Hydromorphone in more recent times has been looked upon with favor by physicians and opioid users alike. Most recent literature shows it to be around 4 times the potency of morphine and faster acting. Its quick onset of effects and short duration make it a well suited narcotic for incidents of sudden onset and breakthrough pain. Hydromorphone is best known under the brand name drug Dilaudid.
Dosing and Bioavailability:
Users must consider the poor bioavailability of HM when taken orally. Approximately 25 percent of an oral dose effectively reaches the brain/CNS, compared with about 50 to 60 percent for oral morphine. This factor is important to consider, and dosage should be selected accordingly. An 8 mg dilaudid (hydromorphone) tablet will effectively provide the activity of about 2 mg; making the 8 mg dose roughly equal to a full 15 mg of morphine taken orally - of which around 8 milligrams will become active within the central compartment.
Rescue analgesia in breakthrough pain:
Hydromorphone taken orally will take effect in 15 to 20 minutes and generally has a duration of 2 to 4 hours in most users/patients. If the drug is to be taken around the clock for persistent pain, this may require dosing 6 or more (even up to 12) times daily. A better option for continuous symptoms is to use a long acting medication such as morphine ER, taken once or twice daily depending on the formulation; with fast acting hydromorphone as an adjunct for use only AS NEEDED. With a continuous level of morphine in the blood providing a steady baseline level of analgesia, a second agent (hydromorphone) will be required in much less frequency, only for episodes of breakthrough pain which the morphine is unable to prevent.
A well structured approach:
Depending on the individual, hydromorphone may work well in combination with long acting forms of morphine, fentanyl as well as methadone; which when combined with a traditional opiate, may provide a highly effective profile of analgesia due to its additional nmda antagonist properties (which suits it for neuropathic pain as well as exhibiting tolerance sparing properties)
Imagine the pain of a severed arm, or a double compound tib/fib fracture (of the lower leg)...
In the hospital setting, hydromorphone has become a common first or second line medication in the Emergency Department and other units, including the operating suite. In these settings it is most commonly given by IV or IM injection, in doses starting at 1 to 2 mg (titrated upwards prn). Its rapid onset and high potency allows highly effective relief within seconds in severely or critically injured patients. HM's side effect profile is generally less troublesome than morphine, with less histaminic effect (less itching and flushing) and less tendency to produce nausea and vomiting.