April 30, 2016

An article by Padma Gulur et al. in Pain Research and Treatment
Volume 2015 (2015), Article ID 482081 looked at morphine and hydromorphone use.  Hydromorphone (Dilaudid) is up to 7.5 times as potent as morphine and its use has dramatically increased in the past decade.  This study has some great background information and resources which I have included below.  The study found that patients given hydromorphone as compared to morphine were:

  1. More frequently given rescue drugs
  2. Discharged earlier
  3. Readmitted more frequently within 30 days.

From the article

In 2001, it was reported that approximately 9 in 10 Americans frequently experience pain [1]. In the United States, it has been estimated that 100 million adults suffer from chronic pain alone [2]. As a result, arguments for the undertreatment of pain in the United States have led to several outcomes. The American Pain Society (APS) released guidelines in 1995, which stated that the first step towards improving pain management is assessment and recording of patients’ pain reports [3]. The Joint Commission addressed the common practice of suboptimal pain management in 2001 by requiring professionals to ask patients about their pain, treat it when necessary, and evaluate the effects of therapy rendered [4]. At about the same time, the Veterans Administration rolled out a Quality Improvement initiative calling for pain the be treated as the fifth vital sign [5]. Both of these initiatives, confronting the undertreatment of pain, contributed to practice changes that increased awareness on the importance of treating pain. These changes are notable considering that Fox and colleagues stated that the most common symptom that motivates people to seek health care is pain [6]. In turn, there have been unprecedented increases in opioid production and prescription in attempt to manage pain in the United States [5, 7]. Specifically, 80% of the worldwide opioid supply is consumed by Americans, who make up less than 5% of the world’s total population [8].

An interesting national trend appears to be the increasing use of hydromorphone compared to morphine. Some evidence in the literature has supported this change [9–11]. This is supported by the US aggregate production data of opioids, which shows a 261.52% increase in hydromorphone production compared to a 190.19% increase in morphine production from 2003 to 2013 [12]. The increase in production and therapeutic use of opioids has paralleled an alarming increase in the diversion, misuse, and development of addiction disorders to prescription opioids. Hydromorphone use, in particular, may contribute to these threats to public health given a faster onset of action and greater euphoric effects when compared to morphine [13].

Morphine is a benzylisoquinoline alkaloid which acts as a potent μ-opioid receptor agonist [14–16]. Morphine is metabolized by glucuronidation into morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) which are active metabolites.

Hydromorphone is a semisynthetic opioid agonist which also acts as a potent μ-opioid receptor agonist and is synthesized somewhat easily by modifying morphine [14]. In comparison to morphine, hydromorphone has a shorter half-life and a greater impact on sedation [13]. Hydromorphone does not form an active 6-glucuronide metabolite; however, it does have the 3-glucoronide metabolite (H3G) which has been shown to have neurotoxic side effects [17, 18].

References

  1. The Joint Commission on Accreditation of Healthcare Organizations and The National Pharmaceutical Council, Pain: Current Understanding of Assessment, Management, and Treatments, National Pharmaceutical Council, 2001, http://www.npcnow.org/system/files/research/download/Pain-Current-Understanding-of-Assessment-Management-and-Treatments.pdf.
  2. Institute of Medicine Report from the Committee on Advancing Pain Research-Care and Education, Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research, The National Academies Press, Washington, DC, USA, 2011, http://books.nap.edu/openbook.php?record_id=13172&page=1.
  3. APS, “American Pain Society guidelines,” 1995.
  4. J. L. Dahl and D. B. Gordon, “Joint Commission pain standards: a progress report,” APS Bulletin, vol. 12, no. 6, pp. 1–8, 2002. View at Google Scholar
  5. R. A. Mularski, F. White-Chu, D. Overbay, L. Miller, S. M. Asch, and L. Ganzini, “Measuring pain as the 5th vital sign does not improve quality of pain management,” Journal of General Internal Medicine, vol. 21, no. 6, pp. 607–612, 2006. View at Publisher · View at Google Scholar · View at Scopus
  6. C. D. Fox, D. Berger, P. G. Fine, et al., “Pain assessment and treatment in the managed care environment. A position statement from the American Pain Society,” The Case Manager, vol. 11, no. 5, pp. 50–53, 2000. View at Google Scholar
  7. H. Vila Jr., R. A. Smith, M. J. Augustyniak et al., “The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: Is patient safety compromised by treatment based solely on numerical pain ratings?” Anesthesia and Analgesia, vol. 101, no. 2, pp. 474–480, 2005. View at Publisher · View at Google Scholar · View at Scopus
  8. L. Manchikanti, “Prescription drug abuse: what is being done to address this new drug epidemic? Testimony before the subcommittee on criminal justice, drug policy and human resources,” Pain Physician, vol. 9, no. 4, pp. 287–321, 2006. View at Google Scholar · View at Scopus
  9. A. K. Chang, P. E. Bijur, R. H. Meyer, M. K. Kenny, C. Solorzano, and E. J. Gallagher, “Safety and efficacy of hydromorphone as an analgesic alternative to morphine in acute pain: a randomized clinical trial,” Annals of Emergency Medicine, vol. 48, no. 2, pp. 164–172, 2006. View at Publisher · View at Google Scholar · View at Scopus
  10. L. Felden, C. Walter, S. Harder et al., “Comparative clinical effects of hydromorphone and morphine: a meta-analysis,” British Journal of Anaesthesia, vol. 107, no. 3, pp. 319–328, 2011. View at Publisher · View at Google Scholar · View at Scopus
  11. D. Hong, P. Flood, and G. Diaz, “The side effects of morphine and hydromorphone patient-controlled analgesia,” Anesthesia and Analgesia, vol. 107, no. 4, pp. 1384–1389, 2008. View at Publisher · View at Google Scholar · View at Scopus
  12. US Department of Justice, Quotas, US Department of Justice, Drug Enforcement Administration, Springfield, Va, USA, 2012, http://www.deadiversion.usdoj.gov/quotas/index.html.
  13. E. O. Bryson, “The anesthetic implications of illicit opioid abuse,” International Anesthesiology Clinics, vol. 49, no. 1, pp. 67–78, 2011. View at Publisher · View at Google Scholar · View at Scopus
  14. T. Ogura and T. D. Egan, “Opioid agonists and antagonists,” in Physiology and Pharmacology for Anesthesia: Foundations and Clinical Application, H. C. Hemmings and T. D. Egan, Eds., pp. 253–271, Elsevier, Philadelphia, Pa, USA, 2013. View at Google Scholar
  15. C. Quigley, “Hydromorphone for acute and chronic pain (review),” Cochrane Database of Systematic Reviews (Online), no. 1, Article ID CD003447, 2002. View at Google Scholar · View at Scopus
  16. P. A. Glare and T. D. Walsh, “Clinical pharmacokinetics of morphine,” Therapeutic Drug Monitoring, vol. 13, no. 1, pp. 1–23, 1991. View at Publisher · View at Google Scholar · View at Scopus
  17. H. F. Hill, B. A. Coda, A. Tanaka, and R. Schaffer, “Multiple-dose evaluation of intravenous hydromorphone pharmacokinetics in normal human subjects,” Anesthesia & Analgesia, vol. 72, no. 3, pp. 330–336, 1991. View at Google Scholar · View at Scopus
  18. A. W. E. Wright, L. E. Mather, and M. T. Smith, “Hydromorphone-3-glucuronide: a more potent neuro-excitant than its structural analogue, morphine-3-glucuronide,” Life Sciences, vol. 69, no. 4, pp. 409–420, 2001. View at Publisher · View at Google Scholar · View at Scopus

 

Source: Morphine versus Hydromorphone: Does Choice of Opioid Influence Outcomes?