Differences in pain medication

puggy232 · Jul 18, 2008

I would always cringe seeing the order of dilaudid-these pts tend to take twice as long to be discharged, regardless of having better assessments,rom and intake of food-pain is always at a ten.

OC_An Khe · Jul 18, 2008

Speed of onset and duration are also critical factors in which type of pain medication is most efficacious for a particular situation. Also there are many different types of opiate receptors in the body and each patient will have a different distribution of these receptors. This explains why some drugs work better then others on a particular patient.

Tweety, BSN, RN · Jul 18, 2008

Vicodin works better for pain on me personally than Percocet go figure.

My patients are loving Dilaudid over Morphine these days.

Sometimes I think there's a little placebo effect when one pain medication doesn't work and you switch.

I work with a lot of ortho patients and pain control is indeed a challenge.

sharona97, BSN, RN · Jul 18, 2008

ocankhe said:
Speed of onset and duration are also critical factors in which type of pain medication is most efficacious for a particular situation. Also there are many different types of opiate receptors in the body and each patient will have a different distribution of these receptors. This explains why some drugs work better then others on a particular patient.

My father-in-law just had a LTK replacement. This guy doesn't even uses Tylenol. He is narcotic naive for sure. He received 2 percocet 8 hours apart. Nurses found him confused, pulling on the Foley and gave IV Ativan. The next morning found him unresponsive and called the rapid response team. We had a family conference and decided with the Doc Tylenol should work. They sent him home on Vicoden and he went goofy again. Scary.

al7139, ASN, RN · Jul 18, 2008

Heres my humble opinion:

Pain meds vary based on the pt, their history and their current problem, and tolerance to pain and meds.

The most common pain meds in hospital use that would be the strongest are probably fentanyl given IV which is usually only used as an adjunct to anesthetic induction prior to surgery, or immediately after surgery in recovery. The onset is almost immediate, but doesn't last more than 1 hour. The fentanyl patches have an onset of 6 hours, with peak at 12-24 hrs, and last 72 hours. If you are putting a patch on someone for the first time, they will not start getting relief for about 6 hours, so it is important to assess them, and give additional pain meds while you wait for the patch to start working (after the first patch, when you change it, there is a residual effect so the onset/peak shortens). You may be giving IV morphine, PO oxy, etc, until the patch takes effect (don't be alarmed, if your pt is alert to their baseline, it's OK). After Fentanyl, a not so common drug:Methadone. Most people know it as the drug that Heroin addicts use to kick their habit, but it was originally developed as a pain drug (as were opioids...Pain control in the 1700's to 1800's? Laudanum was a derivative of opium (brought to Europe from Asia), and put into use by healers for its pain and anesthetic qualities (although if you weren't rich you couldn't afford it). Heroin is made from opium plants, and in the 20th century Methadone was synthesized and is similar in compound to morphine, and it has a longer duration of action and most effective given PO. Lots of MDs are using it for chronic debilitating pain issues, and is usually prescribed by a pain clinic (not every methadone taker is a previous heroin addict!!!! Do not judge your pt on the drugs he takes for pain). I have had pts who take it and see its efficacy in their ability to function pain free without the side effects of some other narcs (it is very carefully prescribed as it can be habit forming for some people, but those I know who are taking it strictly for pain are not what I would call addicted, they are dependent on it for their overall ability to function pain free).

After these, I would say Oxycontin PO with an onset of 15-30minutes, but short 4-6hr duration, Rarely prescribed in hospital unless pt already taking it for chronic pain, or if ongoing pain is predicted on discharge (referred to pain clinic to monitor need/dose, etc.) I hate this drug, because it is so highly addictive, and pts may not realize the serious nature of this drug. Long term use can develop a tolerance to it, and in those people with addictive personalities it can lead to abuse and overdose without monitoring and education.

Next is Dilaudid followed by Morphine. 1mg of Dilaudid=7mg of morphine.

These are very common in hospitals and we have strict protocols to follow for giving them IV push, and via PCA pump. If a pt needs a PCA pump, they are one of these drugs. Which they get depends on age, past meds, present problem, past med history, and personal tolerance to pain. For example, a younger guy (47) with no significant health problems who has bilateral ankle fractures from an accident requiring extensive surgery/rehab will get a dilaudid PCA, with instruction to the pt on how to use it, and we also educate the family that the pt is the ONLY person able to push the button. He is A&O, and can demonstrate how to use the button, and state how often he will get a dose (6-10min depending on order).

An older pt who had a TKR or THR will still get a PCA, but with morphine, and the same instruction on proper use of the pump.

Both patients (ANY pt!) will also have an order for PRN Narcan in case of over sedation, and will usually have the button restricted until pt is fully aware again (per MD orders). The dose may be changed or the timing may be changed. As a side note: If your pt is appearing oversedated, and there is family present, don't be afraid to question if any of them pushed the button for the patient. Don't be judgemental, but I have seen it several times where "Granny" was asleep so we pushed the button for her, and now she won't wake up. I try to kindly let the family know that the button is for patient use only, and if the pt is sleeping, they do not need pain meds, but will wake up if they start hurting, and need to get a dose. They get the hint when I cannot rouse "Granny" and call the doc with "semi-comatose" resp rate 6, sats 91%, and not following commands.Orders for Narcan received and given, at which point the pt wakes up in pain, and we have to explain to her why we cannot let her push her pain button until she is stable and alert...Meanwhile the pt suffers, it takes longer to get pain under control again, and if her family fesses up to her (we don't accuse, just say she was overly sedated, although before she wakes up we tell the family why she is this way) she's mad at all of them. Not fun. Also in addition to PCA or PO narc orders the pt may be prescribed a good NSAID such as Toradol to work on the inflammation associated with bone surgeries. It may be scheduled (if your Doc is with -it, or it could be prescribed PRN, in which case I highly recommend giving it in conjunction with PCA therapy, since often pain is from the inflammation associated from the injury or surgery. Narcs have very little if any antiinflammatory effect. Reduce the inflammation, reduce the pressure on the nerves, the pt will need less narcos.

The previous was for severe pain. After this you have your typical PO's: Percocet, Vicodin, etc. More for moderate pain, and the compound gives the antiinflammatory effect as well.

The odd thing is that I have seen situatiuons where pts on morphine with no relief are switched to po percs, and get better relief (could it be the NSAID in the compound?

In short:

Tolerance varies from pt to pt. A pt with chronic pain needs much more than the average person to keep them in an acceptable pain range.

Orthopedic problems (fractures, joint replcements, spinal surgeries, etc.) are by far the most painful to experience. Believe it or not bone HURTS, and gets inflamed, and affects surrounding tissue. The healing process is long and hard with rehab and no guarantee the pain will go completely away. The pt may need pain meds to function normally even after therapy is complete.

Pain rating is subjective data based on the individual person. What may be a 3 out of 10 for you could be a 9 out of 10 for your patient, so do not judge them based on your personal pain rating.

Advocate for your pt. They may need a different pain med, or an additional antianxiety med prescribed to help them. I have found that "strong pain meds" are not always needed even for pts complaining of severe pain. Everyone is different. You need to observe them, and know what is and is not working.

Amy

GrumpyRN63, ADN, RN · Jul 18, 2008

sharona97 said:
My father-in-law just had a LTK replacement. This guy doesn't even uses Tylenol. He is narcotic naive for sure. He received 2 percocet 8 hours apart. Nurses found him confused, pulling on the Foley and gave IV Ativan. The next morning found him unresponsive and called the rapid response team. We had a family conference and decided with the Doc Tylenol should work. They sent him home on Vicoden and he went goofy again. Scary.

What a lightweight!!! JUST KIDDING :nuke: !! Actually you bring up a valid point, age is a significant factor when dosing and administering, actually the older you get the less need/requirement for pain meds as the elderly have less active pain receptors and as you find out may only need tylenol or sometimes have no pain after surgery, while generally those in their 30's tend to require the most

GrumpyRN63, ADN, RN · Jul 18, 2008

jessi1106 said:
Hmmm....Our facility says that 1 mg Dilaudid =7-10 mg of Morphine. Wonder which is true?

Our facility uses a 1:6 equianalgeisic conversion

sharona97, BSN, RN · Jul 18, 2008

Amy great post. Concerning Methadone use in a heroin addict, do they ever get off the methadone? The addiction started from po meds after a motorcycle accident and continued chronic pain. Just curious about the effects of methadone in a heroin addict going clean. Thanks.

sharona97, BSN, RN · Jul 18, 2008

GrumpyRN63 said:
What a lightweight!!! JUST KIDDING :nuke: !! Actually you bring up a valid point, age is a significant factor when dosing and administering, actually the older you get the less need/requirement for pain meds as the elderly have less active pain receptors and as you find out may only need tylenol or sometimes have no pain after surgery, while generally those in their 30's tend to require the most

My father-in-law is 86 and pretty witty otherwise. What a scare he gave us!

heaverboo · Jul 18, 2008

Wow, thanks everyone for their input! We don't see a lot of fentanyl being used on our floor. There's a few every now and then that are use to being on the fentanyl patches. I had a patient yesterday that has a history of chronic pain and use to taking 8 mg dilaudid PO every 3 hrs PRN, who also takes 30 mg morphine scheduled (can't remember how often), who also has a 75 mcg fentanyl patch!

We also see mepergan fortis being used at times, but usally knocks them out..thanks to the phenergan part of it. Which on the right patient using it can be a good thing.

On our elderly patients I usually do use the tylenol because of the confusion, like some other post who spoke about her father after taking percocet. I'm very cautious about giving these medications, I'd like to keep my license and also most importantly keep my patient breathing!

Thanks again!!!

SweetTeaRN, BSN, RN · Jul 18, 2008

earle58 said:
all are opiate agonists and schedule II substances.
dilaudid, morphine, demerol, fentanyl all indicated for severe, visceral pain.
oxycodone, hydrocodone indicated for mod-severe.
dr's preferences are going to depend on metabolism, distribution, duration, adverse effects and type of pain (skeletal, somatic, visceral, neuro...)
when pts ask these questions, they usually want to know differences r/t strength, duration.
leslie

I totally agree with the prescriber preference and individual factors such as metabolism, age of person, type of pain, whether they are opioid-naive, etc. In the ER, I find myself giving a lot of Dilaudid and morphine IV, and mostly Percocet PO (although sometimes Vicodin.) I have never given Demerol or Fentanyl in our ER. Hydrocodone is considered a weak opioid, it is actually usually a Schedule III drug (unless it is not combined with APAP or there is >15mg hydrocodone per tab I think). I always remember this because I used to be a pharmacy tech and the Vicodin, Norco, Lortab, etc. was on the regular shelves and the techs processed the orders for these, but Percocet was in the locked safe and only the pharmacist could access it (that's how I keep the two straight).

leslie :-D · Jul 18, 2008

You're right, sweet tea.

Hydrocodone alone, is schedule II.

Hydrocodone/acetaminophen, schedule III.