What is up with all the Dilaudid?

Editorial Team / Admin · Apr 20, 2012

Right now it could be an issue with the supply of morphine. We currently are pushing fentanyl and dilaudid instead of morphine for pain (prn, pca, pretty much everything) because we have a critical shortage of morphine with no anticipated date of getting some from the supplier.

Esme12, ASN, BSN, RN · Apr 20, 2012

Depending on the area of the country you work may depend on the popularity of a certain drug. I do know Dilaudid has become a very effective and popular drug of choice for relief of pain.

It is believed that Hydromorphone displays superior solubility and speed of onset, a less troublesome side effect profile. It is thought to be 4-6 times stronger than morphine, but with a lower risk of dependency. Hydromorphone is, therefore, preferred over morphine in many areas ranging from the ongoing treatment of chronic pain syndromes, the emergency department to the operating room.

Hydromorphone lacks the toxic metabolites (e.g., norpethidine) of many opioids related to pethidine and some of the methadone and tends to cause less nausea than morphine. It is a common alternative for those tending to have hallucinations from fentanyl administered through dermal patches and other dosage forms. In addition to the above, hydromorphone usually proves to be the best alternative of choice to morphine and fentanyl in severe chronic pain, especially for severe breakthrough pain.

http://www.uptodate.com/contents/management-of-postoperative-pain

rgroyer1RNBSN, BSN, RN · Apr 20, 2012

Well I work n st.louis and I know we are in short supply of ms, but what I mean is that it seems like patients with minute complaints are getting it to, like no one can stand a little pain and tylenol, hey I am up for treating pain and all but this is rediculous, I guess everyone thinks they need to walk around high all day I dont know, I just know I have been an er nurse for awhile and have never given out this much dilaudid before, like the other day I had this migraine specifacally request 6 mg of dilaudid, toradol, and 25 mgs of phenergan. Which of course somehow managed to talk the md into it. I mean come on, my jaw just about fell off when he threw her er mar in front of me.Rod Rn

Medic7714 · Apr 21, 2012

I see this as a good thing. Pain is easily and safely treatable and has many benefits to doing so. Maybe what you're seeing is finally a trend where we no longer view opiates as taboo medications and are treating pain the way we should be. Narcotics are actually pretty safe in a controlled environment given by healthcare providers.

People are also more educated overall about their care and medications. Back in the day people just took the doctors word for it and assumed the doctor knew best. I think that mentality has shifted and people are taking more control over their health and how they are treated. Maybe the patient who was specific with the request for Dilauded, Torodol, and Phenergan, had this combination for a past migraine and it worked really well. A drug seeker isn't going to be asking for Torodol. Simple logic leads one to request the same thing that worked before. I don't think it's fair to perceive this request as irresponsible or drug seeking.

The major downfall of healthcare providers both in and out-of-hospital is judging a patients pain experience. We all know pain is subjective and it needs to be addressed. You have no idea how many critical patient's I receive from an ED who are minimally treated for pain or not at all. The majority of post-intubated patients I receive have received NOTHING for pain. The nurses around my area seem to have forgotten that propofol and benzos do nothing for pain. Hyperalgesia and allodynia seem to go out the window too.

Why should a human being have to suffer in pain at any level in a hospital or pre-hospital when being care for by EMS?

rgroyer1RNBSN, BSN, RN · Apr 21, 2012

Well I dont have any problems medicating people for pain heck I have had some major abd. surgeries myself and believe me I wanted my pain meds it just seems to me though that we have been giving really huge doses, and not to mention the headache pt. sat right in front of me after I medicated her, half knocked out eating her doritos and drinking her coke that her pain is still a 10, come on.

noyesno, MSN, APRN, NP · Apr 21, 2012

Customer service.

rgroyer1RNBSN, BSN, RN · Apr 21, 2012

And I forgot the toothache guy that my sis who is on nights said he came in at 4 am and recieved 2mg of dilaudid im, I said your kidding right, and I will be da$&ed she wasnt.

Medic7714 · Apr 21, 2012

I do agree sometimes indiscretions occur but overall I feel that pain should be aggressively treated. My favorite equation is 2mg morphine + severe pain = severe pain. As someone else said, customer service. What better way to get good feedback scores from your patients haha.

srobb11 · Apr 22, 2012

Customer service.

Exactly.

brainkandy87 · Apr 22, 2012

It all depends on the doc where I work. Half prefer morphine, half Dilaudid. Honestly, I'd rather give Dilaudid than morphine to an adult.

VICEDRN, BSN, RN · Apr 22, 2012

The two ERs I have worked in aggressively use Morphine as opposed to Dilaudid and this is my preference. I think I would have a difficult time working in an ER that aggressively uses Dilaudid. I have yet to see a seeker request Morphine but they all seem to want Dilaudid (though Esme seems to have looked into the topic and I plan to follow suit as what she/he says is intriguing). On top of that, patients generally seem to itch more with dialudid (and the seekers will request benadryl and phenergan as well) and can generally find tolerable pain relief with less medication that I think we generally think they can.

As for morphine (and in response to 2mg +severe pain=severe pain that Medic brought up), morphine is often underprescribed. Morphine is meant to be dosed: 0.1 mg/kg. 2mg is a dose for a pediatric patient. On the other hand, I find doses 6mg and over require the additional administration of zofran as patients get nauseaus.

Finally, I think we need to move away from narcotics generally as they have been shown to aggravate many conditions rather than improve them (ie kidney stones, migraines, abdominal pain, etc.) and treat a symptom not a problem. (I can NOT tell you how many dental pain patients simply return to our er for...a refill of vicodin having done nothing about their underlying tooth. We have stopped giving scripts for narcotics for dental pain as a result.)