What is the role of Dilaudid (hydromorphone) versus morphine in end-of-life care?

From the Guidelines

Morphine is the preferred opioid for end-of-life care due to its extensive clinical experience, lower cost, and availability in multiple formulations, as supported by the American College of Physicians guideline 1. For end-of-life pain management, morphine is typically started at 2.5-5mg orally every 4 hours or 1-2mg IV/subcutaneously every 2-4 hours. Dilaudid (hydromorphone) is approximately 5-7 times more potent than morphine and may be preferred for patients with renal impairment as it produces fewer active metabolites. Dosing should be individualized based on pain severity, prior opioid exposure, and patient response, with breakthrough doses available as needed (typically 10-15% of the total daily dose). Side effects for both medications include constipation, nausea, sedation, and respiratory depression, though respiratory depression is less concerning in end-of-life care where comfort is the priority. Regular bowel regimens should be implemented, and doses can be titrated upward as needed to achieve comfort, with no maximum dose limit in terminal care when properly monitored, as recommended by the American College of Physicians guideline 1. Additionally, a study published in 2013 in Critical Care found that hydromorphone has a quicker onset of action compared to morphine and is comparable in cost, making it a viable alternative for acute pain management 1. However, the choice between morphine and dilaudid should be based on individual patient needs and clinical judgment. It's also important to note that the evidence-based interventions to improve palliative care of pain, dyspnea, and depression at the end of life, as recommended by the American College of Physicians, include the use of opioids, nonsteroidal anti-inflammatory drugs, and bisphosphonates for pain relief, as well as oxygen for short-term relief of hypoxemia and therapies to manage depression 1. Overall, the goal of end-of-life care is to prioritize patient comfort and alleviate suffering, and the choice of opioid medication should be guided by this principle. Some key points to consider when choosing between morphine and dilaudid include:

• Potency: Dilaudid is approximately 5-7 times more potent than morphine
• Renal impairment: Dilaudid may be preferred for patients with renal impairment due to its fewer active metabolites
• Cost: Morphine is generally less expensive than dilaudid
• Availability: Morphine is available in multiple formulations, including oral and parenteral forms
• Clinical experience: Morphine has extensive clinical experience and is widely used in end-of-life care.

From the Research

End of Life Care with Dilaudid and Morphine

• Dilaudid, also known as hydromorphone, is a potent opioid analgesic used for pain management, including end of life care 2.
• Morphine is another commonly used opioid for pain management at the end of life, and its prescription patterns have been studied in various settings 3, 4.
• A study comparing morphine and hydromorphone found a clinical analgesic equivalence ratio of 3:1, which differs from previously accepted standards 2.
• In end of life care, morphine is often used in continuous infusions to manage pain and dyspnea, with variable patterns of initiation and titration 3.
• The use of sustained-release opioid preparations, including morphine, oxycodone, and transdermal fentanyl, has been compared in hospice patients, with similar outcomes in terms of pain and constipation severity 5.

Comparison of Opioids in End of Life Care

• A study found that patients prescribed transdermal fentanyl had more difficulty communicating with caregivers compared to those prescribed morphine or oxycodone 5.
• The choice of opioid preparation may depend on individual patient needs and circumstances, such as advanced illness and dysphagia 5.
• Education and training for healthcare professionals, including homecare nurses, are essential to improve pain management and correct misconceptions about opioid analgesics 4.

Opioid Dosing and Titration

• The initiation and titration of continuous morphine infusions can vary significantly, with a mean increase of 442% in 24-hour IV morphine equivalent from initiation to time of death 3.
• The number of bolus doses administered and the number of rate adjustments can also vary, highlighting the need for individualized pain management plans 3.