020 A Hydromorphone-Free ED? w/Sergey Motov, MD

Sergey M. Motov, MD, FAAEM Courtesy of Sergey M. Motov, MD Twitter @painfreeED Dr. Motov is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is an Associate Research Director who is passionate about safe and effective pain management in the ED. He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally Missed Episode 011? Low Dose Ketamine for Pain - Administration Explained! Click Here Missed Episode 018? Deep Dive on Continuous Sub-Dissociative Dose Ketamine Infusions, Ketamine in Geriatrics?, Ethics & More Click Here A Candid Conversation on having a Hydromorphone-Free ED with Sergey Motov, MD FAAEM This episode was recorded earlier in the year at the same time as the Deep Dive Continuous Sub-Dissociative Dose Ketamine discussion. Are people forgetting how powerful hydromorphone is? Some people do forget, majority have not been educated. Why are we now using so much hydromorphone? This medication was basically thrown at us. "Use it. It’s a great and safe medication alternative to morphine." Without actual explanations of equi-analgesic conversion, potency, or lipophilicity (lipid solubility) in comparison to morphine. Morphine 8mg or Hydromorphone 1mg? There’s something mental about giving a single digit dose of an opiod versus double digit. It’s much easier to prescribe 1mg, 2mg, 3mg…6mg of hydromorphone than let’s say 10mg of morphine without understanding that hydromorphone 2mg = morphine 16mg. Hydromorphone 1mg = Morphine 8mg Hydromorphone 2mg = Morphine 16mg 48% ED attendings lack pharmacological understanding or validity of why they are using one opioid over another Opioid-Naive Patients First-line medication - should NOT be hydromorphone Initial hydromorphone dose should be 0.2-0.4mg (If you must, for opioid-naive patients) Conversion: Morphine 2-4/5mg dose How to administer opioids? Titrate at Specified Intervals *Clinical Pearl Single dose of opioids will not do the trick. No matter how you dose it (weight based or fixed). Start with a lower dose. Reeval every 10-15 minutes. Ask the patient if they need more. Give another dose as needed. Repeat. No need to wait 4 hours for the next opioid dose. Morphine peak time ~20 minutes Hydromorphone peak time ~15 minutes Morphine, hydromorphone and fentanyl are pure mu receptor agonists with no analgesic ceiling. Titrate opioids up until one or two things will happen: Pain is optimized or they stop breathing Clinical Example: Patient received 3 doses of morphine: 4mg, 4mg, 4mg. Still has pain. Now what? You want to give an opioid. Which one? Some may switch to hydromorphone. But why? Hydromorphone is not any different than morphine except for potency. The most potent opioid is fentanyl. Problem is fentanyl has a shorter half life so will have to re-dose more often. Consider adding non-opioid analgesic modalities If you do switch to hydromorphone - remember to add previous morphine doses and convert equianalgesia for total dosage. i.e. Morphine 12 mg (4mg x3) + Hydromorphone 1mg (Morphine 8mg) = Morphine 20mg Opioid-Induced Hyperalgesia The longer a patient uses opioids to treat pain, the patient will most likely develop hyperalgesia and will ultimately require a higher dose to treat their pain which will eventually lead to tolerance and possibly addiction. Constantly requires a higher dose. Hydromorphone has a Higher Abuse Potential than Morphine Hydromorphone is 10x more lipophilic than morphine. Penetrates the blood brain barrier significantly faster and saturates the mu receptors faster. It translates to a euphoria,