From the Guidelines
Yes, a patient can experience fentanyl withdrawal even if they are receiving hydromorphone (Dilaudid). While both medications are opioids, they have different potencies, durations of action, and receptor binding profiles. Fentanyl is approximately 80-100 times more potent than morphine, while hydromorphone is about 5-7 times more potent 1. When switching from fentanyl to hydromorphone, the dose equivalence must be carefully calculated to prevent withdrawal. Inadequate dosing of hydromorphone will not fully occupy the opioid receptors previously saturated by fentanyl, leading to withdrawal symptoms such as anxiety, muscle aches, runny nose, sweating, diarrhea, and vomiting.
Some key points to consider when transitioning from fentanyl to hydromorphone include:
- Calculating an appropriate equianalgesic dose to prevent withdrawal symptoms
- Considering overlapping the medications during transition to minimize withdrawal symptoms
- Monitoring the patient closely for withdrawal symptoms and adjusting the hydromorphone dose as needed
- Potentially using a longer-acting opioid for managing withdrawal from fentanyl, as noted in the 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV 1.
It's also important to note that buprenorphine, a partial opioid agonist, can be used in conjunction with other opioids like hydromorphone for pain management, and its unique properties may be beneficial in certain cases 1. However, the primary concern when switching from fentanyl to hydromorphone is preventing withdrawal symptoms, and careful dose calculation and monitoring are crucial to achieving this goal.
From the FDA Drug Label
Physical dependence results in withdrawal symptoms after abrupt discontinuation or a significant dosage reduction of a drug. Withdrawal also may be precipitated through the administration of drugs with opioid antagonist activity (e.g., naloxone, nalmefene), mixed agonist/antagonist analgesics (e.g., pentazocine, butorphanol, nalbuphine), or partial agonists (e.g., buprenorphine). Hydromorphone hydrochloride tablets should not be abruptly discontinued in a physically-dependent patient [see Dosage and Administration ( 2. 6)]. If hydromorphone hydrochloride tablets are abruptly discontinued in a physically-dependent patient, a withdrawal syndrome may occur.
The patient can have withdrawal symptoms if they are physically dependent on fentanyl and Dilaudid (hydromorphone) is given, especially if the dose of Dilaudid is not equivalent to the dose of fentanyl.
- Key points:
- Physical dependence can occur with chronic use of opioids.
- Withdrawal symptoms can occur with abrupt discontinuation or significant dosage reduction of an opioid.
- Dilaudid can precipitate withdrawal symptoms in a patient physically dependent on fentanyl if not properly managed. 2
From the Research
Fentanyl Withdrawal and Dilaudid Administration
- Fentanyl withdrawal can occur even if a patient is being administered Dilaudid (hydromorphone), as the two substances have different pharmacokinetic profiles and receptor binding affinities 3, 4.
- The likelihood of fentanyl withdrawal when administering Dilaudid depends on various factors, including the patient's opioid use history, the dose and duration of fentanyl use, and the timing of Dilaudid administration relative to fentanyl use 3.
- Studies have shown that buprenorphine, an opioid agonist/antagonist, can precipitate withdrawal in individuals with recent fentanyl use, highlighting the complexity of opioid withdrawal management 3.
Opioid Withdrawal Management
- Opioid replacement taper with morphine, codeine, or methadone has been a traditional approach to managing heroin withdrawal syndrome, but newer approaches using clonidine and buprenorphine have become more prominent 5.
- The pharmacological management of opioid withdrawal has evolved to prioritize long-term treatment with medications for opioid use disorder, rather than solely focusing on achieving abstinence from all opioids 5.
- Non-opioid medications, such as α-2 adrenergic agonists, can facilitate opioid tapering and provide a gateway to long-term treatment with naltrexone or psychosocial therapies 6.
Factors Influencing Fentanyl Withdrawal
- Body mass index (BMI) can influence fentanyl clearance and withdrawal symptoms, with overweight or obese individuals experiencing slower fentanyl clearance and higher withdrawal symptom scores 4.
- The route of administration and formulation of fentanyl can also impact the risk of abuse, dependence, and withdrawal, with transdermal fentanyl being commonly associated with these adverse effects 7.