Recommended Doses for Acute Pain Management in the Emergency Room
For acute pain management in the emergency room, hydromorphone 0.015 mg/kg IV is recommended as the first-line medication for severe pain due to its quicker onset of action, comparable cost to morphine, and potentially superior analgesic properties. 1
Pain Management Algorithm Based on Pain Severity
Severe Pain
- Hydromorphone 0.015 mg/kg IV is recommended as first-line therapy for severe pain 1, 2
- Consider a "1+1" patient-driven protocol: 1 mg IV hydromorphone followed by an optional second 1 mg dose 15 minutes later if the patient requests more pain medication 1, 3
- This protocol has been shown to provide adequate analgesia in 92.3% of patients versus 76.6% with usual care 3
- The "1+1" protocol is both statistically superior and at least as clinically efficacious and safe as traditional physician-driven treatment 4
- For patients with renal impairment, start with one-fourth to one-half the usual dose of hydromorphone 5
Moderate-Severe Pain
- Fentanyl (1 mcg/kg, then ~30 mcg q 5 min) is recommended over morphine due to its shorter onset of action, higher potency, and better bioavailability 2, 1
- If morphine is used, administer 0.1 mg/kg initially, then 0.05 mg/kg at 30 minutes, with maximum suggested dose of 10 mg 2
- Morphine has a longer onset of action and greater risk for dose stacking, placing patients at higher risk for toxicity 2
Mild-Moderate Pain
- Non-specific NSAIDs (e.g., ibuprofen) are recommended over codeine-acetaminophen combinations 2, 1
- NSAIDs have a lower number needed to treat (2.7 for naproxen vs. 4.4 for codeine-acetaminophen), longer time to re-medication, and safer side effect profile 2
Special Considerations
Hepatic Impairment
- Start patients with hepatic impairment on one-fourth to one-half the usual dose of hydromorphone depending on the extent of impairment 5
Renal Impairment
- Start patients with renal impairment on one-fourth to one-half the usual starting dose of hydromorphone 5
- Hydromorphone is safer than morphine in renal impairment due to lower risk of toxic metabolite accumulation 1
Administration Guidelines
- For IV hydromorphone, administer slowly over at least 2-3 minutes 5
- For elderly or debilitated patients, consider reducing the initial dose to 0.2 mg 5
- When converting from other opioids to hydromorphone, reduce the calculated equivalent dose by 50% due to incomplete cross-tolerance 5
Monitoring and Safety
- Monitor patients for respiratory depression, which can occur at any time during opioid therapy, especially when initiating and following dosage increases 5
- In clinical trials of the "1+1" hydromorphone protocol, only 5% of patients experienced transient oxygen desaturation below 95%, which was promptly corrected with oxygen 6
- No patients required naloxone in studies of the "1+1" protocol 3, 6
- The addition of IV acetaminophen (1g) to hydromorphone (1mg) has not been shown to provide clinically meaningful or statistically superior analgesia compared to hydromorphone alone 7
Titration and Maintenance
- Titrate the dose based on individual patient response to their initial dose 5
- Continually reevaluate patients to assess maintenance of pain control and monitor for adverse reactions 5
- If pain increases after dosage stabilization, identify the source of increased pain before increasing the hydromorphone dosage 5
- For discontinuation in patients who have been taking hydromorphone regularly, taper the dose gradually by 25-50% every 2-4 days to avoid withdrawal symptoms 5