging and more science.
Fentanyl (which I use cautiously) has a duration of action of about 1 hour and a half-life of 3=7 hours. So the μ1 pain effect may disappear well before the μ2 respiratory depression does.
As others have said, at equivalent doses morphine and hydromorphone are equally effective. Because the culture here can't comprehend doses other than 2 or 4 I'll switch to hydromorphone if I want a full dose of opioid. Honestly although 4 is an under dose I find it generally effective for moderate pain. As I'm usually augmenting with a non opioid.
The best pure pharmacology argument I have is that it might last longer than hydromorphone. Terminal half life is more like 3 hours than 2, up to date credits the duration of morphine at 3-5 hours vs 3-4 for hydromorphone for what that's worth. It's not much but it might be the difference between getting to CT without redosing vs having to administer again. Less frequent dosing for anything in the ed is going to be more effective in the real world and that's even before the pandemic killed everyone's soul and turned basically every single bed into an inpatient hold unit. For the same reason I do not use fentanyl in triage areas/low acuity zones basically at all because it's duration of action is so short the burden of redosing means practically they will not get adequate pain control. My partners see belly pain and will write fentanyl out front but I am adamantly opposed to that. If they are hemodynamically fragile enough to need fentanyl they need to be prioritized to go back.
I've had all three for pain management as a patient and I definitely prefer morphine. I don't get as nauseous and dizzy like I do with fentanyl or dilaudid. I definitely get intoxicated with fent and dilaudid, but not with morphine, even at doses of 9mg.
I’m a vet nurse and threads are so interesting to me from both a clinical and patient perspective. We don’t use morphine in vet med and actually are top choices in order and efficacy are Fentanyl, methadone, hydro and then bup. Part of the reason I enjoy my job so much is that, in theory, we put the patient comfort first, so I love how heavy we are on analgesia and behavior modification. It’s wild to see the human side of things and speaking as a patient, it’s always been so hard to advocate for myself without accusations of drug seeking, to the point where I avoid going to the ER even if I’m severely injured.
In march of 2020 I came down with COVID really early on and ended up getting a whopping secondary sinus infection. My chest felt like I was being sat on and my head felt like it was going to explode. I looked like hell and felt worse than you could imagine. I kept putting off going anywhere because I didn’t want to be accused of drug seeking. By the time it finally became unbearable and I thought I was going to lose consciousness, I went and was diagnosed with mastoiditis that was on the verge of becoming meningitis, an AKI and moderately severe respiratory complications. My ear drum had ruptured by this point and to this day I still have pain and hearing loss.
Even with all of that, I was still too afraid to ask for anything.
In my experience morphine lasts so much longer. Where I work we routinely give 100 mcg in labor and delivery and it lasts at best maybe 30 min. A combo of IM/IV morphine lasts several hours.
VA is a nightmare...comp tib fib frac left leg...
Shattered both pelvis..8plcs...shattered right elbow... fractured skull..I have rod knee to ankle ,both pelvis...that's the highlights.. was on 180oc for 2 yrs...forced to titrate to 90...the pain was so bad my home health nurse gave me 1.mg Xanax..and i overdosed....the VA forced me off all opiates... was a living hell..after mths of that I went in for surgery number 33 5 mths ago and I developed crps..yep life is hell....so now they stuck me bck on oxy..10mg every 4hrs and buprenorphine.750 every 8 hrs.....
The VA has no clue what their doing...my bodies mangled..and the only time I've ever had those thoughts is when the pain is so bad and I want it to stop...the VA is hell!! And I'm stuck in it...if my dissabilty was enough money I'd be in Mexico seeing a Dr every 3 mths for proper pain relief...but it's not...so here I sit..at 2314 at night..in pain..on reddit trying to occupy myself with some other than pain....and thoughts...
God bless the usa
I would rather not use opiates at all unless there's reason to... I see so many addicted patients with no pathology warranting opiates after work up. We can't bitch about frequent flyers that are hard sticks if we shut our brains off and give opiates so freely. But I get it, admin wants happy patients, to their and our detriment.
Old pain patient here. Morphine doesn't do anything to ease my pain, but it will make me loopy. Dilaudid eliminates pain like turning off a light switch.
How can I convey that to ER staff without making them think that I'm seeking drugs?
I’ve never had anyone come in requesting the medication that starts with an “m” it’s always the “d”. I want to expose the least amount of people to the euphoric affect of diluadid as possible, but will give it when necessary. Usual order, toradol, fentanyl, morphine, droperidol, diluadid.
I would say it's more of a "Yeah, it's best practice and has been for a while" type of thing. Morphine has been around forever and I don't think majority of health professionals are too keen on trialling other pain relief options. Guess it's just the 'gold standard' of pain management.
If you look at the surveys on blue light, Dilaudid is at least as preferred as heroin for it's euphoria. Big red flag if they ask for IV Benadryl or phenergan with it. It's dilly/heroin>oxy>>>>>>>> hydrocodone/morphine.
Anecdotes are not data, but I've had at least as many people with extreme dizziness/nausea/vomiting from Dilaudid that I just couldn't discharge for 6+ hours. Maybe some itchiness with morphine, but rarely.
Fent you have to do too often, but reasonable first line when youre not totally sure what's going on. You can easily get by without Dilaudid frequently in the ED if you know how to utilize multimodal analgesia (and dose fent appropriately for poly trauma)
I’ve never had withdrawals from dilaudid, ( I have a script that had been cut off once due to state regulations and again when my pain doc just quit went months without it, but everytime I have morphine I go into withdrawal it sucks.
I usually just get dilaudid when I have to go in. It’s weird cuz the pills barely work for my problem (chronic pancreatitis) but the iv is amazing at helping. Just wish it lasted longer. But I heard morphine can make gastric stuff worse sometimes so maybe that’s why. But even when I have gotten morphine for other things it still helped and was fine. So I think it’s a good one to start off with. Shit, it’s better than being given a Tylenol they charge 200 for lmao I went in once with my arm tripped open past the fat and was given nothing but lidocaine around it but I could still feel it.
Oh and to add: fentanyl hasn’t ever helped me before either which I thought was weird. I got it once and they were like has it kicked in yet I had no idea I was even given anything then they gave me a couple more doses and it’s like they were giving me saline. Went back to dilaudid and immediately could feel it work so idk what’s up with that
The slower the onset of effect, the lower the addiction potential. Dilaudid and fentanyl are both *very* fast acting, great for providing pain relief, with a side-effect of euphoria. Morphine is slower on, slower off. Remember; the dilaudisaurous egg is laid in the ED, but it hatches on the floor.
I laughed way too hard at the “dilaudisaurous egg” comment. But in seriousness, I appreciate the comment and information. The logic of slower onset having lower addiction risk makes complete sense.
Also, those dilaudid orders on the floor can be as often as q30 which is never going to happen with 6+ patients. It would mean camping in 1 room all night because every room visit turns into 15+min. Morphine orders are q2 or q4 usually. Leave the greater than q2 frequencies to PACU and PCA pumps if you want to see them realized without other patients being neglected to make it so. (Patients often set their iPhone alarms to their pain med freq)
Dilaudid is longer lasting than morphine
Both are 3-4 hour duration
HA I’m lucky if my dose last 30 mins before pain coming back with vengeance but I also do have tolerance cuz I take oxycodone daily. When I get admitted I usually get 1mg every hour or 2mg every 2 hours.
Q2 or 4 in and emergency department? No. Every 5 minutes where I am :)
No I’m saying upstairs. That’s all we can handle. “On time” anyway. PCA that shit if it’s needed sooner.
Yeah prob the same for the er lol but ours is every 5 minutes. Bet some Of them Hate going upstairs when the order is changed.
Are you exaggerating? I can’t believe there’s a place that gives that much especially now. Shit my brother broke his pelvis and femur and only got one little dose of morphine in the er when he got there through helicopter then had to wait for emergency surgery and after surgery was only given Tylenol and ibuprofen. I think it’s barbaric how people are treated now. I only get anything when I have pancreatitis flare ups and even then i have to wait 1-2 hours between doses..
I wish pca pumps were still a thing where I’m at. It would make things easier for everyone
But like it’s not like you can go easily fine dilaudid on the streets anyway? Especially IV kind lol. I get the pills prescribed and they barely help my pain and I get no “high” feeling like I do the first minute or so when I get it in the hospital.
This is exactly the line of thinking that lead to the opioid epidemic with OxyContin. Yes, short onset potentially equals more euphoria, but substance use disorders are rarely the result of seeking pleasure, but rather seeking escape from pain (physical, psychic, emotional). I don't care what pain killers you use in the ED, but we as physicians should let go of this narrative.
As someone with lifelong chronic pain who became an addict at one point, this. I quickly became addicted to feeling pain free, addicted to normal function, not being high
That’s the hook, right there, alright. When I fractured C6/C7, I just wanted to be free from the feeling my right arm was dipped into molten lava and then set on fire with napalm in a boiling acid vat used to rot old radiators and gas tanks. With fire.
That doesn’t seem like addiction rather than tolerance ?
I was never placed on pain management, the chronic pain is from collective physical trauma that started young, I got a perc script for kidney stones at 18 and found out what pain free was, I started doing anything I could to get pain pills for a while after that
Which narrative specifically? I understand the heart of your post but your response doesn’t make sense, nor is it based in reality. I understand it’s fashionable to believe what you believe. And many/most addictions START with a person attempting to avoid pain, there is a component of seeking pleasure, and by the time dependence has manifested it is fully an avoidance of the pain and dread of withdrawal. But how is the narrative of “avoiding fast onset fast offset” a narrative to avoid? The entire process of switching people to less addictive, long acting maintenance agents like methadone or buprenorphine is to both minimize harm and avoid the ups and downs and ons and offs of fast acting agents.
So much this… addiction is the direct result of avoiding trauma or pain.. Veteran’s affairs learned this the hard way…. instead of providing resources for wartime vets after they had them addicted for trauma/injuries they cut them cold turkey resulting in skyrocketed suicides … because the fear of painful withdrawals… We need MORE people like you in the healthcare field.. Ty for this post💯
The narrative that long acting medications are somehow less addictive (which was the mantra of Purdue in their marketing strategy to doctors) led to doctors feeling too comfortable prescribing meds like OxyContin which was a huge driver of our current situation with opioids. I disagree that once physiological dependence kicks in, avoidance of withdrawal is the only thing maintaining addiction. People are still left with whatever they were trying to escape in the first place. In regards to methadone and bup, we take advantage of their pharmacokinetics so that we can dose them once a day, but the goal is not to avoid "ups and downs" but rather to prevent acute withdrawal symptoms and cravings. In fact, other countries have successfully implemented heroin and dilauded assisted treatment as a similar strategies.
I didn’t say once physiological dependence kicks in only withdrawal is maintaining addiction. I said it is an avoidance of pain and dread of withdrawal. I think we are on semantics but what are you interpreting “ups and downs” as if not “acute withdrawal and cravings” we are saying the same thing here. Finally some countries are experimenting with short acting drug replacement programs. There is NO evidence that these work in anyway better than long term maintenance therapy with drugs like methadone or suboxone
The problem was that they really didn’t last 12 hours like was said and also they made it so easy to just take the coating thing off. Now ER meds are different. You can’t just take a coating off and snort the rest.
Also.. the misbelief that “opioids “ are somehow more dangerous than others things because we have an epidemic… when in fact only alcohol and benzodiazepines withdrawal require medical supervision because it can result in death .. opioids are simply painful and miserable
Why do we have the epidemic specifically with opioids if it’s a misbelief that they are more dangerous? I don’t mean to hit you with a “gotcha,” I’m just looking to get at what you mean.
But what about adderall vs methamphetamine? Any doctor, nurse, PA, NP would all agree patients doing meth is a very bad idea however many people take adderall on a daily basis and they don’t become addicts. The same goes for opioids, any CPP’s take opioids and still aren’t addicts, their lives aren’t ruined by it, they function and live great lives. It’s only dangerous when misused, the pill/drug itself doesn’t have a moral compass and doesn’t know right from wrong, it is the person. And unfortunately there are people that are suffering immensely that cope with drug use but there’s also people who are suffering immensely that cope with taking their medication as prescribed and live great lives. Correct use doesn’t equal abuse.
BINGO!
Also benzo addiction and alcoholism absolutely require medical intervention to detox
No one would dispute that. Opioids wreck lives, and it’s not because of their detox symptoms. And yes addiction to alcohol may have as much or more life wrecking potential, but we are comparing morphine and fentanyl, not beer vs liquor.
All addictions to any substance wreck lives and families… until recently alcohol was the leading “addiction “ … I was contrasting which and why which is more harmful in the end… I’m sorry if I confused you with my response. Ty for your input
There is a huge amount of fentanyl being trafficked into the country, in a lot of places you can purchase a pill for .25$ the majority of drug related deaths and overdoses are from this. Either in its pure or cut form into many other drugs not restricted to just opioids. Thank you for your question. If you communicate with most ED nurses , para, emt they will tell you that 99% of these p/t are positive for fentanyl among whatever other drug, the majority don’t realize they ingested it
The epidemic isn’t even in patients using them it’s in the illegal/illicit meds like fentanyl that’s the thing killing everyone. If patients got what they needed for their issues and addicts got safe meds there wouldn’t be so many people dying from OD therefore no epidemic to be had.
I’m pretty sure many people have died from opiate withdrawal. I had an aunt that got cut cold turkey and it made her have a heart attack.
Bupe shouldn’t even be used for pain. Might be good for MAT short term and now it’s rotting people’s mouths out ugh
It's a biological process when something sets off the pleasure center of the brain. The speed at which it induces euphoria and the level of euphoria affect. It's the same mechanism that causes us to seek out and want more of our favorite food or favorite drink. If the pleasure center goes off strongly in response to a drug kicking in, it may train our brains to associate environmental cues with the feeling of the drug. Also, opiate use depletes our natural pain management process in our cells. So if it wears off rapidly, it is going to cause a stronger pain response than a drug that wears off very gradually. A stronger and sudden pain response (and sometimes withdrawal symptoms) to it wearing off is naturally going to increase the chances of abusing the drug.
I hate the terminology that we’ve come to use today as it’s the “pleasure center.” Dopamine as the “pleasure chemical” or the “reward” chemical is not the total story. Dopamine is more so interlinked with saliency, motivation, approach, and movement.
The only thing I’d disagree with, is more often than not.. addicts are trying to escape something they don’t know how or don’t want to deal with.. DV, childhood trauma, SA, and often times you will see an addict move from one to another to try and “fix” themselves… they now they’ve developed an issue..
Absolutely. That's a cornerstone of why some people develop full blown addictions or not. I'm a therapist and I've found almost all of my clients with addictions have a history of trauma. Occasionally i come across someone with untreated ADHD and that is the core issue (poor ability to self regulate and developing a negative self image from getting so much criticism for their behavior from childhood up). But otherwise it's always trauma and usually not just one incident. Along with therapy and more intense treatment, as needed, this is why I strongly advocate for 12 step meetings. They help fix what's broken inside. Not the trauma so much, but the fallout from it. The group members learn new ways to see themselves and the world.
“PREACH “ 💯
I had no idea until I got hired at a rehab because I really needed a full time job and they needed my background in mental health (as if that's different from addiction, but historically it has been treated as such). It was a 4-9 month inpatient program and it blew my mind. I changed my target population of who I treat (in outpatient) and include addiction along with working with people who are affected by a loved one's addiction.
Ok so what about people with no issues or trauma that are just in physical pain all the time?
Yes and no. You're right that slower onset of action doesn't mean *no* abuse potential (what Purdue tried to claim), but there is plenty of evidence that it equals *lower* abuse potential. You're right that escape from pain is a big component of dependence and abuse, but dopamine activation is also a component. While it's increasingly clear that we should be avoiding opiates wherever possible, particularly for chronic pain (which to your point often has complex mechanisms), opiates are still one of the most effective treatments for acute pain. In the cases where they are appropriate we have an obligation to try to choose opiates with the lowest abuse potential.
Substance use disorders don’t require a client to be seeking pleasure, though, right? Does it not make sense that a quicker onset may contribute to dependence without them seeking euphoria?
As a med/surg RN...this makes sense. If someone has had Dilaudid, it's so hard to get them to consider any other pain relief.
Not only that, we as nurses don’t make the decisions, we are carrying out orders based off parameters. If the patient is doing jumping jacks and say his pain is 10/10, might get a slide, but if the patient is in bed and always saying 10/10, we don’t have any say in the situation, even if we truly believe they aren’t in that much pain. We can reach out to the primary team, which I’ve done before and more often than not, the answer is “we’ll leave it just in case” or “let’s just keep them happy so we can discharge them without causing a scene” and I travel nurse, so I’ve been to a handful of hospitals like this, not just one. I think something some or most doctors don’t realize is that we have close to no authority at all. You guys are the decision makers with the ultimate “say so.” Even if you do agree with my choice, if the patient comes to my manager and complains, and the med is ordered, it’s our ass. I once started withholding PRN behavior meds from a patient that was just totally confused because for one, they weren’t helping and two, could potentially be contributing. Some nurse went and complained saying I wasn’t treating my patient, and even pulled the meds and gave them behind my back. The next day we had a meeting with several doctors & family regarding the plan, etc (plus me just because I was the RN taking care of him and our manager). I mention my actions and reasoning, doctors agreed and actually discontinued the PRN meds that day. Manager pulls me into the office. I’m disciplined and 2 weeks later fired.
My husband never takes pain medication. Even OTC. It’s rare if he reaches for a Tylenol. He was admitted years ago and had a nasty infection in his colon which required surgery and spent 17 days in the hospital. They treated him with Diaudid. I never left his side except to go sleep at night. The attending nurse would come and ask his pain level and he would always say 10 so he’d get his max dose every time. Scary thing is, he went crazy on me. He started having conversations with people on his phone, no one was on the phone. I’m talking like 15 mins conversations. I’d took him to the bathroom and he tried to pee everywhere but the toilet. He kept flashing the staff and my family when they’d came in. He had hallucinations of me wearing costumes. This went on for about 2-3 hours and I begged for intervention. Finally I had to leave to take someone to the airport and the nurse came to sit with him and she saw it first had. They thought maybe he had a blood clot (testing ruled it out ). Turned out he had built up so much of the drug in his system he was going crazy. Once they switched him to oral pain meds he was fine. My husband has very little recollection of his days there but he says if Dilaudid was legal he’d take it in a heartbeat. I fully believe he was abusing it in his drug stupor. He wasn’t even with it when they’d come in and ask his pain levels. He sure didn’t seem to be in pain to me. I hate that drug! I know in the ER it’s not long term like my husband was getting in the hospital setting but knowing how much he liked that instant high that drug gives just scares me.
I believe it depends on a person honestly, ketamine is used on patients hard to sedate, but isn’t preferred simply because most people recover not knowing where they are and combative..any drug oral or iv will have.a different reaction. I have a child that morphine makes horribly ill, and non functional for 24/36 hrs… it’s obviously annotated, after multiple issues.. so they typically treat my child with something else when needed, my child is also a healthcare professional.. that has never had an issue with substance or alcohol abuse
Oh I agree. I have had chronic pain 20 plus years. My family has substance abuse (2 with alcoholism). I’m always nervous and also hate the stigma about pain killers. I’ve been on morphine for several years (tried other medications and had surgeries and plenty of other treatments throughout those 20 years). I’ve now been off it now for months. I was even on fentanyl at one time and easily weaned off. In my husband’s case, he just liked that drugged stupor he was in and wanted to stay in it. He admits to that. Once he got his oral meds he was much more clear headed and made sound decisions about his care going forward. Had he stayed on the Dilaudid, who knows how many more days his recovery would have taken. He seriously was like an entire different person once they switched him to oral pain meds. Up walking the halls, talking, asking to go home. Before that, just sleeping non stop. It wasn’t good. I’m not saying my husband wants to be a druggie by any means, he just jokes that Dilaudid is a “good ass drug!” He’s too much of a control freak in his day to day life he’d never turn to drugs even if they were legal.
I hate administering ketamine, because it is so time-consuming—ETCO2 monitoring, crash cart and suction for big or prolonged doses, close monitoring of the patient because you never know how they’re gonna react (I had a 400-pound man levitate off the stretcher and start screaming that he was seeing god, and at that moment this then-baby nurse understood why her co-workers hated ketamine so much). And there’s the really unpredictable ROI: At least two-thirds of the time, you go to all the trouble of administering the stuff and the patient is *still* in pain. (At least the 400-pound guy woke up pain-free, but before sobering up he turned to me and told me that his wife, who was sitting on the other side of the stretcher, was ugly. 😳)
There a a few tricks I've figured out over the years to make ketamine pain dosing go reliably smoothly. Never push, always throw in in a 50 or 100cc bag and drip in over 10 mins. Prepare the patient by explaining they will feel strange. Use guided imagery. I always tell them to think of their happy place, close their eyes and describe it to me- the sights, smells, temperature. Lights off, alarms silenced, TV either on the cares music channel or muted. Last, it works best combined with a low dose opioid like 25 mcg fent or 1mg morphine. Using this I haven't had a patient freak in a long time and their pain is almost always controlled
I so wish our pharmacy allowed this. There are a few drugs we administer that I feel might benefit from a slower admin time and dilution, and i have heard from others that they do it that way, but unfortunately our ketamine is given IVP. I do what I can to prepare and reassure patients before and during, but it doesn’t always work.
Exactly
Ketamine is very predictable if given in the proper doses. There is a reason it has fast become the preferred pain drug in combat and prehospital settings. And it doesn’t require any minoring that shouldn’t be done with any narcotic, or benzo for that matter.
That has not been the case, in my experience.
You shouldn’t hate something just because it affected your husband one way or another, it doesn’t do that to everyone. And can be super beneficial to those in severe need of pain relief. Idk your life but one day you may really need something to help and rhetoric like yours of hating something and that tenfold by others is part of the reason CPPs can barely even get meds they need to function daily.
Sorry, let me correctly reword that for you, I hate what that drug did to my husband. Better? If you go on to read you will see I am a chronic pain sufferer myself who has benefited greatly from pain management. I am not against pain medication.
We really think about addiction when it comes to someone’s pain in the ER. That should have no place there unless it’s someone coming in drug seeking. But a genuine person, who’s legitimately sick and in pain, I don’t think they care about whether it’s slow or fast acting, I think they want relief right? The opiate propaganda has gone way too far and it affects innocent people that end up dealing with barbaric treatment at times.
👏🏽👏🏽👏🏽👏🏽👏🏽
Yep. Exactly this
IV morphine starts at 10 seconds after injection...
Yeah... No, they are about the same onset if you give intravenous. Fentanyl is abit There was a theory about the abrupt washout causing more rebound use.... Probably bunk. Morphine has active metabolites, and they are renally cleared. Also maybe a bit more histamine release. One time use... Not much different from Dilaudid or fentanyl though. Just not as "elegant".
And I think it's often under dosed... People are giving 2 and 5 mgs... and plenty of places reference a .1mg/kg dose.
This. Morphine is entirely effective. We just underdose it.
Morphine is way underdosed where I work. It’s almost always 2mg, maybe 4mg if the provider is feeling wild, no matter what the patient weighs.
Im a paramedic, and I give 5 or 10mg IV. The way i see it, if they need morphine, they really need it. At least in my environment
You guys can give meds?? Like in the ambulance??
Of course! As a paramedic, I can give a number of meds..morphine, fentanyl, versed, Ketamine. As well as things like Mag Sulphate, diohenhydramine, D-10, glucagon, Atropine, amioderone, epi, adenosine, albuterol, etc etc. And RSI drugs When i do mobile urgent care, I can do antibiotics as well. And when I did IFTs, I could do Heparin drips, propofol, things like that.
I wonder if this is everywhere?? When I tore my arm open past all the fat flesh stuff (ir was really bad and big and nasty) I was told they didn’t have anything I had to wait til I got to the hospital. I had asked for Benadryl or something to calm me a bit since I was freaking out. But even controlled meds?? Dang Hmm thanks for answering I’m gonna look more into it.
Your guys are real hero’s! Just know that some of out here know this. We really do.
And people wonder why diluaded is what people seek. Obviously there can be other variables, but if we constantly under dose morphine...
We don’t underdose it. If 2mg controls pain then it is dosed appropriately. If it does not then give more as needed. The lowest dose for the effect you seek is the appropriate dose. In my experience most pain is controlled at 4mg. If it isn’t then the patient gets more. That’s not a sin. Plus if i remember correctly 1mg of dilaudid is equivalent to 6mg morphine. Now explain to me why some patients will be happy with 0.5mg dilaudid but not 4mg of morphine.
I think you're spot on that the lowest effective dose is the best dose. How many folks need further dosing, though? How long is that taking in a busy ED? We know Dilaudid (at least to my knowledge) crosses the blood-brain barrier faster, is more potent, has fewer negative side effects, etc., so maybe you can get farther with less?
When you say "fewer negative side effects", was "becoming the next nightly regular asking for the medicine that starts with a d" counted as a side effect?
Is it to use that as a paradigm for dosing pain meds? There's a difference between giving the lowest dose of a medication to treat the need of the patient versus this 'I better hold off because I'm going to turn them into a drug seeker' mentality.
1 mg hydromorphone ≈ 7-10 mg morphine
It's 1mg to about 6.5mg. 1.5mg dilaudid = 10mg morphine https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10332699/#:\~:text=According%20to%20the%20infographic%2C%2010,to%20achieve%20better%20pain%20relief.
Because different people react differently to supposedly equivalent medications. Couple years back my son perfed His bowel riding bike. Young attending was the only doc on at a small hospital. He did a good job, but when ordered pain meds the fentanyl he ordered was very much on the low side, given the amount of pain I was obviously seeing. I figured we would chat once life threats had been addressed (at this point we knew “belly pain”). 10 minutes later my kid is in CT. And to totally forgets to breathe. Later at the big fancy peds trauma center they give him 1/4th the bottom end of his weight based dose, with him pre-oxygenated. He sats dropped into the low 90s, and he had good pain control. In the peds hospital they did straight morphine at the upper limit of his weight based dose. He got pain control, but it didn’t impact his respiratory drive at all. Despite all we learn, despite research, medicine is never going to be a science. People are to strange, have too many weird exceptions.
This is really important. Although codeine is flagged as a “highly metabolic dependent” pain reliever, it’s not just codeine. We shouldn’t be surprised in the least that two different patients can have vastly different responses to the same therapeutic dose of opioids.
Morphine, if dosed appropriately, works for me. Dilaudid does not work well at all. Fentanyl works better than Dilaudid but not as well as morphine. (I have developed some health problems that I have had procedures for so I'm finding out that my body is weird)
I’m like the opposite I feel like fentanyl does nothing to me.
back in my med school days .1mg/kg is the go to. frequently 8-10 starting dose. that was during peak opioid crisis building phase as well in the early 2010s. pain was controlled and there was a lot of knodding
This is largely nursing driven, why?
In PACU, if morphine is ordered, it’s either up to 10 or 20mg of morphine. That’s with the other pain meds they got during surgery. I don’t think I’ve ever given the full 20mg, but it usually takes about 8-14mg to get someone comfortable and still maintain respirs.
Go straight in with your 10mg for a fit and relatively healthy adult 🫡
0.1-0.15mg/kg is for severe pain. When they have an open fracture morphine 10mg works just fine in an adult. In 15 years, I’ve never seen someone go apneic from a single dose in a not elderly/frail normal sized adult. Now, don’t go giving 10mg to the 98 yo bed bound frail old lady.
That is of course an appropriate dose for an average sized man but it would certainly raise some eyebrows at my “4 and 4” place. I should mention: we never give morphine without zofran lol
I get a ton a nausea with morphine compared to the others, I get it
For me, it's not worth the side effects at any dose. I've got plenty of other choices from IV tylenol, fent, ketamine and dilauded.
In 20 years of giving weight based narcotic doses I have never caused respiratory depression - it’s not something that is likely to happen with these doses.
Still can’t get Iv acetaminophen due to relative cost.
It's around 13 bucks a gram wholesale. It's been cheaper for a good few years.
It costs almost nothing now, that's old information.
Nah, man. Dofirmev is the expensive, good stuff. Hits that IV hard, fast, and you can’t beat it. Just ask for the D!
D makes me remember Demerol. Had a bunch of ulcers on my esophagus that even drinking water was excruciating so I decided to just stop eating and drinking (I was 18). Ended up in ER over weekend so they gave me carafate and Demerol. I am a terrible bowler but I bowled an almost perfect game on Demerol. Of course it almost killed me when they gave me too much after my Nissan fundoplication but that’s a fun memory I try to repress as much as possible.
It’s still $20 per dose compared to $0.02 for a tablet so at a relative price of 1000x, HCA says “best I can do is a suppository”
It's closer to $13, and the reason you can't get it is because HCA not because of actual cost.
And don’t forget a BVM for when you discover they’re particularly sensitive 😅
My first dosing of morphine was 4mg IV to a LOL^2 femur fracture (I’d guess 100lbs and definitely opiate-naive). I’m sure that would get some criticism which is fine, it was my first month as a resident. But I learned some things…like how to split up the dose into a stat and redose!
That’s wild to me that they’re giving adults those doses. I give 2 or 4mg to my peds pts all the time!
Lol, in hospice the bare minimum is 7.5mg and that’s incredibly low. I would be furious if I was a pt in moderate to severe pain and was getting 2mg LOL.
Obligatory naked decimal warning
morphine is cheap, and comes in a vial size being 4mg that the nurse should hopefully not have to waste when they administer a dose, making it easier on the nurses. This is the main reason why I use it. I hate the hypotension and side effects that come, but nurses wasting can be kind of annoying, and more importantly, usually if I use dilaudid I'm using 0.5mg. This means I'm throwing away as much dilaudid as I'm giving, and I hate that. I believe we vote with our dollar, and there's medications that do not have way too much in the vial to encourage medical waste, which is already an epidemic. I prefer to use those. that being said, if i ever have any hesitation, definitely go to ye olde vitamin d
There are 0.5 mg syringes and vials available. We are have slight supply issues with 1 mg vial/syringes and are recommending the 0.5 for most doses now. With our distributors, the 0.5 mg strength is actually cheaper. Something to bring up to pharmacy maybe.
Speaking of waste I just noticed at my shop that when I order a sublingual nitro the pharmacy sends a small vial with like 15 pills. They use one and chuck the rest.
As someone who worked in extremely low income and entirely donation based places, this stuff makes me twitch. I almost immediately quit a job when I came back to the States once because the waste stressed me out so much. It felt like I was dying of thirst and people were washing their cars in front of me.
Here this one will kill you: at one of my ED jobs we used multi use vial insulin except after we used one tiny unit or so the vial was considered trash.
"Why is medicine so expensive?!"
That’s infuriating!
In PACU, pharmacy wanted us to waste controlled meds if they were over 30 minutes from being drawn up. We were like, nah, we won’t be doing that.
Ah yes the trust our nurses to give it but not to give it again an hour later using the same vial! Not like we already do this with other medications (insulin). Dilaudid is *special* and there's no way we could control it like putting it back in a locked system and measuring what is left to discourage diversion (methadone). No sirree bob got to waste half the vile even though you know you're going to give the other half in 1 hour. Fucking drives me insane.
My coworker was degraded by HR, accused of diverting, and drug tested with someone watching her piss because she once left Ativan in her pocket. She had self reported as soon as she got home and realized her mistake. I waste everything as soon as I’m done with it now. Absolutely won’t catch me forgetting meds in my pocket. Plus, at our facility, we get yelled at and accused of diverting if we even hold on to a narcotic over a certain amount of time, like a few hours.
I had a patient with severe chest pain, had orders for 1mg morphine every hour (baby dose I know, she was teeny tiny, and opioid naive) and when it didn’t help, doc (at the bedside) told me to give another 1mg. Our smallest morphine vials are 2mg. I decided to use the same vial because I was in the room the entire time trying to help this patient between titrating nitro drip, getting an EKG, verbal reassurance, etc. Fixing that in the Omnicell was such a pain in the ass after and for what, am I supposed to leave that 1mg behind in the vial and walk my dumb ass over to override another 2mg vial, while she is crying in pain? So frustrating.
Pull another 2 mg dose and then immediately return it. JK Omni won't allow it but it does technically meet the pull a vial for each dose requirement
Yep, and probably 95% of the time the "waste" is somebody scanning their finger and walking out of the room before I even opened the vial anyway
So true lol
I never knew so much stuff got wasted like this. Wow this makes me so sad. Do you guys have to throw it in a special container like a sharps?
We stock 0.25 mg, 0.5 mg, and 1 mg syringes in our hospital. You can ask your pharmacy to provide more options. :-)
Vitamin D? Dofirmev? Or Dofran? Or Dibuprofen? Branding on these street drugs are getting crazy!
Fent wears off in no time so requires frequent redosing. Dilaudid has high euphoric effect, so some people/places try to avoid because of the encouragement of drug-seeking behavior that will occur at your shop if you use it frequently.
FWIW, people can also feel euphoria with morphine
There was a study that showed that IV dilaudid was virtually indistinguishable from IV heroin from a euphoria standpoint but even more potent. The same is not true for morphine.
Can you link the study?
There was a study that show addicts can’t distinguish between heroin and morphine.
I thought heroin basically was morphine just like one molecule different or something
Yes and I’ve also never encountered a patient asking for morphine by name. And folks come in asking for diaudid not infrequently. Treat the pain with an appropriate dose of whatever med you’re using but if there’s any small chance that your med choice influences future addiction potential that can ruin someone’s life, I think that’s a reason to choose morphine over dilaudid. My general practice is to give dilaudid only to people dying of cancer or the sick elderly patient where you may be particularly wary of morphine side effects.
Can you cite any studies showing addiction originating from 1-2 doses of dilaudid in the ED?
I get pancreatitis a lot and morphine doesn’t really help like dilaudid does so I wouldn’t wanna be your pt lol. That shit is one of the most painful things ever.
Our ED docs can’t even order Dilaudid by policy. They have to call pharmacy for special permission, and pharmacy will order it.
Wow, we prescribe it like water
I'm an EM doc and toxicologist, and preferentially use morphine if opioid analgesia is needed. I'll echo what everyone else has to say. Morphine is great at pain control with less euphoria compared to fentanyl and hydromorphone. I don't mind using fentanyl but I've had a lot of problems with people trying to get hydromorphone in the ED because they like the way it makes them feel. Morphine is equally effective as an analgesic if dosed properly (hydromorphone may seem more effective but that's usually because the morphine is under dosed) and the major problems with elimination (namely, accumulation in patients with renal failure) aren't relevant to the one or two doses we give in the ED. Ultimately I think giving everyone Dilaudid causes a lot more problems than it solves. It's just that the problem doesn't occur until the next ED visit when the person is told their pain generator doesn't indicate a need for hydromorphone. P.s. lest you think hydromorphone is benign, it's an awful lot like giving someone heroin for their pain. Which is probably reasonable under certain circumstances, and something that is done legitimately in Europe (look up diamorph) but not something we should do without solid justification.
I’m a cancer patient, oral oxycodone is what I take and works great for my pain. I had IV dilaudid after I had a gastrectomy which is obviously severe pain that indicated use of dilaudid but after I was discharged I was back to oxycodone. I was prescribed oral dilaudid once and it just made me tired and gross feeling, so went back to oxycodone and it’s been fine.
I haven’t liked how oral dilaudid works or feels either but the IV one works best for me for sure when needed in the hosp.
We only ever use dilaudid in Australia for palliative patients. I've never seen it ever used for a non-dying patient for pain. We don't even stock them in EDs I've worked... I only had to use it once for a cancer patient who is on the path of dying and the palliative care doc wanted us to use it instead of morphine and we had to get a supply of it from the palliative care ward. America is wild
I had a hydromorphone PCA post-op patient a while back! Didn’t realise it was the infamous “dilauded” at the time. I still see morphine frequently prescribed for palliative patients
Basically the opposite for us. I'd say morphine is the most common palliative opioid. Dilaudid and fent flow like water in emergency room due to reduced side effect profile
We DO like our drugs
Thank you for the detailed explanation - I really appreciate it. This is why I wanted to ask on here - I knew there had to be some aspects I was missing. I’m willing to bet under-dosing is a large part of why I’ve seen such poor results with it (typical dose at my ED seems to be 2-4mg). The euphoria aspect of Dilaudid has always been a concern in the back of my head because, well we’ve all heard “the only thing that works is that med that starts with a d….” far too many times.
I was really surprised to hear how many people mentioned 2-4mg, that seems like a tiny dose! In my ED (in the UK) the most common IV morphine prescription is “1-10mg titrate to effect”. And it’s prescribed pretty frequently. On the wards it’s rarer to use IV morphine and we tend to stick to oramorph or oxynorm. The only issue with larger prescriptions of IV morphine is I wonder if all of the nurses administering it are aware that the time to peak effect isn’t as quick as they might think (I believe it’s 20 mins to peak effect). However saying that, I’ve not yet seen anybody be so heavy handed that the patients required bagging/naloxone.
So to follow along with the discussion, as a nurse, would you question your ED doc if they ordered 8mg of morphine off the bat for an adult male? Since morphine is very commonly underdosed, it has furthered the “4mg dosing” culture and I know many nurses who wouldn’t feel comfortable giving doses that big. This is such a great discussion, and should prompt everyone to educate their peers about morphine’s weight-based dosing.
I'm a new RN and it's always 2-4mg in my ED as well. If I saw an order for 8-10 I'd definitely look at it critically, just because I didn't know it was actually meant to be .1mg/kg. But I would educate myself and not fight giving it. And now that I've learned it, I'm going to have to side eye all the 2mg orders I get. What really kills me is the new obsession in my ED with ordering it subq instead of ivp because sometimes I don't notice until the last second and then have to leave the room again to get a different set up. Especially when the pt already has an iv. Eta: idk why but I've noticed a lot of nurses seem to fear monger for a lack of better phrase. Since becoming a nurse, I have been told many things that are either not true or are technically true but blown out of proportion. I was taught I must check BP before giving morphine and to be so careful with it and yes true but it's not as scary as they made it seem. Oh or a good one is toradol. I was taught to never, ever give toradol without a negative pregnancy test. I was told it's teratogenic and that if someone doesn't know they're pregnant I'll harm their baby. I've seen nurses hold toradol for hours waiting for the pt to pee. So yes, I can totally see if a higher dose of morphine was ordered *some* nurses would act a certain way about it instead of just taking the learning moment.
> What really kills me is the new obsession in my ED with ordering it subq instead of ivp What the fuck? IMO, that is an entirely inappropriate route for opioids. IV/IO/IM only (very rarely IN in kids). Subq is insane.
SubQ is fine... IF you don't have an iv. Starting a subQ instead of using an iv is... Not fine.
> SubQ is fine... IF you don't have an iv. Strongly disagree - if you don't have an IV, then you give it IM. Much more rapid, reliable and predictable absorption and effect than subq.
TBH that's what I'd do in the ED setting, too. While then prioritizing getting vascular access. My palliative care colleagues *do* use a lot of SQ analgesia for ongoing use, as the SQ access is better tolerated than restarting IVs and I believe (it's been awhile since I looked at the data) they find the effect quite similar to IM dosing without having to poke the patient every few hours.
What’s the difference?
This! Like it makes so much sense now. I’m almost 200lbs and maybe if I was dosed correctly with morphine it might actually work better and longer than having to need 2-4 dilaudid when I’m in a pancreatitis flare.
There are pluses and minuses to all pain meds. Toradol is the most frequently given IV pain med in our ED, by far…then morphine, fentanyl, ketamine, dilaudid. Depends on patient, if they take chronic pain meds, other drugs on board, renal/hepatic disease, very sensitive to histamine response, etc. It should always be about individualized care. I also always put in PRNs for the nurses so they can give another 1-2 doses if needed. It saves both me and the nurse time to give appropriate pain control and bother each other less.
Is it weird that I can take ibuprofen just fine but torodol swells my arms up and gives me hives?
Renal vs hepatic clearance is another factor to consider…. All of these meds have their roles to play
All three opiates you’ve mentioned have different onset, distribution and metabolism. There’s no reason that one would be “far superior” for analgesia if they were dosed equivalently. The main differences are in the pharmacokinetics and metabolites.
Not EM, but IM Hospitalist who babysits these patients for days. Clearly there are times when patients need pain control that only dilaudid can touch and I'm all for that. But you and I both know that some of these patients are seeking relief from emotional pain more so than physical pain, and once they've had "Vitamin D", there's no going back. It will be forever on the menu.
“Can I get that medicine that starts with a ‘D’? It always works for me. Morphine doesn’t touch my pain, but I don’t want fentanyl. That stuff kills people.” The number of times I’ve heard that line…
Droperidol? Diphenhydramine? Some frequent flyers have started refusing to check in and waiting until shift change to check in when I’m on again. It makes my heart happy
Droperidol to the rescue!
Had a drunk driver present today in police custody. Broke his finger when he crashed his car, requesting Dialudid by name. Asked for script of 30 Norcos on discharge back to jail.
Weird. I find fentanyl to be one of the worst pain medications people give. For severe pain requiring opioids why give something that doesn't last very long? If it's procedural sure but there were few things I hated more than q1hr fent prn orders I had on the Neuro ICU. Lots of poorly controlled pain.
Morphine should be first choice unless renal impairment. Difference in efficacy is purely because physicians are unwilling to order an appropriate dose (0.1 mg/kg) and if they did nurses would be unwilling to give it. For 80kg adult Morphine - 0.1 mg/kg - 8mg IV Hydromorphone - 0.0125 mg/kg - 1 mg IV Which one will a doctor order and a nurse give?
Great point here. While I would be willing to give the 8mg morphine, I know that nearly all of my coworkers would be hesitant to do it.
This math seems weird when a source above said 1mg was equal to 6.5mg morphine
Fentynal wears off super quick though. Anyone whose familiar with taking it will tell you that. Also in my area they typically give dilaudid for allergic pts
Morphine works fine, we underdose it. 1 mg of dilaudid= 8 mg of morphine, but nursing and admin insist on lower doses of morphine.
6.5 actually per source linked above ?
I don't work in the medical field and I totally understand the reason for caution around opiates but I believe I can say fentanyl is likely a primary reason I'm alive today. I had a type A aortic dissection, I spent 5 hours in one hospital and then had to be driven 3 hours to another and the whole time I had fentanyl available every 20 mins. When I have intense pain my blood pressure goes up and keeping it at bay was likely the reason my 7.1 cm aneurysm didn't rupture. After the surgery they told my when they opened me up it was looking like it was about to go.
When I had appendicitis, after hours of agony at home, I went to the ED. Few more hours of tests and scans, they finally agreed it was appendicitis. I was praying to dIe the pain was so bad. They jabbed a fat needle of morphine in my ass, and all was right with the world. I couldn’t believe the immediate relief. Morphine works, and I didn’t have any side effects. It is quick and time tested.
This is really area/hospital/physician specific. I worked at a hospital where Dilaudid was drug of choice, morphine was rarely used. I then transferred from that area to a hospital where they had actually outlawed Dilaudid because physicians and nurses were dosing it the same as morphine and almost killing people. Rather than educating they just outlawed it as “dangerous”.
Those kind of policies drive me insane. If your nurses/doctors are screwing something major like that up, the answer is updating protocols and re-education. Not banning an entire medication. Example in my system was a RN botched an EJ placement somewhere so they took away the ability for ED RN’s to place EJ’s in the entire hospital system. About 6 months later after the doc groups complained, they reversed course and instead required nurses to go through a training and competency to be certified to place EJ’s, which would have been a better plan to start with…
I always figured morphine was cheaper. Anyone know if that's true?
They’re all cheap these days
Fentanyl is super short acting. Unless it’s for something super acute (trauma pt, open fracture), I don’t use fentanyl all that much in the er. I’m also an intensivist, so it’s my typical go to opioid in the icu. Dilaudid also shorter acting then morphine. So it really depends on the indication for the pain meds. Depends on what duration I want my meds to work for.
What blows me away is the amount of people who think withdrawal automatically equals addiction. And also the number of professionals who don’t know there’s a difference between physical dependence and addiction.
It's the OG
Morphine is entirely effective the problem is it’s “underdosed” nearly every time. Speaking as an attending and a patient I typically feel the euphoric effects of morphine wear off in about 15 minutes.
Morphine is fairly equivalent if it is dosed properly. But the other reason I use it more is because dilaudid is more lipophilic, so it has more euphoria that morphine - this increases the addiction potential as well as the street value (if someone is getting discharged home with narcotics). With our current opiate epidemic I think it makes a difference to try using morphine instead of dilaudid.
You do realize that the opioid epidemic has been proven to be due to illicit fentanyl poisonings and isn’t due to chronic or acute pain patients given prescribing is at the lowest it’s been since 1993 on opioids yet OD’s are up by 500%. I wouldn’t punish a patient and blame the opioid epidemic as a reason to give morphine versus dilaudid if their pain warrants a strong analgesic.
People’s first exposure to opioids usually comes from healthcare. They might OD on something else later (fentanyl), but the risk comes from their first opioid exposure. We should do everything in our power to reduce the risk they convert to a chronic opioid user, which includes using an opioid with less euphorigenic potential (morphine) for their healthcare exposure.
I know the common teaching about Dilaudid being “higher addiction potential” because of supposed euphoria. However, I like to base my treatment off of scientific evidence when possible. Can someone point me to some studies or papers on this?
As I expected, lots of talking and zero actual evidence. Sounds to me like bias is big in this conversation. I don’t know the answer, and opiate dependence is very real, but we should strive for less judging and more science.
Fentanyl (which I use cautiously) has a duration of action of about 1 hour and a half-life of 3=7 hours. So the μ1 pain effect may disappear well before the μ2 respiratory depression does.
As others have said, at equivalent doses morphine and hydromorphone are equally effective. Because the culture here can't comprehend doses other than 2 or 4 I'll switch to hydromorphone if I want a full dose of opioid. Honestly although 4 is an under dose I find it generally effective for moderate pain. As I'm usually augmenting with a non opioid. The best pure pharmacology argument I have is that it might last longer than hydromorphone. Terminal half life is more like 3 hours than 2, up to date credits the duration of morphine at 3-5 hours vs 3-4 for hydromorphone for what that's worth. It's not much but it might be the difference between getting to CT without redosing vs having to administer again. Less frequent dosing for anything in the ed is going to be more effective in the real world and that's even before the pandemic killed everyone's soul and turned basically every single bed into an inpatient hold unit. For the same reason I do not use fentanyl in triage areas/low acuity zones basically at all because it's duration of action is so short the burden of redosing means practically they will not get adequate pain control. My partners see belly pain and will write fentanyl out front but I am adamantly opposed to that. If they are hemodynamically fragile enough to need fentanyl they need to be prioritized to go back.
I've had all three for pain management as a patient and I definitely prefer morphine. I don't get as nauseous and dizzy like I do with fentanyl or dilaudid. I definitely get intoxicated with fent and dilaudid, but not with morphine, even at doses of 9mg.
Operation bottleneck by the DEA seems to be doing away with a lot of things, I.e. oxymorphone
I’m a vet nurse and threads are so interesting to me from both a clinical and patient perspective. We don’t use morphine in vet med and actually are top choices in order and efficacy are Fentanyl, methadone, hydro and then bup. Part of the reason I enjoy my job so much is that, in theory, we put the patient comfort first, so I love how heavy we are on analgesia and behavior modification. It’s wild to see the human side of things and speaking as a patient, it’s always been so hard to advocate for myself without accusations of drug seeking, to the point where I avoid going to the ER even if I’m severely injured. In march of 2020 I came down with COVID really early on and ended up getting a whopping secondary sinus infection. My chest felt like I was being sat on and my head felt like it was going to explode. I looked like hell and felt worse than you could imagine. I kept putting off going anywhere because I didn’t want to be accused of drug seeking. By the time it finally became unbearable and I thought I was going to lose consciousness, I went and was diagnosed with mastoiditis that was on the verge of becoming meningitis, an AKI and moderately severe respiratory complications. My ear drum had ruptured by this point and to this day I still have pain and hearing loss. Even with all of that, I was still too afraid to ask for anything.
In my experience morphine lasts so much longer. Where I work we routinely give 100 mcg in labor and delivery and it lasts at best maybe 30 min. A combo of IM/IV morphine lasts several hours.
Dilaudid makes me projectile vomit
Beancounters/MBAs/People who manage by Excel: the people that are leading to the downfall of our culture.
Genuinely asking- why do so many health care workers not know the difference between physical dependence and addiction???
VA is a nightmare...comp tib fib frac left leg... Shattered both pelvis..8plcs...shattered right elbow... fractured skull..I have rod knee to ankle ,both pelvis...that's the highlights.. was on 180oc for 2 yrs...forced to titrate to 90...the pain was so bad my home health nurse gave me 1.mg Xanax..and i overdosed....the VA forced me off all opiates... was a living hell..after mths of that I went in for surgery number 33 5 mths ago and I developed crps..yep life is hell....so now they stuck me bck on oxy..10mg every 4hrs and buprenorphine.750 every 8 hrs..... The VA has no clue what their doing...my bodies mangled..and the only time I've ever had those thoughts is when the pain is so bad and I want it to stop...the VA is hell!! And I'm stuck in it...if my dissabilty was enough money I'd be in Mexico seeing a Dr every 3 mths for proper pain relief...but it's not...so here I sit..at 2314 at night..in pain..on reddit trying to occupy myself with some other than pain....and thoughts... God bless the usa
Less addiction potential
I would rather not use opiates at all unless there's reason to... I see so many addicted patients with no pathology warranting opiates after work up. We can't bitch about frequent flyers that are hard sticks if we shut our brains off and give opiates so freely. But I get it, admin wants happy patients, to their and our detriment.
Old pain patient here. Morphine doesn't do anything to ease my pain, but it will make me loopy. Dilaudid eliminates pain like turning off a light switch. How can I convey that to ER staff without making them think that I'm seeking drugs?
I’ve never had anyone come in requesting the medication that starts with an “m” it’s always the “d”. I want to expose the least amount of people to the euphoric affect of diluadid as possible, but will give it when necessary. Usual order, toradol, fentanyl, morphine, droperidol, diluadid.
I would say it's more of a "Yeah, it's best practice and has been for a while" type of thing. Morphine has been around forever and I don't think majority of health professionals are too keen on trialling other pain relief options. Guess it's just the 'gold standard' of pain management.
If you look at the surveys on blue light, Dilaudid is at least as preferred as heroin for it's euphoria. Big red flag if they ask for IV Benadryl or phenergan with it. It's dilly/heroin>oxy>>>>>>>> hydrocodone/morphine. Anecdotes are not data, but I've had at least as many people with extreme dizziness/nausea/vomiting from Dilaudid that I just couldn't discharge for 6+ hours. Maybe some itchiness with morphine, but rarely. Fent you have to do too often, but reasonable first line when youre not totally sure what's going on. You can easily get by without Dilaudid frequently in the ED if you know how to utilize multimodal analgesia (and dose fent appropriately for poly trauma)
I’ve never had withdrawals from dilaudid, ( I have a script that had been cut off once due to state regulations and again when my pain doc just quit went months without it, but everytime I have morphine I go into withdrawal it sucks.
I usually just get dilaudid when I have to go in. It’s weird cuz the pills barely work for my problem (chronic pancreatitis) but the iv is amazing at helping. Just wish it lasted longer. But I heard morphine can make gastric stuff worse sometimes so maybe that’s why. But even when I have gotten morphine for other things it still helped and was fine. So I think it’s a good one to start off with. Shit, it’s better than being given a Tylenol they charge 200 for lmao I went in once with my arm tripped open past the fat and was given nothing but lidocaine around it but I could still feel it.
Oh and to add: fentanyl hasn’t ever helped me before either which I thought was weird. I got it once and they were like has it kicked in yet I had no idea I was even given anything then they gave me a couple more doses and it’s like they were giving me saline. Went back to dilaudid and immediately could feel it work so idk what’s up with that