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Introduction to Hydromorphone

Hydromorphone is a potent narcotic pain medication that is used to treat moderate to severe pain. It is in the opioid drug class and works in the body by binding to opioid receptors in the central nervous system, preventing pain sensations from being sent to the brain. 

Some common brand names for hydromorphone include Dilaudid, Exalgo, and Palladone. It comes in both immediate-release and extended-release formulations for oral administration. The extended-release formulations provide longer-lasting pain relief by slowly releasing the medication over time.

Hydromorphone was first developed in Germany in the 1920s. It was initially introduced as an alternative to morphine and other opioid pain medications. Hydromorphone became widely used for pain management starting in the 1960s and remains an important option today for treating severe acute and chronic pain when other medications are insufficient. It is available by prescription only and is classified as a Schedule II controlled substance due to its potential for abuse.

Medical Uses of Hydromorphone

Hydromorphone is commonly used to treat moderate to severe pain, especially after surgery or injury. It is frequently prescribed when other opioid medications, like morphine or oxycodone, have proven ineffective for a patient. 

As an opioid drug, hydromorphone works by binding to opioid receptors in the brain and spinal cord. This blocks pain signals from being transmitted through the central nervous system. 

Hydromorphone is available in immediate and extended-release oral formulations. The extended-release version provides around-the-clock pain relief, while the immediate-release form acts more rapidly for acute pain episodes. 

As with other potent opioids, the use of hydromorphone for pain requires close monitoring to avoid overdose. However, it remains an important option for managing severe pain when other treatments fail to provide sufficient relief.

Dosages and Administration of Hydromorphone

Hydromorphone is available in both oral and injectable formulations. The oral forms include immediate-release tablets and oral solutions as well as extended-release capsules and tablets. 

For acute pain relief, the typical oral dosage for an opioid-naive adult is 2 to 4 mg every 4 to 6 hours as needed. The starting dose may be even lower at 1 to 2 mg in debilitated or elderly patients. For chronic pain, dosages usually start at 2 to 4 mg orally every 4 to 6 hours and are then titrated to effect. 

The injectable formulation is commonly used in medical settings to provide rapid pain relief. Usual parenteral doses for opioid-naive patients range from 0.2 to 1 mg given slowly through an IV every 2 to 3 hours as needed. Intramuscular injections can also be given in increments of 1 to 2 mg.

Common Side Effects of Hydromorphone

Hydromorphone use can lead to several side effects, especially when misused or abused. Patients should be informed about the potential adverse effects listed below:

Drowsiness: Hydromorphone can cause drowsiness, tiredness, and feelings of relaxation. This is more likely when first starting treatment or increasing the dosage. It’s important not to drive or operate machinery until knowing how hydromorphone affects you.

Dizziness: Some patients report feeling lightheaded or dizzy after taking hydromorphone, especially when changing positions. Standing up slowly and using caution on stairs can help reduce the risk of falls. Notify your doctor if dizziness is severe or persists over time.

Nausea: Nausea and vomiting are common side effects, reported in up to 24% of patients taking hydromorphone. Taking the medication with food can help minimize stomach upset.

Constipation: Like other opioids, hydromorphone frequently causes constipation. Staying hydrated, eating high-fiber foods, and using laxatives can help manage this troublesome side effect.

Dependence and Addiction: Hydromorphone has a high potential for dependence and addiction. With prolonged use, patients may require higher doses to achieve the same effect. Stopping abruptly can cause withdrawal symptoms.

Overdose: An overdose of hydromorphone depresses breathing and can be fatal. Symptoms include extreme drowsiness, slow heartbeat, cold clammy skin, very small pupils, and slow or troubled breathing.

Warnings and Precautions

Hydromorphone should be used with care, as it comes with several warnings and precautions that patients should be aware of:

Alcohol

Hydromorphone should not be used in conjunction with alcohol. The combination can lead to dangerous effects such as extreme drowsiness, respiratory depression, coma and death. Patients prescribed hydromorphone should avoid any intake of alcohol.

Elderly Patients

Elderly patients are at a heightened risk of dangerous side effects from hydromorphone such as respiratory depression, sedation and confusion. They require extra caution and reduced dosages. Elderly patients and their caregivers should monitor closely for side effects when taking hydromorphone. The initial dose should be lowered substantially in geriatric patients.

Interactions of Hydromorphone

Hydromorphone has potentially unsafe interactions with certain medications and substances. It is important to inform your doctor and pharmacist about all prescription and over-the-counter medications, supplements, and herbal products you are taking before starting hydromorphone. 

Unsafe interactions can occur with:

Alcohol – Concurrent use can increase the risk of dangerous side effects of both alcohol and hydromorphone, including respiratory depression, hypotension, profound sedation, and death. Avoid alcohol when taking hydromorphone.

Benzodiazepines like alprazolam, diazepam, and lorazepam – Taking benzodiazepines with hydromorphone significantly increases the risk of respiratory depression, profound sedation, coma, and death due to combined CNS depressant effects. Use together only if needed and under medical supervision.  

Antidepressants like citalopram, fluoxetine, and sertraline – Can increase hydromorphone levels and effects. Risk of serotonin syndrome. Use caution.

Muscle relaxants like cyclobenzaprine, and carisoprodol – Additive CNS depression and respiratory depression. Avoid combination if possible.

Antihistamines like diphenhydramine – Increased risk of severe drowsiness and respiratory depression. Use together only if needed.

Other opioid analgesics – Potentially fatal overdose when combined. Use together only under medical supervision.

MAO inhibitors – Can cause serotonin syndrome, a life-threatening reaction. Allow 14 days after stopping MAOI before starting hydromorphone.

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