[circa9870]

I have notices a lot of people asking questions about which drug is stonger than which with pain medicines, but I have seen very few people respond correctly (not just on this forum, every forum that mentions chronic pain or medications). Almost always do people respond with an answer explaining which opioids are more POTENT than others, potentency does not necessarilly reflect that medications strength. For example hydrocodone is more potent than demerol (5mgs of hydrocodone equals something like 20mgs of demerol), but there is no question that demerol is the stronger of the two (that is it has more potential to fight pain and at the equianalgesic doses ussually does so more effectively than hydrocodone).

Normally however the case is not so cut and dry, it ussually depends on each individual patients response the equianalgesic doses of each medicine, the doses have to be proportional to make a proper comparison though. Say one med is 10 times stronger than the other, you would use 1mg of the first and 10mg of the second, those doses are equianalgesic. Take morphine and fentanyl. fentanyl is many times more potent than morpine, but not neccessarily stronger. Some patients respond better to morphine, some to fentanyl.

So when saying which medication is stronger it is best to do so by its subjective effects, not by its potency. This will ussually be alot more accurate and true to which med is more powerful and has more pain fighting ability.

I hope everybody has a great, pain-free day,
Circa

[Cats Meow]

Potentency does reflect the medications strength, but cross tolerance should be factored in, the drugs published strength is the only way one can compare drug vs. drug without an actual clinical trial on an individual basis. What you suggest is impractical, and only a small percentage of time will a weaker opioid be more effective. How would you suggest a subjective answer to a post on this topic (besides a disclaimer)?

When a drug like Fentanyl is 50-100 times strong then Morphine it is "necessarily stronger", there's no way around it. I understand people have their preference, but I see no reasonable way to convey information other then to use the opioid comparison charts or narcotic calculators, there's no other accurate way to do it.

[circa9870]

You are still talking about potency. Fentanyl is 50-100 more potent than morphine. It doesnt work 50-100 better than morphine at equianalgesic doses (doses that are calculated using those charts you mentioned) . What I mean by stronger is what has more potential to kill pain and create other subjective effects. You realise that demerol is less potent than hydrocodone. But is certainly stronger. Most other cases are more individualized. Most people would say that Oxymorphone, Hydromorphone, and Diamorphine (Heroin) are all 'stronger' or at least as strong as fentanyl, despite be much less potent. Strength is mostly subjective, however, most people share the same opinion, though there are always some who break the mold.

Now is my point more clear. Strength and potency are independent of eachother. Potency is more like a chemical property, and strength is more like the subjective view that people have of the chemical's effects.

And the way to go about determining which opioid is best for each patient is simple. If one is not effective enough (strong enough), try another until you find one that the patient prefers. As for the problem of classifying them by 'strength' it is difficult becasue it is very subjective, becasue pain is subjective, and becasue drugs affect everyone differently. I think I would put into just a few categories. Weak opioids-codien, tramadol anything along those lines. Medium-Hydrocodone, Oxycodone (on the verge of strong),demerol, etc. Strong-Hydromorphone, Oxymorphone, Morphine, Levorphanol, Diamorphine, Fentanyl etc

Also do not think I am saying that potency is not important imformation to take into account. If you look at all of what I have said you will see I am always talking about finding the equianalgesic doses, and the only way you can do that is by knowing the potency of each medication. So of course potency is also a very important thing to know. I am just saying that it is not the same as strength.

[SiestaKeys]

Thank you for your vast knowledge. If people only took the time to research the meds they put into themselves, people like us would not need to explain everything all the time.
Not to be argumentative, but the category of "Strong" pain meds is a little off. You classify hydromorphone and oxymorphone as strong and oxycodone as mid-strength. Yes, oxymorphone is given in doses less than 10mg but that is because it is what the liver metabolizes oxycodone into; hydromorphone & oxymorphone are Rx'd to people with liver problems so they are more potent.
With Fentanyl, I always classified it at the top of strength due partly to why it is mainly Rx'd for cancer patients. Therefore, I have never asked my doctor about it(instead of hydrocodone). I dont like oxycodone at all and morphine does nothing at moderate doses. Moreover, is there any stigma attached to Fentanyl like oxy & hydro?

[circa9870]

Ya you are right about the oxy, I was going to correct that, but there is no edit here. I would really say it is mid-strong only because it is in so many formulations. The problem is it does not have the same kind of strength as the other meds in the Strong category, yet it is much stronger than the ones in the Medium category. So I was going to actually put it iin both and say that weaker forumulations like percocet would be in the medium category while ones like Oxycontin and the high dose Roxicodone would be in the Strong category. I would also include Methadone and Levorphanol in the strong category certainly, there are countless strong opioids that are rarely used also, or that or only used in Europe, like Ketobemidone (this one is possibly the strongest opioid of all in terms of treating pain, for some reason we dont use it in the US, they use in Eastern Europe mainly apparently from what I have read). You are right about oxymorphone being a metabolite of oxycodone, however it is not a primary metabolite and therefore it only contributes a moderate amount of oxycodones analgesic affect. Same with hydrocodone and hydromorphone. I read a study that showed how the liver metabolized them both, it was pretty interesting. I hope I cleared some things up.

For the stigma attatched to fentanyl, I dont think that your AVERAGE joe knows what it is. Among more educated people who do it probably has the same stigma as any other pain med (the 'hes a drug addict' stigma), I certainly do not think it would be anything like Oxycodone (Oxycontin in particular) or especially Methadone. As for fentanyl being at the top, when you get to things like Oxymorphone, Hydromorphone, Diamorphine, and Fentanyl, I think that the difference really lies with the patient and they are all just about equally strong. However take this into account, in England doctors apparently usually use Diamorphine (heroin) for the most severe types of pain (unresponsive cancer pain, end stage terminal cancers, people with high tolerances etc.). Really though I think it depends on the patient, usually they are all capable of providing a tremendous amount of analgesia, it just depends on which one the patient tolerates best, which is why they use Diamorphine for the worst in England, it causes less side effects than the others when people are on very high doses of pain meds. It is absolutely ridiculous and a tragedy that it is not available for medical use in the US, it is simply due to a stigma that ignorant people have about it being so addictive (even though many addicts openly say they prefer Oxymorphone, Levorphanol, or Hyrdomorphone to get high, they just are not very available, and all of these are legal), and like not having it available for prescription and denying pain patients relief has made it unavailable in the US. I could go out and buy heroin in any city in the US easily, it is readily available anywhere. It just makes me angry, Pain patients are a causality of the failed drug war. Anyway moving on...

Yes you are also right. Almost every question on this website would take less than 5 min of research for people to find out on their own. I really dont understand how people can take meds without knowing ANYTHING about them, I mean the questions indicate that they did not even read the pamphlet that came with the prescription at the pharmacy. It just boggles the mind. I hope that more people can educate themselves about these kind of things, the same thing goes for recreational drugs. People need to research the recreational drugs they take, what doses to take, what they interact with, and what the possible consequences of them are so that there would be less accidental overdoses and mistakes that lead to problems. I think that most overdoses are due to ignorance, if someone had done a little reading, they would know they couldnt take 10 valiums, 8 klonopins, and shoot their herion up and still be safe unless they have an absolutely tremdous tolerance. This kind of drug education would save lives and it should be done, its the same situation as the Sex-ed debate, everyone knows that education would lead to better choices and less bad consequences but the puritanical conservative Christians want to force everyone to stick to the failed 'Just Say No!' mantra, but I am a little off topic.

I hope that everybody has a pain-free and great day,
Circa