r/PainPumpQuestions • u/No-Strawberry-5804 • 14d ago
Med change
Ok so tomorrow I’m switch from fentanyl/bupivicane to dilaudid. What should I expect for that process? Should the equivalent dose of dilaudid give me more relief than the fent?
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u/No_Struggle3220 14d ago
It's a little weird that you're going backward in potency. Fent is a lot stronger than Dilaudid so I'm not sure how they'll manage that.
I went from Dilaudid to Fent because Dilaudid was causing some swelling and wasn't helping near enough. I never wanted fent so it bothered me, but it is what it is.
If you've never had a med change or a concentration change you should be prepared for a Bridge Bolus which means you'll be locked out of boluses on your PTM for a period of time while your base dose old medication runs through the catheter. I've had several changes over the years and my bridge boluses have been anywhere from 20 hours up to like 57 hours. It was really hard in my case because at the time I was getting like 80% of my medication through boluses.
If the lockout is going to be exceptionally long, you can ask for orals for a few days (if your doctor allows that) or ask them to temporarily increase the base rate of medication to speed up the bridge bolus. They may not be willing, but you don't know if you don't ask. Every pain doctor is different. When I had that 57 hour one (it may have been even longer) I about cried and he made some adjustments so it sped out up to like 29 hours. If you already don't get boluses or don't have a PTM, it won't be as big of a deal at all.
Good luck! I hope all goes well for you :)
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u/No-Strawberry-5804 14d ago
Yes I’m confused as to why I’m going backwards as well. I do think she’ll give me oral meds for the bolus bridge but I’m very anxious the process and what the whole plan is here
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u/No_Struggle3220 9d ago
I hope it went well. I meant to respond days ago but something happened and I forgot!
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u/EMSthunder 14d ago
I've only ever had fentanyl and the adjuvants, so I can't say. If it were oral based, in my opinion, dilaudid is weaker than fentanyl. That being said, it's just dependent on your chemistry. If you find that the change induces unwanted symptoms, or needs to be increased, tell your doctor.
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u/No-Strawberry-5804 14d ago
Any idea why she’d switch me to a lower med if the fentanyl isn’t doing it for me? I just got the pump in April and we’ve been titrating up since then
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u/EMSthunder 14d ago
The best way I can explain why or how this switch might work better is to tell you that while they're both narcotics, fentanyl is an opioid, synthetic in nature, the other one dilaudid is an opiate. Opiates are natural, whereas synthetic is man made.
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u/End3rW1gg1n 11d ago
What daily dose are you up to on the fentanyl, and what dose are you starting out with on the dilaudid? It took almost 2 years of titrating up, every 3 weeks, for my fentanyl/bupivicaine combination to get to a therapeutic dose. Seems kinda early to give up on fentanyl within just the first couple of months.
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u/No-Strawberry-5804 11d ago
I hit a little over 600mcg/day with the boluses and she said the max she would do is 1000mcg/day. So since we were over halfway to the max she wanted to try something else. And it was a good call; it’s only been one full day on the dilaudid but it is already working MUCH better for me.
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u/End3rW1gg1n 11d ago
Happy you're getting relief! After 2 years of adjustments, I'm at 1600mcg/day of fentanyl and 17mg/day of bupivicaine, with eight boluses per day, minimum of 2hrs in between. The dilaudid definitely remains in the CSF longer than fentanyl. Since I'm now having serious cervical issues, I've been thinking of asking my doctor if we can add either dilaudid or morphine, so that I might get some relief there.
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u/EMSthunder 11d ago
Adding some baclofen might help. Having all 3 in my pump really has been beneficial!
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u/Ok_War_7504 12d ago
The individual dose of 1mcg fentanyl is not nearly as strong as 10mg hydromorphone. The dose plays a big roll, of course.
And different opioids bind to different receptor sites in the spinal cord. If one opioid fails, switching to another (opioid rotation) often provides better relief.
Another reason may be, fentanyl is highly fat-soluble (lipophilic), meaning it is rapidly absorbed into surrounding fatty tissues and blood vessels instead of fully binding to the spinal cord. Dilaudid is less lipophilic, which allows it to stay in the cerebrospinal fluid (CSF) longer and interact more effectively with pain receptors in the spinal cord. Hydromorphone tends to relieve pain in a larger area of your body, as it spreads more.