Dilaudid vs Fentanyl for terminally ill

[VespaVixen]

So as you all may know,
Im young, and dying.....great.
My doctor prescribed me 4mg Dilaudid and they dont do a damn thing. After I had to hound him about the shit because I was so sick I didnt eat for days at a time because I was so damn sick and vomitting.
All Dilaudid does is make me even mkre exhaustes than I already am!
I feel NO difference at all.
He just put me on 8mg, still nothing.
He is suggesting Fentanyl wanta to start me on 50
Im a wreck cuz isnt that the type of stuff once you have a tolerance with it, good luck if you need pain meds later on?
Advice?
Thanks!%)
Ps dont you love how doctors control this shit and even torture those of us that KNOW we are dying and just want to enjoy the time we still have?
Days like this make me hate still being around.

 

[melange]

I am sorry about your predicament.

Have you tried opana?

Fentanyl is one of the drugs of choice for break through pain, and is a typical route a lot of clinicians take.

 

[fryingsquirrel]

How do you do your dilaudid? They suck orally, but snorted, plugged, or especially IV they are much better. I usually wouldn't advise IV to anyone who doesn't already, but for someone who is terminal addiction isn't really a concern.

 

[newtzilla]

i know it's played out advice, but have you tried high-grade cannibas to enhance pain meds and dampen naseau? My positive thoughts are with you now, and I hope you can live pain free for a long time. I know your pain, as in 2005 I was one of those unlucky dudes to be diagnosed with breast cancer. Doctors suck, the entire pharmacutical industry is set up to make the average civilian in to a mark in their big con game, but, most of all, not being well sucks. I hope your pain gets better and if I prayed, you'd be in my prayers. Keep your chin up and keep fightin!

 

[ThizzXTC]

Once you become dependent on opiates, they will never be as effective on you as it will for a non opiate user (it sucks). Fentanyl and Dilaudid are equally as bad, Fetanyl being more powerful and will probably be more effective for your pain. Your Dilaudid isn't working because they are meant to be IV'd (not suggesting, but its a know fact). They are almost pointless in pill form, but yet its extremely powerful when shot up. Dilaudid was a great pain killer when I had back surgery, but the withdrawals were pretty severe. Tapering with high amounts of Hydrocodone wasn't even good enough to keep me comfortable.

I would DEFINITELY try the Fentanyl if you can, but just beware of how powerful it really is (Dilaudid being right there as well when working). Dependency is extremely likely to occur, making opiates less effective over time while the withdrawals make your pain even worse. We're talking about one of the powerful opiates here. Its synthetic, but doesn't matter. Its just as powerful as Heroin and is much more potent. Best of luck and I hope you can get rid of most of that pain!

 

[Deleted member 137730]

You might wanna think about methadone if its for pain, its the most potent pain killing opiate even outdoing fentanyl IMO.

If you want to get high and enjoy your last months or years, i would angle for roxicodone 30mg instant release which is oxycodone or go for opana which is oxymorphone. They are the easiest to get high off of and pretty potent. Hydrocodone would be too weak and plain morphine sucks if it isnt injected. Oxycontin or roxicodone would be my choice. Fentanyl is good for pain but harder to get high off of and more dangerous to get high off of since you have to estimate gel and stuff.

Hell if you dieing, i would just buy heroin.

 

[ThizzXTC]

^ I know where your coming from bben. I'd do the same thing, but not Heroin. You have to think about your family and how they will remember you. You dont want to be remembered as a junkie (no offense to Heroin addicts). Just get the best meds you can and live comfortably. If that means getting high, do it. To be honest, if I was dying and I KNEW I could hide a Heroin addiction, I'd do it, with the occasional white with it (sounds nice). Thats if I was 100% sure I could hide it. Even though Heroin is an opiate just like all the other meds hes taking, most people look down on Heroin, forgetting its medicinal use. Heroin isn't that nasty if it was clean, not cut. But just for its reputation, I'd rather do other opiates.

 

[negrogesic]

For those who are dying or near death I often prescribe duragesic patches, which admittedly, is not the "best", but it is effective and is easy for gravely-ill patients to use (no pills, etc). I also generally write a fast acting oral like oxycodone or morphine sulfate oral suspension, PRN (as needed), which is something physicians dislike writing because they are C-II's (opioids in particular).

On occasion I will prescribe methadone in rather high doses, which often works well at treating severe pain that is resistant to other opioids. Plus, given the state of the patient, methadone generally doesn't cause the same degree of cognitive impairment seen with equianalgesic doses of morphine, hydromorphone, fentanyl etc equianalgesic. If there is a 24-hr nurse involved or inpatient hospice, I sometimes try more exotic opioids if the patient has been catheterized and is wired and plugged in (aka life-support/monitors).

Obviously, the goal is to both effectively treat the pain and keep the patient conscious enough to speak and have some final time with their family/loved ones. And no, the Brompton cocktail would not go over well here in the US, my methods are already rather unorthodox. I have, however, prescribed d-amphetamine to younger terminally ill patients (particularly for some of the painfully slow AID's-related complications--->death).

 

[Deleted member 137730]

For those who are dying or near death I often prescribe duragesic patches, which admittedly, is not the "best", but it is effective and is easy for gravely-ill patients to use (no pills, etc). I also generally write a fast acting oral like oxycodone or morphine sulfate oral suspension, PRN (as needed), which is something physicians dislike writing because they are C-II's (opioids in particular).

On occasion I will prescribe methadone in rather high doses, which often works well at treating severe pain that is resistant to other opioids. Plus, given the state of the patient, methadone generally doesn't cause the same degree of cognitive impairment seen with equianalgesic doses of morphine, hydromorphone, fentanyl etc equianalgesic. If there is a 24-hr nurse involved or inpatient hospice, I sometimes try more exotic opioids if the patient has been catheterized and is wired and plugged in (aka life-support/monitors).

Obviously, the goal is to both effectively treat the pain and keep the patient conscious enough to speak and have some final time with their family/loved ones. And no, the Brompton cocktail would not go over well here in the US, my methods are already rather unorthodox. I have, however, prescribed d-amphetamine to younger terminally ill patients (particularly for some of the painfully slow AID's-related complications--->death).

I take d-amphetamine and opiates legally and im not terminally ill, just bored.

Anyway i find your statement that methadone causes less cognitive issues then straight opiates to be suspicious considering it has strong NMDA antagonist qualities along with SSRI properties and NRI properties. If anything methadone is well known among the opiate using community for making people stupider than normal opiates do lol.


To the other guy, if your dieing i doubt your family is gonna judge you for using heroin, if they do they arnt worth a dam. Just do whatever eases your pain. Personally id go for IR oxycodone since its really the best oral option, while dilauded would be best if your hooked up to a PUMP, which really at end of life you should be.

Or fly to england for palliative care, they allow injectable diamorphine there still at end of life .

 

[Wizzle]

What about a subcutaneous morphine/hydromorphone pump? Or, to decrease peripheral side effects Intrathecal morphine/hydromorphone pump. Correct me if I'm wrong but the dosage is one tenth of IV/. It might feel like overkill but seems like the best end-of-life treatment to me. Best do it before your tolerance skyrockets right?

 

[negrogesic]

I take d-amphetamine and opiates legally and im not terminally ill, just bored.

Anyway i find your statement that methadone causes less cognitive issues then straight opiates to be suspicious considering it has strong NMDA antagonist qualities along with SSRI properties and NRI properties. If anything methadone is well known among the opiate using community for making people stupider than normal opiates do lol.


To the other guy, if your dieing i doubt your family is gonna judge you for using heroin, if they do they arnt worth a dam. Just do whatever eases your pain. Personally id go for IR oxycodone since its really the best oral option, while dilauded would be best if your hooked up to a PUMP, which really at end of life you should be.

Or fly to england for palliative care, they allow injectable diamorphine there still at end of life .

D-methadone is certainly a NMDA-antagonist (non-competitive), but in its racemic form, d,l methadone does NOT have pronounced or debilitating psychotomimetic/dissociative properties. I know this from first-hand experience and clinical observation. While d-methadone does have affinity for the NMDA receptor, it is in uM range, whereas levo-methadone, has strong affinity for the MOR in the low nM range. I have taken massive doses of methadone, and still felt no ketamine/PCP psychotomimetic features. Even with very large doses of methadone, one is more likely to nod off or OD from levo-methadone's MOR affinity well before before you elicit any pronounced dissociative effect from d-methadone. Personally, I find morphine to have more psychotomimetic properties, and high dose fentanyl has a rather eerie, "cold" and "fluorescent" delirium (very hard to describe......but I am referring to ultra high dose fentanyl abuse, with heavy tolerance, not in a clinical setting).

And yes, technically, it is a very slow acting and mild SNRI, but this is generally not clinically significant, even at high doses. Then again, if you want to get "technical", you get into the ultimately irrelevant "affinities" of innumerable compounds (ex. Modafinil must be a DRI because it has some minor affinity for the DAT, or that "if you took a few hundred milligrams of d-methylphenidate, you might get some 5-HT inhibition").

This is an excerpt from some literature regarding palliative oncology:

Methadone presents some advantages over other strong opioid analgesics: (1) its lower cost (eg, 10 to 20 times cheaper than morphine), (2) the low number of daily administrations relative to opioids with short terminal half-life, (3) its potential to control pain that is unresponsive to morphine or other opioids (methadone shows incomplete cross-tolerance with other µ opioid receptor agonist analgesics), and (4) its superiority over other opioids when accumulation of active metabolite causes side effects such as myoclonus, sedation, confusion, nausea, and vomiting.

I did not say that methadone is a first line treatment, but in some cases is extremely effective and well tolerated for patients who have been using opioids for quite some time or poorly tolerate more "traditional" palliatives. Patients who require significant amounts of opioids for a terminal condition of relatively long duration is almost always rotated when it comes to opioid analgesics. Various cancers etc, immunological disorders etc.....

 

[KeepingThingsReal]

So as you all may know,
Im young, and dying.....great.
My doctor prescribed me 4mg Dilaudid and they dont do a damn thing. After I had to hound him about the shit because I was so sick I didnt eat for days at a time because I was so damn sick and vomitting.
All Dilaudid does is make me even mkre exhaustes than I already am!
I feel NO difference at all.
He just put me on 8mg, still nothing.
He is suggesting Fentanyl wanta to start me on 50
Im a wreck cuz isnt that the type of stuff once you have a tolerance with it, good luck if you need pain meds later on?
Advice?
Thanks!%)
Ps dont you love how doctors control this shit and even torture those of us that KNOW we are dying and just want to enjoy the time we still have?
Days like this make me hate still being around.

Sorry for not helping but I just wanted to say I hope you the best. Keep fighting man! Mad props.

 

[dirtyoldman]

fent patches

So as you all may know,
Im young, and dying.....great.
My doctor prescribed me 4mg Dilaudid and they dont do a damn thing. After I had to hound him about the shit because I was so sick I didnt eat for days at a time because I was so damn sick and vomitting.
All Dilaudid does is make me even mkre exhaustes than I already am!
I feel NO difference at all.
He just put me on 8mg, still nothing.
He is suggesting Fentanyl wanta to start me on 50
Im a wreck cuz isnt that the type of stuff once you have a tolerance with it, good luck if you need pain meds later on?
Advice?
Thanks!%)
Ps dont you love how doctors control this shit and even torture those of us that KNOW we are dying and just want to enjoy the time we still have?
Days like this make me hate still being around.

because of the nausea issue fentanyl patches might just be the thing for you.

 

[negrogesic]

Again sounds like methadone's a choice here.......less pro-emetic than fentanyl (especially fentanyl transdermal)......throw in some mirtazapine if it is an issue.

High oral methadone is my gold standard for treatment resistant terminal pain. Legally, a terminal patient in the US does not have a right to "get high", but the right is somewhat implied (so long as its not something like advanced cirrhosis of the liver from alcoholism....not a ton of sympathy there, which is still fucked up....dying is dying regardless of cause or even more absurd "fault").

The only issue with methadone is that patients generally will need to dose 2x a day, whereas the fentanyl patch is easier to use. But again, I find the incidence of nausea, vomiting and sedation to be lower with methadone, in fact, we often see increase in appetite, particularly in concert with mirtazapine or ondansetron.

There was once a near-death cancer patient at a veterans hospital where I did some rotations, who was found smoking base cocaine in his room (the guy was plugged and wired, O2 flowing etc). He was sent to the "county" hospital......a place no one wants to end up (this is where the bottom of the class med-school residents end up, under-staffed, over-worked). I never saw the patient, just heard about the incident. Unfortunate that he got "punished" for this, but I do understand, one should not be smoking base cocaine in a hospital setting, especially with the O2 on and other patients near-by......

 

[Deleted member 137730]

Again sounds like methadone's a choice here.......less pro-emetic than fentanyl (especially fentanyl transdermal)......throw in some mirtazapine if it is an issue.

High oral methadone is my gold standard for treatment resistant terminal pain. Legally, a terminal patient in the US does not have a right to "get high", but the right is somewhat implied (so long as its not something like advanced cirrhosis of the liver from alcoholism....not a ton of sympathy there, which is still fucked up....dying is dying regardless of cause or even more absurd "fault").

The only issue with methadone is that patients generally will need to dose 2x a day, whereas the fentanyl patch is easier to use. But again, I find the incidence of nausea, vomiting and sedation to be lower with methadone, in fact, we often see increase in appetite, particularly in concert with mirtazapine or ondansetron.

There was once a near-death cancer patient at a veterans hospital where I did some rotations, who was found smoking base cocaine in his room (the guy was plugged and wired, O2 flowing etc). He was sent to the "county" hospital......a place no one wants to end up (this is where the bottom of the class med-school residents end up, under-staffed, over-worked). I never saw the patient, just heard about the incident. Unfortunate that he got "punished" for this, but I do understand, one should not be smoking base cocaine in a hospital setting, especially with the O2 on and other patients near-by......

I went into surgery as an opiate addict and told them before it started. I got a high dose MIX of fentanyl and demerol, that was the ultimate pain killing opiate combo. so i bet a mix of opiates would work really well.

 

[OhSeeAT]

Of course a mix of opiates is the best option because your not overly raising the bar too high for one drug in the body. Personally it sounds like having a fast acting opiate like Oxycodone 30mg IR with something longer lasting, like the fentynal patch would be best for pain management, as well as mood elevation. I'm not completely positive that it's 100% clinically safe for this particular case, but it would be my personal reccomendation if I was the patient in NEED.

 

[negrogesic]

Fentanyl is actually rather "safe" at proper doses given its wide therapeutic window. Duragesics are the most common script for terminal illness in my area. On top of this , it is extremely common to write very large scripts of 7.5mg-10mg hydrocodone tablets (it may seem stupid, but there is some logic to it; personally I do not use hydrocodone for such patients). There are some circumstances in which transdermal fentanyl is either ineffective (namely active IV opioid addicts) or is poorly tolerated (emesis, sedation, delirium). In the later stages, oral morphine sulfate suspension is almost always used (non-inpatient setting), given the ease of administration. The downside with oral methadone is also its upside; unique pharmacokinetics. For someone who is in severe pain, methadone oral will simply take too long to take effect. Intravenous methadone essentially solves this problem, but intravenous methadone is almost never prescribed outside of a hospital setting. This is generally due to issues regarding QT interval and respiratory depression.

In terms of "end of life" analgesia (aka, euth.), morphine is still very common. IV methadone is in my opinion a much better agent for this controversial yet prevalent practice. However, in the event of autopsy, lethal doses of methadone are harder to" explain", whereas morphine is very easy. In otherwords, lethal doses of morphine are acceptable, and can be considered accidental, whereas a large dose of methadone suggests someone knew what they were doing, which in the US is technically illegal (rarely prosecuted, but tends to occur when a physician facilitates a patients "right to die" prematurely or without the" implied" consent of the family). Fortunately my work is almost exclusively perioperative, so I only occasionally deal with terminal palliative medicine.

But i admit to being lazy; writting the standard duragesic script and referring them to a pain mgmt specialist.

 

[Smyth]

Take Dilaudid, fents just gets boring after a while, strong high though.

I've taken super-high fent dosage (+10mg) so I know all about this drug.

Withdrawals are complete hell but only after u use it for several months; after a weeks usage it is nonexistant.

 

[melange]

Fentanyl is actually rather "safe" at proper doses given its wide therapeutic window. Duragesics are the most common script for terminal illness in my area. On top of this , it is extremely common to write very large scripts of 7.5mg-10mg hydrocodone tablets (it may seem stupid, but there is some logic to it; personally I do not use hydrocodone for such patients). There are some circumstances in which transdermal fentanyl is either ineffective (namely active IV opioid addicts) or is poorly tolerated (emesis, sedation, delirium). In the later stages, oral morphine sulfate suspension is almost always used (non-inpatient setting), given the ease of administration. The downside with oral methadone is also its upside; unique pharmacokinetics. For someone who is in severe pain, methadone oral will simply take too long to take effect. Intravenous methadone essentially solves this problem, but intravenous methadone is almost never prescribed outside of a hospital setting. This is generally due to issues regarding QT interval and respiratory depression.

In terms of "end of life" analgesia (aka, euth.), morphine is still very common. IV methadone is in my opinion a much better agent for this controversial yet prevalent practice. However, in the event of autopsy, lethal doses of methadone are harder to" explain", whereas morphine is very easy. In otherwords, lethal doses of morphine are acceptable, and can be considered accidental, whereas a large dose of methadone suggests someone knew what they were doing, which in the US is technically illegal (rarely prosecuted, but tends to occur when a physician facilitates a patients "right to die" prematurely or without the" implied" consent of the family). Fortunately my work is almost exclusively perioperative, so I only occasionally deal with terminal palliative medicine.

But i admit to being lazy; writting the standard duragesic script and referring them to a pain mgmt specialist.

I'm your next patient



I kid

 

[nuke]

Not really sure where this goes

OD probably has more experience with clinical opiates