Comparison of hydromorphone and meperidine for ureteral colic

Recent trends in the prescription of opioids in the emergency department in patients with urolithiasis

PURPOSE

Pain management is central in the treatment of urolithiasis. We aimed to estimate the impact of the 2017 Department of Health and Human Services declaration of an opioid crisis on prescribing patterns of opioids and NSAIDs in emergency department visits for urolithiasis.

METHODS

The National Health Ambulatory Medical Care Survey (NHAMCS) was queried for emergency department visits of adults with a diagnosis of urolithiasis. The association between urolithiasis and narcotic and NSAIDs prescription patterns was evaluated and compared at pre-declaration (2014-2016) to post-declaration (2017-2018) periods.

RESULTS

Opioids were prescribed in about 211 million (41.1%) out of 513 million emergency department visits, over a 5-year period. Diagnosis of urolithiasis accounted for 1.9% of the visits (6.0 million). The use of opioids was higher in urolithiasis (82.7%) compared to non-urolithiasis diagnosis (40.3%), as well as the use of multiple opioids per visit (p < 0.01 for all). There was an overall decrease in opioid prescriptions in the post-declaration period, - 4.3% for urolithiasis (p = 0.254) and - 5.6% for non-urolithiasis visits (p < 0.05). A decrease in the use of hydromorphone (- 47.5%. p < 0.001), an increase in the use of morphine (+ 59.7% p = 0.006), and an increase of 'other' opioids (+ 98.8%, p < 0.041), were observed. Opioids combined with NSAIDs comprised 72.6% of the opioid prescriptions and 62.3% of all analgesic prescriptions in visits with urolithiasis diagnosis.

CONCLUSIONS

The use of opioids when managing urolithiasis decreased 4.3% after the crisis declaration; however, statistically are not different from pre-declaration numbers. Most often, opioids were prescribed with NSAIDs in urolithiasis patients.

The Evolving Landscape of Acute Pain Management in the Era of the Opioid Crisis

PURPOSE OF REVIEW

The purpose of the study is to evaluate and analyze the role of both opioid and non-opioid analgesics in the emergency department (ED).

RECENT FINDINGS

Studies have shown that the implementation of opioid-prescribing policies in the ED has the potential to reduce the opioid addiction burden. Clinical studies point to inconsistencies in providers' approach to pain treatment. In this review, we discuss specific aspects of opioid utilization and explore alternative non-opioid approaches to pain management. Pain is the most common reason patients present to the ED. As such, emergency medicine (EM) providers must be well versed in treating pain. EM providers must be comfortable using a wide variety of analgesic medications. Opioid analgesics, while effective for some indications, are associated with significant adverse effects and abuse potential. EM providers should utilize opioid analgesics in a safe and rational manner in an effort to combat the opioid epidemic and to avoid therapeutic misadventures. EM providers should be aware of all of their therapeutic options, e.g., opioid and non-opioid, in order to provide effective analgesia for their patients, while avoiding adverse effects and minimizing the potential for misuse.

Pain management of renal colic in the emergency department with intravenous lidocaine

OBJECTIVE

To describe our experience with intravenous lidocaine (IVL) to manage pain of renal colic origin in the emergency department (ED).

METHODS

A retrospective analysis of all patients presenting with pain of renal colic origin from the periods of 2014 to 2017 by using the ED electronic medical record database (Allscripts™).

RESULTS

Forty-four patients received IVL for renal colic over a three-year period. The average dose of IVL as a primary analgesic was 117.2 mg, and as a rescue was 108 mg. Administration of IVL resulted in a decrease in overall pain score by 6.3 points (numerical rating scale), by 7.4 points when IVL was used as a primary analgesic, and by 5.2 points when IVL was given as a rescue. There were no documented adverse effects.

CONCLUSION

Intravenous lidocaine has a potential of being used for patients presenting to the ED with a pain of renal colic origin as a primary analgesic or as a rescue. Although promising, this therapy will need to be studied in prospective randomized fashion and larger patients' population with underlying cardiac disease before it can be recommended for broad use in the ED.

Emesis after Intravenous Meperidine Administration to Emergency Department Patients

Objective:

To determine the frequency of emesis after intravenous administration of meperidine, with and without concurrent intravenous antiemetics, in emergency department (ED) patients.

Design:

Record review of consecutive patients who received intravenous meperidine in the ED.

Setting:

The ED of an urban teaching hospital.

Patients:

All patients who received intravenous meperidine during a 5-month period.

Main Outcome Measures:

Documentation of emesis and therapeutic measures commonly used to treat emesis.

Results:

Meperidine was administered intravenously at 173 patient visits; at 81 visits, meperidine was administered alone, and at 92 visits, concurrent antiemetics were administered. The prevalence of emesis was similar in both treatment groups (8.6%; p = 0.79).

Conclusions:

The prevalence of emesis associated with intravenous administration of meperidine is relatively infrequent in ED patients and generally associated with abdominal signs and symptoms at presentation. The concurrent administration of an intravenous antiemetic did not decrease the frequency of meperidine-associated emesis.

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.

Randomized clinical trial of efficacy and safety of a single 2-mg intravenous dose of hydromorphone versus usual care in the management of acute pain

OBJECTIVES

The objective was to test the efficacy and safety of 2 mg of intravenous (IV) hydromorphone (Dilaudid) against "usual care" in emergency department (ED) patients with acute severe pain.

METHODS

This was a randomized clinical trial. Patients allocated to 2 mg of IV hydromorphone received their medication in a single dose. Those randomized to usual care received any IV opioid, with type, dose, and frequency chosen by the ED attending. All patients received 2 L/min. nasal cannula oxygen. The primary outcome was the difference in the proportion of patients who achieved clinically satisfactory analgesia by 30 minutes. This was defined as the patient declining additional analgesia when asked the question, "Do you want more pain medicine?" A 10% absolute difference was chosen a priori as the minimum difference considered clinically significant.

RESULTS

Of 175 subjects randomized to each group, 164 in the 2 mg hydromorphone group and 161 in the usual care group had sufficient data for analysis. Additional pain medication was declined by 77.4% of patients in the 2 mg hydromorphone group at 30 minutes, compared to 65.8% in the usual care group. This difference of 11.6% was statistically and clinically significant (95% confidence interval [CI] = 1.8% to 21.1%). Safety profiles were similar and no patient required naloxone. There was more pruritus in the hydromorphone group (18.3% vs. 8.7%; difference = 9.6%, 95% CI = 2.6% to 16.6%).

CONCLUSIONS

Using a simple dichotomous patient-centered endpoint in which a difference of 10% in proportion obtaining adequate analgesia was considered clinically significant, 2 mg of hydromorphone in a single IV dose is clinically and statistically more efficacious when compared to usual care for acute pain management in the ED.

Parenteral opioids in emergency medicine - A systematic review of efficacy and safety

Introduction and aim Pain is a frequent symptom in emergency patients and opioids are commonly used to treat it at emergency departments and at pre-hospital settings. The aim of this systematic review is to examine the efficacy and safety of parenteral opioids used for acute pain in emergency medicine. Method Qualitative review of randomized controlled trials (RCTs) on parenteral opioids for acute pain in adult emergency patients. Main outcome measures were: type and dose of the opioid, analgesic efficacy as compared to either placebo or another opioid and adverse effects. Results Twenty double-blind RCTs with results on 2322 patients were included. Seven studies were placebo controlled. Majority of studies were performed in the emergency department. Only five studies were in prehospital setting. Prehospital studies Four studies were on mainly trauma-related pain, one ischemic chest pain. One study compared two different doses of morphine in mainly trauma pain showing faster analgesia with the larger dose but no difference at 30 min postdrug. Three other studies on the same pain model showed equal analgesic effects with morphine and other opioids. Alfentanil was more effective than morphine in ischemic chest pain. Emergency department studies Pain models used were acute abdominal pain seven, renal colic four, mixed (mainly abdominal pain) three and trauma pain one study. Five studies compared morphine to placebo in acute abdominal pain and in all studies morphine was more effective than placebo. In four out of five studies on acute abdominal pain morphine did not change diagnostic accuracy, clinical or radiological findings. Most commonly used morphine dose in the emergency department was 0.1 mg/kg (five studies). Other opioids showed analgesic effect comparable to morphine. Adverse effects Recording and reporting of adverse effects was very variable. Vital signs were recorded in 15 of the 20 studies (including all prehospital studies). Incidence of adverse effects in the opioid groups was 5-38% of the patients in the prehospital setting and 4-46% of the patients in the emergency department. Nausea or vomiting was reported in 11-25% of the patients given opioids. Study drug was discontinued because of adverse effects five patients (one placebo, two sufentanil, two morphine). Eight studies commented on administration of naloxone for reversal of opioid effects. One patient out of 1266 was given naloxone for drowsiness. Ventilatory depression defined by variable criteria occurred in occurred in 7 out of 756 emergency department patients. Conclusion Evidence for selection of optimal opioid and dose is scarce. Opioids, especially morphine, are effective in relieving acute pain also in emergency medicine patients. Studies so far are small and reporting of adverse effects is very variable. Therefore the safety of different opioids and doses remains to be studied. Also the optimal titration regimens need to be evaluated in future studies. The prevention and treatment of opioid-induced nausea and vomiting is an important clinical consideration that requires further clinical and scientific attention in this patient group.

Intravenous Opioids for Severe Acute Pain in the Emergency Department

Objective:

To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy.

Data Sources:

Articles were identified through a search of Ovid/MEDLINE (1948-August 2010), PubMed (1950-August 2010), Cochrane Central Register of Controlled Trials (1991-August 2010), and Google Scholar (1900-August 2010). The search terms used were pain, opioid, and emergency department.

Study Selection and Data Extraction:

The search was limited by age group to adults and by publication type to comparative studies. Studies comparing routes of administration other than intravenous or using non-opioid comparators were not included. Bibliographies of all retrieved articles were reviewed to obtain additional articles. The focus of the search was to identify original research that compared intravenous opioids used for treatment of severe acute pain for adults in the ED.

Data Synthesis:

At equipotent doses, randomized controlled trials have not shown clinically significant differences in analgesic response or adverse effects between opioids studied. Single opioid doses less than 0.1 mg/kg of intravenous morphine, 0.015 mg/kg of intravenous hydromorphone, or 1 μg/kg of intravenous fentanyl are likely to be inadequate for severe, acute pain and the need for additional doses should be anticipated. In none of the randomized controlled trials did patients develop respiratory depression requiring the use of naloxone. Future trials could investigate the safety and efficacy of higher doses of opioids. Implementation of nurse-initiated and patient-driven pain management protocols for opioids in the ED has shown improvements in timely provision of appropriate analgesics and has resulted in better pain reduction.

Conclusions:

Currently, intravenous administration of opioids for severe acute pain in the ED appears to be inadequate. Opioid doses in the ED should be high enough to provide adequate analgesia without additional risk to the patient. EDs could implement institution-specific protocols to standardize the management of pain.

Assessment and management of acute pain in adult medical inpatients: a systematic review

OBJECTIVE

To review the literature addressing effective care for acute pain in inpatients on medical wards.

METHODS

We searched Medline, PubMed Clinical Queries, and the Cochrane Database for systematic reviews published in 1996 through April 2007 on the assessment and management of acute pain in inpatients, including patients with impaired self-report or chemical dependencies. We conducted a focused search for studies on the timing and frequency of assessment, and on the use of patient-controlled analgesia (PCA) for nonsurgical pain. Two investigators performed a critical analysis of the literature and compiled narrative summaries to address the key questions.

RESULTS

We found no evidence that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients. There is good evidence that treating abdominal pain does not compromise timely diagnosis and treatment of the surgical abdomen. Pain management teams and other systemwide interventions improve assessment and use of analgesics, but do not clearly affect pain outcomes. The safety and effectiveness of PCA in medical patients have not been studied. There is weak evidence that most cognitively impaired individuals can understand at least one self-assessment measure. Almost no evidence is available to guide management of pain in delirium. Evidence for managing pain in patients with substance abuse disorders or chronic opioid use is weak, being derived from case reports, retrospective studies, and expert opinion.

CONCLUSIONS

Pain is a prevalent problem for medical inpatients. Clinical research is needed to guide the assessment and management of pain in this setting.

Safety and Efficacy of Hydromorphone as an Analgesic Alternative to Morphine in Acute Pain: A Randomized Clinical Trial

STUDY OBJECTIVE

We compare a standard weight-based dose of intravenous hydromorphone (Dilaudid) to a standard weight-based dose of intravenous morphine in adults presenting to the ED with acute severe pain.

METHODS

This was a prospective, randomized, double-blind, clinical trial conducted in an academic medical center. Of the 198 adult patients presenting to the ED with acute severe pain who were randomized to receive either intravenous hydromorphone at 0.015 mg/kg or intravenous morphine at 0.1 mg/kg, 191 patients had sufficient data for analysis. The main outcome measure was the difference between the 2 groups in pain reduction at 30 minutes as measured on a validated numeric rating scale. Adverse effects, pain reduction at 5 minutes and 2 hours postbaseline, and additional analgesics and antiemetics were tracked as secondary outcome measures.

RESULTS

The mean change of pain from baseline to 30 minutes postbaseline in patients allocated to intravenous hydromorphone was -5.5 numeric rating scale units versus -4.1 in patients allocated to intravenous morphine (difference -1.3; 95% confidence interval -2.2 to -0.5). Adverse effects were similar in both groups, with the exception of pruritus, which did not occur in patients receiving hydromorphone (0% versus 6% [difference -6%; 95% confidence interval -11% to -1%]). No patient required naloxone.

CONCLUSION

For the treatment of acute, severe pain in the emergency department, intravenous hydromorphone at 0.015 mg/kg represents a feasible alternative to intravenous morphine at 0.1 mg/kg.

Basic pharmacology and advances in emergency medicine

To provide optimal pain control for their patients, emergency physicians should have an in-depth understanding of analgesic drugs and how to use and combine them effectively. The purpose of this article is to describe the pharmacology and use of analgesic agents that are most useful in the management of acute pain in the emergency department.

Intravenous patient-controlled analgesia: one size does not fit all

Patient-controlled analgesia was introduced as a technique that would allow greater flexibility in opioid delivery for the management of acute pain. However, so far, any benefit compared with conventional methods of pain relief appears to be small. This article reviews some of the factors that could limit the usefulness of intravenous patient-controlled analgesia in the clinical setting and what strategies might allow patient-controlled analgesia to become more effective.

Hydromorphone

Hydromorphone is a semi-synthetic opioid that has been used widely for acute pain, chronic cancer pain and to a lesser extent, in chronic nonmalignant pain. Its pharmacokinetics and pharmacodynamics have been well studied, including immediate release oral preparations, a variety of slow release oral preparations, as well as administration through intravenous, subcutaneous, epidural, intrathecal and other routes. It is known to be metabolized to analgesically inactive metabolites that have been associated with neuroexcitatory states and other toxicity. There is no evidence that hydromorphone has any greater abuse liability than other opioids. Further research is needed to address remaining areas of uncertainty: equianalgesic ratios; relative risk of toxicity compared with other opioids, its use in nonmalignant pain, and the role of specific hydromorophone metabolites in the development of toxicity, particularly in association with organ failure.

A systematic review of hydromorphone in acute and chronic pain

While morphine is historically the gold standard for the management of severe cancer pain, some patients either do not achieve adequate analgesia, or suffer intolerable side effects from this drug. For these patients, alternatives such as hydromorphone are recommended. This review explores the evidence for the efficacy of hydromorphone in the management of pain. A systematic search, from 1966 to 2000, of published and unpublished randomized trials that involved the administration of hydromorphone for both acute and chronic pain conditions in adults and children, was conducted. Forty-three studies were included in the review; 11 involved chronic cancer pain and 32 acute pain. Approximately half the studies received a low quality score. In addition, the heterogeneity of the studies precluded combination of data and results. Overall, hydromorphone appears to be a potent analgesic. The limited number of studies available suggests that there is little difference between hydromorphone and other opioids in terms of analgesic efficacy, adverse effect profile and patient preference. However, most studies involved small numbers of patients and wide ranges in equianalgesic dose ratios, making it difficult to determine real differences between interventions.

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.

Meperidine: a critical review

Meperidine was initially synthesized as an anticholinergic agent but was soon discovered to have analgesic properties. Although meperidine's anticholinergic effects were demonstrated in vivo, the anticholinergic effects on the biliary and renal tracts have not been demonstrated in vivo. Studies have clearly demonstrated that meperidine is no more efficacious in treating biliary or renal tract spasm than comparative mu opioids. The initial studies demonstrating the analgesic efficacy of meperidine were mostly case reports and not double-blind, randomized, controlled trials in specific populations. Subsequent comparative studies failed to demonstrate any advantages of meperidine over comparable doses of other analgesics. Meperidine was portrayed in practice and teaching as having unique clinical advantages. The analgesic effects of meperidine are not pronounced, and, in addition, meperidine use is complicated by unique side effects including serotonergic crisis and normeperidine toxicity. Meperidine's poor efficacy, toxicity, and multiple drug interactions have resulted in a movement to replace meperidine with more efficacious and less toxic opioid analgesics.

Pearls, pitfalls, and updates for pain management

Pain management is one of the most challenging areas we encounter as emergency physicians. However, many of us fail to adequately meet this challenge. This article discusses frequently encountered pain syndromes and pain management options.