Narcotics pyramid/tier

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!
It's good that you're seeking additional knowledge. However, I'm a little distressed that a nurse with 2 years experience practicing in acute care would make the statement that "2mg morphine = 1mg Dilaudid".Look up an equi-analgesic chart, STAT. Your own hospital's pharmacy can be your first resource.

That would be why the statement "I have been told..." I was trying to give an example of the information format that I am looking for. I thought that it was more than that, but this is the rumor that is going around. I wanted to have some kind of viable chart to educate everyone.

5 mg morphine is equal to 1mg dilaudid. This is what I was told by our ER physician. either way dilaudid is a great pain medication when used correctly. I recently had back surgery and was on a morphine drip. The morphine didn't do anything but make me nauseated and get me high. Once they put me on the dilaudid, my pain was very well managed and I wasn't "high". It was like night and day. The drips are less potent than the IVP. I had an IVP of 2 mg dilaudid before I left and it about put me on the ground. I don't know how people can take 4 mg of dilaudid and 50 of phenergan and still function.

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.

I got ya. We have had conversations recently on my floor about equating this verses that, but what really got me was that I recently had surgery myself and was prescribed percocet. I would take 1 and then in about 20 minutes I would be nauseous, then in about 30 minutes I would itch everywhere and by 45 minutes be out cold! I have had so many pts tell me OMG PERCOCET, might as well give me an aspirin! Now granted, my body is narcotic nieve since I really don't take anything other than ibuprophen.I get you about morphine. During the clean up phase of my C-section I was having a lot of pain from the contractions and the MD noticed. He said here ya go and uped the morphine drip. Well, the pain was still there, but I could not verbalized it at that point. Floating and in pain....not a good combo.

As a general rule, certain narcotics are stronger than others. With myself and people I know, though (personally, not patients), I've seen how much that can vary.For example, Percocet and Dilaudid (oral) are stronger meds. My sis was prescribed both after her recent surgery, and felt that the Dilaudid did nothing (I had the same experience with PO Dilaudid). For her, Morphine IV also does absolutely nothing for pain, but Dilaudid works. Go figure.The best way to look things up, IMO, is with an equi-analgesic chart. This compares specific doses rather than the meds themselves. The other rule of thumb is the schedule of the med.....Percocet is Schedule II, Vicodin is Schedule III, so Percocet is stronger (schedule I is the highest class, and that includes illegal narcotics).

I guess I'm the meanie who is the only one disturbed by the unit of nurses who "discuss" whether 2mg morphine equals 1mg Dilaudid ...Don't know something about a med? Look it up!1mg Dilaudid = 5-7mg of morphine. How does this info affect what you may have been "suggesting" that your physicians order?

There is a ton of information out therehttp://www.globalrph.com/narcotic.htmhttp://www.globalrph.com/narcoticonv.htm http://www2.massgeneral.org/painreli...esic_table.pdfhttp://www.mywhatever.com/cifwriter/...fact/ff36.htmlhttp://endoflife.stanford.edu/M11_pa...ncy_table.htmlhttp://ocw.tufts.edu/data/41/530635.pdfhttp://www.ganfyd.org/index.php?title=Analgesic_ladderI hope this helps....

Esme 12, thank you! This is exactly what I was looking for. I knew someone out there had to have this information at hand. I started looking but everything I found was not exactly right.

Quote from TonyaM73Esme 12, thank you! This is exactly what I was looking for. I knew someone out there had to have this information at hand. I started looking but everything I found was not exactly right.

As far as oral medications go (IMHO, been in pain management for 3+ years so I've been through the ringer as far as opiates go-trial and error) oral dilaudid and oral morphine have a terrible bioavailability, where as IV morphine and IV dilaudid work well(I and my patients find IV or PCA dilaudid more effective than IV or PCA morphine). Oral oxycodone(without the APAP) has a MUCH better bioavailablity than both oral morphine and dilaudid (for the patients with tolerance). For the opiate naive percocet seems to be the favorite as far as pain relief goes. Now we can go into extended release medications but their are just too many to discuss. And as a few others say 1mg of IVP dilaudid is equal to about 6mgs IVP morphine. Also I had a fentanyl PCA after a surgery(also had a dilaudid PCA after a different surgery and I loved it) and it really didn't help me with the pain...it just made me sleepy. Also with the PCA's it makes a BIG difference when I had it and to my patients if their is a basal rate and bolus as opposed to just the bolus rate. If you fall asleep with no basal rate and wake up then you have to try to get back on track with the bolus rate, which is why where I work we always have the bolus and basal on the PCA'sI was prescribed a fentanyl TDP for a while and it was wonderful...and that's all I am going to say about extended release forms of medications.

Quote from brownbookI 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.