Comparative efficacy of oral extended-release hydromorphone and immediate-release hydromorphone in patients with persistent moderate to severe pain: two randomized controlled trials

Efficacy and safety of hydromorphone for cancer pain: a systematic review and meta-analysis

BACKGROUND

Cancer pain significantly impacts individuals' quality of life, with opioids being employed as the primary means for pain relief. Nevertheless, concerns persist regarding the adverse reactions and effectiveness of opioids such as morphine. Hydromorphone, recognized as a potent opioid, is a viable alternative for managing cancer-related pain. The goal of this systematic review and meta-analysis was to determine the effectiveness and safety characteristics of hydromorphone in comparison to other opioids, as well as different methods of administering this medication within the scope of cancer pain treatment.

METHODS

The PubMed, Embase, Cochrane Library, Scopus, and Web of Science databases were searched on December 25th, 2023. Following the PRISMA guidelines, a systematic investigation of databases was carried out, and suitable studies were chosen according to predetermined criteria (PICO framework). The meta-analyses were performed using a random-effects model.

RESULTS

This review included 18 RCTs with 2271 patients who compared hydromorphone with morphine, oxycodone, or fentanyl, as well as other types of hydromorphone. Hydromorphone demonstrated efficacy similar to that of morphine and oxycodone in reducing cancer pain intensity, decreasing additional analgesic consumption, and improving quality of life. However, morphine showed slight superiority over hydromorphone in reducing breakthrough pain. Adverse events were comparable between hydromorphone and morphine or oxycodone. Patient-controlled and clinician-controlled hydromorphone administration routes yielded similar outcomes.

CONCLUSIONS

The outcomes of this study substantiate the efficacy of hydromorphone in the management of cancer-related pain, demonstrating similar levels of effectiveness and safety as morphine and oxycodone. These findings are consistent with prior comprehensive analyses, suggesting that hydromorphone is a feasible choice for alleviating cancer-associated pain. Additional investigations are warranted to determine its efficacy in distinct patient cohorts and for different modes of administration.

TRIAL REGISTRATION

Prospero registration ID: CRD42024517513. Link: https://www.crd.york.ac.uk/PROSPERO/#recordDetails .

The 50% effective dose of hydromorphone and morphine for epidural analgesia in the hemorrhoidectomy: a double-blind, sequential dose-finding study

BACKGROUND

Although previous studies have showed that epidural morphine can be used as a complement to local anesthetics for analgesia after postcesarean delivery under spinal anesthesia, there is little known about the analgesic dosage of epidural morphine and hydromorphone for hemorrhoidectomy. Therefore, we conducted this study to examine the potency ratio of hydromorphone to epidural morphine as well as effective analgesic dose for 50% patients (ED50) undergoing elective hemorrhoidectomy.

METHODS

80 patients under elective hemorrhoidectomy with combined spinal and epidural anesthesia(CSEA) in department of anesthesia, Dongguan Tungwah hospital. To assess the ED50, patients were treated with epidural morphine or epidural hydromorphone randomly using a biased coin method-determined dose with a sequential allocation procedure. Following surgery, standardized multimodal analgesia was administered to all patients. A pain response score of ≤ 3 (on a scale of 0-10) was determined to be the effective dose after 24 h following CSEA. The ED50 in both groups were determined using the probit regression and isotonic regression method. We also measured pain intensity by patient interview using a 10 point verbal numeric rating scale prospectively at 6, 12 and 24 h after CSEA, and adverse effects were also noted.

RESULTS

The ED50 was 0.350 mg (95% CI, 0.259-0.376 mg) in hydromorphone group and 1.129 mg (95% CI, 0.903-1.187 mg) in morphine group, respectively, estimated by isotonic regression method. Regression analysis with the probit, the ED50 of epidural hydromorphone was 0.366 mg (95% CI, 0.276-0.388 mg) and epidural morphine was 1.138 mg (95% CI, 0.910-1.201 mg). Exploratory findings showed that there was no difference between the most frequent dosages of epidural hydromorphone or epidural morphine in the occurrence of nausea, vomiting and pruritus. When administered with epidural opioids at ED50 doses or higher, 97.5% (39/40) of epidural morphine patients and 97.5% (39/40) epidural hydromorphone of patients were satisfied with their analgesia.

CONCLUSION

Effective hemorrhoidectomy analgesia requires a 3:1 ratio of epidural morphine to epidural hydromorphone. Both drugs provide excellent patient satisfaction.

Effect of an opioid management program for Colorado workers' compensation providers on adherence to treatment guidelines for chronic pain

OBJECTIVE

The aim of this study was to examine adherence of state guidelines for Colorado workers' compensation physicians/providers treating individuals as injured workers with chronic pain after initiation of an opioid management program and provider incentives.

METHODS

A retrospective cohort of chronic, non-cancer pain claims was constructed from the Colorado's workers' compensation database. Adherence to treatment guidelines and opioid prescribing practices were evaluated during implementation of a new billing code to incentivize adherence.

RESULTS

Overall, less than 33% of claims showed evidence of opioid management. Comprehensive opioid management was observed in only 4.4% of claims. In 2010, after implementing the new billing code, the ratio of long acting opioids to short acting opioids decreased from 0.2 to 0.13; returning to 0.2 in one year. Similarly, morphine equivalent doses declined for a short period.

CONCLUSIONS

Incentivizing physicians to adhere to chronic pain management guidelines only temporarily improves prescribing practices.

Association Between Commonly Prescribed Opioids and Androgen Deficiency in Men: A Retrospective Cohort Analysis

Objective. Androgen deficiency is common among men who use opioids daily for chronic pain. In previous studies, we found that long-acting opioids are associated with greater odds of androgen suppression than equipotent doses of short-acting opioids. Here we examined whether specific commonly prescribed opioids were associated with greater odds of androgen deficiency compared to hydrocodone.

Design. Retrospective cohort study.

Setting and Patients. Within a large, integrated health care delivery system, this study was comprised of men ages 18–80 on a stable regimen of a single opioid for chronic non-cancer pain.

Methods. Morning serum total testosterone levels were measured in subjects prescribed one opioid for at least 90 days. The association between individual opioids and androgen deficiency was assessed with logistic regression, controlling for dose, obesity, age, hypertension, hyperlipidemia, and diabetes, using hydrocodone as a referent.

Results. This study included 1,159 men. Men on fentanyl (odds ratio [OR] 25.7, 95% CI 2.82–234.97), methadone (OR 7.33, 95% CI 3.29–16.33), or oxycodone (OR 3.15, 95% CI 1.87–5.33) were more likely to be androgen deficient than men on hydrocodone. Increases in dose affected the odds of androgen deficiency differently for different opioids. Increased doses of hydrocodone (OR 1.18 per 10-mg increase in drug, 95% CI 1.09–1.28) and oxycodone (OR 1.01, 95% CI 1.00–1.02) were associated with increased odds of androgen deficiency.

Conclusions. Our results suggest that certain opioids are associated with increased odds of androgen deficiency compared with hydrocodone. Transdermal fentanyl, methadone and oxycodone were associated with higher odds of androgen deficiency than hydrocodone.

Hydromorphone for neuropathic pain in adults

BACKGROUND

Opioid drugs, including hydromorphone, are commonly used to treat neuropathic pain, and are considered effective by some professionals. Most reviews have examined all opioids together. This review sought evidence specifically for hydromorphone, at any dose, and by any route of administration. Other opioids are considered in separate reviews.This review is part of an update of a previous review, Hydromorphone for acute and chronic pain that was withdrawn in 2013 because it needed updating and splitting to be more specific for different pain conditions. This review focuses only on neuropathic pain.

OBJECTIVES

To assess the analgesic efficacy of hydromorphone for chronic neuropathic pain in adults, and the adverse events associated with its use in clinical trials.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), via the CRSO; MEDLINE via Ovid; and EMBASE via Ovid from inception to 17 November 2015, together with reference lists of retrieved papers and reviews, and two online study registries.

SELECTION CRITERIA

We included randomised, double-blind studies of two weeks' duration or longer, comparing hydromorphone (at any dose, by any route of administration, or in any formulation) with placebo or another active treatment in chronic neuropathic pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched for studies, extracted efficacy and adverse event data, and examined issues of study quality. We did not carry out any pooled analyses. We assessed the quality of the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

MAIN RESULTS

Searches identified seven publications relating to four studies. We excluded three studies. One post hoc (secondary) analysis of a study published in four reports assessed the efficacy of hydromorphone in neuropathic pain, satisfied our inclusion criteria, and was included in the review. The single included study had an enriched enrolment, randomised withdrawal design with 94 participants who were successfully switched from oral morphine to oral hydromorphone extended release (about 60% of those enrolled). These participants were then randomised to continuing hydromorphone for 12 weeks or tapering down the hydromorphone dose to placebo. The methodological quality of the study was generally good, but we judged the risk of bias for incomplete outcome data as unclear, and for study size as high.Since we identified only one study for inclusion, we were unable to carry out any analyses. The included study did not report any of our prespecified primary outcomes, which relate to the number of participants achieving moderate or substantial levels of pain relief. It did report a slightly larger increase in average pain intensity for placebo in the randomised withdrawal phase than for continuing with hydromorphone. It also reported the number of participants who withdrew due to lack of efficacy in the randomised withdrawal phase, which may be an indicator of efficacy. However, in addition to using an enriched enrolment, randomised withdrawal study design, there was an unusual choice of imputation methods for withdrawals (about 50% of participants); the evidence was of very low quality and inadequate to make a judgement on efficacy. Adverse events occurred in about half of participants with hydromorphone, the most common being constipation and nausea. A similar proportion of participants experienced adverse events with placebo, the most common being opioid withdrawal syndrome (very low quality evidence). Most adverse events were mild or moderate in intensity. One in eight participants withdrew while taking hydromorphone during the conversion and titration phase, despite participants being opioid-tolerant (very low quality evidence).We downgraded the quality of the evidence to very low because there was only one study with few participants, it did not report clinically useful efficacy outcomes, and it was a post hoc analysis.

AUTHORS' CONCLUSIONS

There was insufficient evidence to support or refute the suggestion that hydromorphone has any efficacy in any neuropathic pain condition.

Efficacy of a new once daily hydromorphone formulation in comparison with twice daily administration in chronic pain: a randomized, double-blind, cross-over study

Objective Efficacy and safety of a novel multiple-unit hydromorphone once daily (HOD) was compared to an established hydromorphone twice daily (HTD) regimen in patients with moderate-to-severe chronic pain. Design and methods The results from a randomized, double-blind, multicenter, cross-over trial in patients (n = 37) with chronic malignant or non-malignant pain are reported. The primary efficacy parameter was current pain on 0-100 mm VAS assessed four times daily and prior to intake of rescue medication (immediate-release hydromorphone) throughout the last 5 days with each treatment (after an 8 day build-up period to avoid carry-over effects). Total daily dose of hydromorphone (TDD: 8-32 mg/day) was kept stable during the double-blind treatment phase. Results The difference observed in mean current pain (-0.92 mm VAS) over the 5 day assessment period between HOD and HTD (28.44 mm vs. 29.36 mm VAS) was found to lack clinical relevance, as the 95% CI (-4.10 to 2.28 mm VAS) did not exceed the prespecified limit for non-inferiority of 9 mm VAS. Results from the full analysis set were consistent with per protocol data confirming robustness, as did the data for 12 h recalled pain assessed at 08:00 h and 20:00 h, showing no significant differences between once and twice daily medication. Both treatments produced effective and stable pain control with only minor day-to-day and intra-day fluctuations. Switching between treatments was suitable, considering both efficacy and safety, as no relevant or significant differences in adverse events were seen (25.0% HOD, 24.3% HTD). Most frequently typical side-effects of opioid therapy were observed, such as nausea, vomiting and headache. Conclusion Although this study was of short duration and included a limited number of patients, the results confirm that the new HOD is as effective and safe as the established HTD.

Elucidating risk factors for androgen deficiency associated with daily opioid use

BACKGROUND

Opioids can suppress testosterone in men, which can lead to extensive morbidity. Identifying risk factors for androgen deficiency in men using daily opioids could improve monitoring and safety.

METHODS

In a retrospective cohort study, we used Kaiser Permanente Northern California databases to identify men on stable doses of opioids. These subjects had no diagnoses of cancer or endocrine disorders except treated primary hypothyroidism. Subjects were divided into those using long-acting opioids and short-acting opioids. Total testosterone was measured in blood drawn in the morning while the subjects were on their regular dose of opioid. The association between opioid duration of action and androgen deficiency, controlling for dose, body mass index, age, diabetes, hyperlipidemia, and hypertension, was assessed using logistic regression.

RESULTS

The study included 1585 men. Men on long-acting opioids were more likely to be androgen deficient than men on short-acting opioids (57% vs 35%, P < 0.001; odds ratio [OR] 3.39; 95% confidence interval [CI], 2.39-4.77). As dose increased, the odds of androgen deficiency increased; however, dose was more strongly associated with androgen deficiency in men on short-acting opioids (OR 1.16; 95% CI, 1.09-1.23, for each 10-mg increase in dose) than in men on long-acting opioids (OR 1.01; 95% CI, 1.01-1.02).

CONCLUSION

Use of long-acting opioids is a key risk factor in the development of androgen deficiency. Dose was significantly associated with androgen deficiency, but more so for men on short-acting than on long-acting opioids.

Clinical evaluation of the first oxycodone once daily prolonged release tablet in moderate to severe chronic pain: a randomized, double-blind, multicenter, cross-over, non-inferiority study to investigate efficacy and safety in comparison with an established oxycodone twice daily prolonged release tablet

OBJECTIVE

The first oxycodone once daily (OOD) has been developed and after successful pharmacokinetic characterization, therapeutic efficacy and safety were compared to an established oxycodone twice daily (OTD: Oxygesic/OxyContin, Mundipharma).

DESIGN AND METHODS

A randomized, double-blind, multicenter, cross-over, non-inferiority study was conducted in patients (n = 68) with chronic malignant or non-malignant pain. The new OOD was compared to OTD at identical total daily doses (TDD: 40-120 mg/day) employing intensive, five times daily current pain (0-100 mm visual analog scale, VAS) and twice daily 12 h recalled pain assessments as well as safety parameters such as nausea and sedation (VAS) over 5 days for each treatment (after a 5 day run-in phase).

RESULTS

There was no significant difference in analgesic potency detected between the two treatments based on 95% CI for difference in the daily mean current pain (-2.09 mm VAS) over 5 days, determined as -5.09 to 0.91 mm VAS. A difference ≤12 mm VAS indicated non-inferiority of OOD, i.e. lack of clinically relevant difference in analgesia. Intake of rescue medication had no effect on study results as evaluated by ANCOVA. The difference in adverse events (AEs) between the two treatments did not reach significance, as 19.1% and 23.5% of patients experienced treatment-related AEs while on OOD and OTD, respectively. Advantages for OOD regarding consistency of analgesia (i.e. use of rescue medication, current and recalled pain) and sedation did not reach statistical significance in this limited study population.

CONCLUSION

Despite the small number of patients and short study duration, the results support the conclusion that new OOD is (at least) equivalent to established OTD regarding safety and efficacy.

WITHDRAWN: Hydromorphone for acute and chronic pain

The original author team were unavailable to complete the update. At September 2013, a new author team is preparing a new protocol for publication in early 2014, with the revised title 'Hydromorphone for cancer pain'.

The editorial group responsible for this previously published document have withdrawn it from publication.

Miotic and subject-rated effects of therapeutic doses of tapentadol, tramadol, and hydromorphone in occasional opioid users

RATIONALE

Tapentadol is a novel analgesic that activates mu-opioid receptors and blocks norepinephrine reuptake. There is very little information available regarding the non-analgesic pharmacodynamic effects of tapentadol.

OBJECTIVES

This outpatient study evaluated the physiological, subject-rated, and performance effects of therapeutic doses of tapentadol compared to two control drugs in humans.

METHODS

This double-blind, within-subject study examined the effects of oral placebo, tapentadol (25, 50, and 75 mg), tramadol (50, 100, and 150 mg), and hydromorphone (2, 4, and 6 mg). Nine occasional opioid users completed the study. Pharmacodynamic drug effects were measured before and for 6 h after drug administration.

RESULTS

All three doses of the tested drugs produced comparable, time-dependent decreases in pupil diameter, but the effects were generally not dose dependent. The high dose of tapentadol, as well as all three doses of tramadol and hydromorphone, increased positive subject-rated effects (e.g., "Good Effects" and "Like the Drug") as a function of time. Only tramadol increased negative subject-rated effects (e.g., "Bad Effects" and "Nauseous"); however, these were of low magnitude.

CONCLUSIONS

The highest tested dose of tapentadol produced a profile of positive effects comparable to that of hydromorphone, whereas tramadol produced positive and negative subject-rated effects. The mixed findings for tramadol are consistent with previous findings indicating that it has a distinct profile of effects relative to prototypic opioids. Future research should examine the effects of higher tapentadol doses, as well as the factors contributing to the different subject-rated profile of effects observed for tramadol relative to tapentadol and hydromorphone.

The role of hydromorphone in cancer pain treatment: a systematic review

The aim of this systematic review is to evaluate the scientific evidence for the efficacy and side effects of hydromorphone in the management of moderate to severe cancer pain. Randomized and non-randomized clinical trials, reporting data on efficacy and/or side effects of hydromorphone, were identified. Thirteen eligible studies, involving 1208 patients, were selected. Seven studies compared hydromorphone with other opioids (five with morphine, one with oxycodone and one with fentanyl and buprenorphine) and five of them were randomized controlled trials (RCTs). Most of the studies were conducted on patients already receiving opioid treatment, often at stabilized doses, and most had methodological limitations. The RCTs comparing hydromorphone with morphine and oxycodone showed similar analgesic results, while the comparison of side effects showed minor differences, not consistent across studies. Due to clinical and methodological heterogeneity of the studies, a meta-analysis was not performed. In conclusion there is evidence to support the efficacy and tolerability of hydromorphone for moderate to severe cancer pain as an alternative to morphine and oxycodone, while there is no evidence to demonstrate its superiority or inferiority in comparison with morphine as the first choice opioid for the same indication.

A comparison of long- and short-acting opioids for the treatment of chronic noncancer pain: tailoring therapy to meet patient needs

Management of chronic noncancer pain (CNCP) requires a comprehensive assessment of the patient, the institution of a structured treatment regimen, an ongoing reassessment of the painful condition and its response to therapy, and a continual appraisal of the patient's adherence to treatment. For many patients with CNCP, the analgesic regimen will include opioids. Physicians should consider the available evidence of efficacy, the routes of administration, and the pharmacokinetics and pharmacodynamics of the various formulations as they relate to the temporal characteristics of the patient's pain. When making initial decisions, physicians should decide whether to prescribe a short-acting opioid (SAO) with a relatively quick onset of action and short duration of analgesic activity, a long-acting opioid (LAO) with a longer duration of analgesic action but a potentially longer onset of action, or both. Studies suggest that SAOs and LAOs are both effective for most types of CNCP. A review of published studies found no data to suggest that either SAOs or LAOs are generally more efficacious for treating any particular CNCP condition. The LAOs may provide more stable analgesia with less frequent dosing; however, opioid therapy should be tailored to the pain state and the individual patient, and SAOs may be appropriate for some patients with CNCP. MEDLINE and PubMed searches were conducted to locate relevant studies published from January 1975 to April 2008 using the following search terms: opioids, short-acting opioids, long-acting opioids, chronic pain, chronic pain AND opioids, and narcotics. English-only randomized controlled trials and nonrandomized studies were considered.

A new extended release formulation (OROS) of hydromorphone in the management of pain

Opioid analgesics are essential in the treatment of moderate to severe cancer-related pain. Opioids are also recognized as important in the management of other severe, persistent refractory painful conditions, such as sickle cell disease and arthritis. In the clinical practice of pain management, stable opioid dosing generally depends on achieving maximal analgesia with tolerable side effects typical of opioid analgesics. There is a wide interindividual variability of responsiveness to exogenous opioids both in terms of analgesic efficacy and side effects. Optimizing pain management for the individual patient may require sequential trials of opioid medications until the regimen with the most favorable therapeutic ratio of efficacy to side effects is determined.

[Differential therapeutic aspects of analgesia with oral sustained-release strong opioids: application intervals, metabolism and immunosuppression]

The oral "around-the clock" administration of sustained-release strong opioids has been recommended for the long-term treatment of patients suffering from chronic severe pain. At present a plethora of products are available in Germany. Modern galenics even allow for only once-daily oral application without clinically relevant negative chronobiological interference. This application scheme has been shown to improve compliance and sleep quality, factors that influence treatment outcome. Randomized controlled studies revealed no relevant differences between the different strong opioids with respect to efficacy and tolerability. However, hydromorphone and oxycodone appear to be advantageous over morphine due to a lack of immunosuppression. Hydromorphone has the additional benefit of a lower risk of intoxication by accumulation of active metabolites in patients with decreased renal function. As a result, although morphine has been regarded as the standard for the treatment of chronic severe pain, hydromorphone and oxycodone may be better and safer alternatives for certain patient groups (e.g. older age, multimorbidity, cancer).

Endogenous opiates and behavior: 2005

This paper is the 28th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2005 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity, neurophysiology and transmitter release (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); immunological responses (Section 17).

Capillary electrophoresis contributions to the hydromorphone metabolism in man

CE-ESI multistage IT-MS (CE-MS(n), n < or = 4) and computer simulation of fragmentation are demonstrated to be effective tools to detect and identify phase I and phase II metabolites of hydromorphone (HMOR) in human urine. Using the same CE conditions as previously developed for the analysis of urinary oxycodone and its metabolites, HMOR and its phase I metabolites produced by N-demethylation, 6-keto-reduction and N-oxidation and phase II conjugates of HMOR and its metabolites formed with glucuronic acid, glucose, and sulfuric acid could be detected in urine samples of a patient that were collected during a pharmacotherapy episode with daily ingestion of 48 mg of HMOR chloride. The CE-MS(n) data obtained with the HMOR standard, synthesized hydromorphol and hydromorphone-N-oxide, and CYP3A4 in vitro produced norhydromorphone were employed to identify the metabolites. This approach led to the identification of previously unknown HMOR metabolites, including HMOR-3O-glucide and various N-oxides, structures for which no standard compounds or mass spectra library data were available. Furthermore, the separation of alpha- and beta-hydromorphol, the stereoisomers of 6-keto-reduced HMOR, was achieved by CE in the presence of the single isomer heptakis(2,3-diacetyl-6-sulfato)-beta-CD. The obtained data indicate that the urinary excretion of alpha-hydromorphol is larger than that of beta-hydromorphol.

Extended-release opioids for the management of chronic non-malignant pain

Recent clinical trials have documented the use of extended-release (ER) opioids in the management of chronic non-malignant pain. This manuscript reviews the clinical pharmacology of investigational and current marketed ER opioids. Recent randomised clinical trials of ER opioids that document the efficacy and safety of opioid therapy for chronic pain are reviewed. Finally, the abuse liability of ER opioids is discussed. Current technologies aimed at defeating the abuse of ER opioids will also be presented.

Multicenter, open-label, prospective evaluation of the conversion from previous opioid analgesics to extended-release hydromorphone hydrochloride administered every 24 hours to patients with persistent moderate to severe pain

BACKGROUND

Hydromorphone hydrochloride is a mu-opioid agonist with dose-dependent analgesic properties. Extended-release hydromorphone hydrochloride (ER hydromorphone HCl) capsules have been developed for administration every 24 hours.

OBJECTIVES

This prospective evaluation focused on the first (ie, conversion) phase of 2 identically designed, randomized, controlled studies that compared the safety and efficacy of once-daily ER hydromorphone HCl capsules with immediate-release hydromorphone hydrochloride (IR hydromorphone HCl) tablets administered 4 times daily in the treatment of persistent moderate to severe cancer- and noncancer-related pain.

METHODS

Patients being treated with opioid analgesics for persistent moderate to severe pain were converted to ER hydromorphone HCl using an 8:1 conversion ratio. The dose was titrated to attain an average pain intensity (API) score < or = 4 on a 0- to 10-point numeric rating scale. Supplemental oral IR hydromorphone HCl tablets were used as rescue medication at a dose of one eighth to one sixth of the daily ER hydromorphone HCl dose.

RESULTS

A total of 343 patients (272 [79%] with cancer pain; mean age, 57.8 years) were enrolled and converted to ER hydromorphone HCl from their previous opioids. About half (51%) were women. At baseline, the mean (SD) API score was 5.3 (2.1). Mean (SD) API scores were 4.7 (2.0) after the first 48 hours and 3.4 (2.1) by the end of titration. After 4 to 21 days of titration, 239 (70%) patients reached stabilization defined as a > or = 48-hour period with an API score of < or =4, unchanged ER hydromorphone HCl dose, and < or = 2 rescue doses per day. The stabilized patients had mean (SD) API scores of 2.7 (1.1) at the end of titration. At stabilization, 102 (43%) of 239 patients remained at their initial conversion dose, 129 (54%) had a dose increase, and 8 (3%) had a dose decrease. Frequent (> or =10% of patients) adverse events that occurred within the first 48 hours after conversion and during the entire titration phase were nausea, somnolence, headache, constipation, vomiting, and dizziness.

CONCLUSION

In this prospective evaluation of the conversion and titration phase of 2 randomized, controlled studies, a conversion ratio of 8:1 mg of oral morphine to oral ER hydromorphone HCl was found to be clinically useful in patients with persistent moderate to severe cancer-related or noncancer-related pain.

Hydromorphone for acute and chronic pain

BACKGROUND

While morphine is the gold standard for the management of severe cancer pain, some patients either do not achieve adequate analgesia, or suffer intolerable morphine-related toxicity. For these patients alternatives such as hydromorphone are recommended. However, there appear to be gaps in our understanding of the efficacy and potency of hydromorphone.

OBJECTIVES

This review explores and assesses the evidence for the efficacy of hydromorphone in the management of pain.

SEARCH STRATEGY

Randomised trials which included hydromorphone were sought using electronic databases and by handsearching relevant journals. Date of the most recent search: February 2000.

SELECTION CRITERIA

RCTs which involved the administration of hydromorphone, for both acute and chronic pain conditions, in adults and children, were included.

DATA COLLECTION AND ANALYSIS

A data extraction form was designed for the purpose of the review. The validity of each trial for inclusion was assessed using criteria described in the Cochrane Handbook. A grade was allocated to each study on the basis of allocation concealment. A checklist was used to assess blinding.

MAIN RESULTS

Forty three studies (2725 subjects) were included in the review. Approximately half of these studies received a low quality score. In addition, the heterogeneity of the studies precluded combination of data and results. A meta-analysis was therefore not possible. Of the 43 included studies, 11 (645 subjects) involved chronic pain conditions (all cancer) and 32 (2080 subjects) acute pain. Three studies were placebo-controlled. Of the remainder, hydromorphone was compared with other opioids (morphine, fentanyl, sufentanyl, meperidine, oxycodone, diamorphine), bupivicaine and with itself, using different formulations. The routes of administration included intravenous, oral, spinal, intramuscular and subcutaneous. Overall, hydromorphone appears to be a potent analgesic. The limited number of studies available suggest that there is little difference between morphine and hydromorphone in terms of analgesic efficacy, adverse effect profile and patient preference. However, as most studies involved small numbers of patients, it is difficult to determine real differences between both drugs. In the context of both acute and chronic pain, the issue of equi-analgesic ratios between morphine and hydromorphone was not resolved.

REVIEWER'S CONCLUSIONS

The studies included in this review were varied in terms of quality and methodology. However, the majority demonstrated that hydromorphone is a potent analgesic, that the clinical effects of hydromorphone appear to be dose-related, and that the adverse effect profile of hydromorphone is similar to that of other mu opioid receptor agonists.