Narcotics pyramid/tier

[TonyaM73]

We have been having a lot of discussion about the levels of narcotics that are prescribed to pts and am wondering if anyone has any sites of information about some kind of narcotic pyramid/tier. I have been told that 2mg of Morphine iv is equal to 1mg of Dilaudid, but what about the other types of narcotics out there. Say you would start off with tylenol, but the pain is out of control, where would your next step be. This discussion is for any kind of pain, not just post op. Obviously with post op we would be giving iv dilaudid or morphine, but then how would you progress down?

A little background here. I work med/surg and so we get everything and anything from pre-op, post-op, GI, strokes and other neurological problems, cardiac, DVT, PNA, and should I even mention...lots and lots of generalized abdominal pain w/o clinical evidence. We have a lot of MDs that you can suggest things to and they will take it into account or just plain say "write for it".

Thanks guys!

[~Mi Vida Loca~RN, ASN, RN]

I am no pain, narcotic, expert. I know from first hand knowledge every patient is different. I have given patients repeated amounts of morphine, they seriously ask me if I am giving them salt water, then I switch to one dose of fentanyl and they finally get relief. But you could replace the name of any drug of your choice for the examples I gave.

I read once that our chemical receptor sites are (of course) genetically based. Some patients don't have any, or as many, chemical receptor sites for commonly used narcotics as others.

This is a very important statement right here.

People vary and their tolerance to medications will vary. If a patient is saying Vicodin does not help their pain at all, listen to them. Because if we started with tylenol, then with vicodin, then with percocet; this patient is going to be going without pain relief while waiting to see if "this works" or "that works" and will also be pushing the tylenol limits.

With IV push meds were they don't last as long I could see starting at the smaller range but again, listen to the patients. Sure some patients are drug seekers and the only thing they can have is 4mg of Dilaudid and Phenergan and Benadryl for itching and so on. But I think this would be the minority and not the majority of people so I would ask them first what has worked well for them in the past and what hasn't worked.

Now if they have never had pain medication and aren't sure what works then I would start with some Norco and go from there.

Or if you have IVP and a range I would start at the lowest range and go from there.

[~Mi Vida Loca~RN, ASN, RN]

Also a pet peeve of mine, if your patient is on a PCA and you are switching to Orals, Do not take away the PCA as soon as you give the Orals. It takes the PO on average 30-45 mins to kick in. I have seen many nurses take away the PCA and then give the oral and then the patient has to deal with the pain until the orals kick in.

[KaksRN]

There is a ton of information out there

http://www.globalrph.com/narcotic.htm

http://www.globalrph.com/narcoticonv.htm

http://www2.massgeneral.org/painrelief/PCS_Pain_Files/App_J_Equianalgesic_table.pdf

http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff36.html

http://endoflife.stanford.edu/M11_pain_control/equivalency_table.html

http://ocw.tufts.edu/data/41/530635.pdf

http://www.ganfyd.org/index.php?title=Analgesic_ladder

I hope this helps....

THANK YOU!

[Skip219, BSN, RN]

I have had the opportunity to be a patient and medicate many

pts for pain. Demerol and morphine are old drugs which have many side effects. Demerol can accumulate in dialysis pts and cause seizures. Morphine has very slow onset and long half life. It has a metabolite which is stronger than morphine and bad choice for elderly and dialysis pts. Fentanyl and dilaudid are effective for mod to severe pain without n/v.

[cherrybreeze, ADN, RN]

This is a very important statement right here.

People vary and their tolerance to medications will vary. If a patient is saying Vicodin does not help their pain at all, listen to them. Because if we started with tylenol, then with vicodin, then with percocet; this patient is going to be going without pain relief while waiting to see if "this works" or "that works" and will also be pushing the tylenol limits.

With IV push meds were they don't last as long I could see starting at the smaller range but again, listen to the patients. Sure some patients are drug seekers and the only thing they can have is 4mg of Dilaudid and Phenergan and Benadryl for itching and so on. But I think this would be the minority and not the majority of people so I would ask them first what has worked well for them in the past and what hasn't worked.

Now if they have never had pain medication and aren't sure what works then I would start with some Norco and go from there.

Or if you have IVP and a range I would start at the lowest range and go from there.

This is true; reminded me of something else (again with my sis): she had surgery a few years back for a kidney stone, had a stent placed. She had MAJOR issues with pain afterwards (turns out the stent was likely not sitting right in the ureter, that was what the nurse commented that pulled it out....I felt so bad that she was in such pain for DAYS due to this, and the uro was a real jackwagon, but anyway....). She was given just a TON of pain medication post op, to try to control this pain, and nothing was helping. I believe they started with IV morphine, she also got Toradol, Valium, some oral meds (T3's, I think), a B&O supp....on and on. Her resps were way down, even, it was scary....I kept shaking her to keep her awake and breathing regularly!! Despite ALL of that, she was in a ton of pain. I got them to finally get an order for IV Dilaudid (a starter dose, then a PCA for overnight). That did the trick! People (as in doctors and nurses) tend to think that if a patient says, "x med doesn't work for me, but y med does") that they are seeking, but that's just not the case. When sis went in for this last surgery a couple of weeks ago, I mentioned it to the doc beforehand that IV morphine didn't work, and could she have Dilaudid instead? (She was being admitted to the floor for several hours for pain control, until the surgeon was done with some other cases.) She was grateful, since she was very upset and anxious and didn't think about it. I figured, easier to ask ahead of time than have to call the doc back later in case he ordered the morphine first, which is generally the default order in my region. She certainly isn't any kind of addict/seeker/whatever, we just know from experience that giving her morphine is like giving her saline.