Background and Objectives
Opioid titration is an effective strategy for treating pain. However, titration is generally impractical in the busy emergency department (ED) setting. Our objective was to test a rapid, 2-step, hydromorphone titration protocol against usual care in older patients presenting to the ED with acute severe pain.
Methods
This was a prospective, randomized clinical trial of patients 65 years of age and older presenting to an adult, urban, academic ED with acute severe pain. The study was registered at www.clinicaltrials.gov (NCT01429285). Patients randomized to the hydromorphone titration protocol initially received 0.5 mg intravenous (IV) hydromorphone. Patients randomized to usual care received any dose of any IV opioid. At 15 minutes, patients in both groups were asked, “Do you want more pain medication?” Patients in the hydromorphone titration group who answered “yes” received a second dose of 0.5 mg IV hydromorphone. Patients in the usual care group who answered “yes” had their treating attending notified, who then could administer any (or no) additional medication. The primary efficacy outcome was satisfactory analgesia defined a priori as the patient declining additional analgesia at least once when asked at 15 or 60 minutes after administration of initial opioid. Dose was calculated in morphine equivalent units (MEU: 1 mg hydromorphone = 7 mg morphine). Need for naloxone to reverse adverse opioid effects was the primary safety outcome.
Results
83.0% of 153 patients in hydromorphone titration group achieved satisfactory analgesia compared to 82.5% of 166 patients in the usual care group (p=0.91). Patients in the hydromorphone titration group received lower mean initial doses of opioids at baseline than patients in UC (3.5 MEU vs. 4.7 MEU respectively, p=<0.001) and lower total opioids through 60 minutes (5.3 MEU vs. 6.0 MEU, p=0.03). No patient needed naloxone.
Conclusions
Low-dose titration of IV hydromorphone in increments of 0.5 mg provides comparable analgesia to usual care with less opioid over 60 minutes.