Is it appropriate to continue a patient's long-term prescription of Hydromorphone (Dilaudid) 18mg twice daily (BID) and Hydromorphone (Dilaudid) 1mg four times daily as needed (QID PRN) and 4mg three times daily as needed (TID PRN) after a spine injury?

Continuing Long-Term Hydromorphone After Provider Transition

Yes, it is appropriate to continue this patient's established hydromorphone regimen after transitioning care from their retired family physician, as abruptly discontinuing or refusing to prescribe opioids in patients on long-term opioid therapy (LTOT) creates serious risks of withdrawal, uncontrolled pain, and potential harm. 1

Ethical and Clinical Obligations When Accepting Legacy Patients

You have a professional obligation to provide continuity of care for this patient who has been on stable LTOT for years following a legitimate spine injury. 1

• Health care systems frequently fail to facilitate transition of care when primary opioid prescribers leave their practice, leaving patients desperate for continuing LTOT 1
• These "legacy patients" need special consideration and treatment to preserve their safety and functioning 1
• The 2020 Mayo Clinic consensus panel specifically addressed this scenario, emphasizing that clinicians should not abandon patients on established opioid therapy 1

Current Prescription Analysis

The current regimen totals approximately 54 mg oral hydromorphone daily (36 mg scheduled + up to 18 mg PRN), which represents a moderate-to-high dose for chronic pain management. 2

Breakdown of Daily Dosing:

• Scheduled component: Hydromorph Contin 18 mg BID = 36 mg/day 2
• PRN component: Hydromorphone 1 mg QID (4 mg/day) + 4 mg TID (12 mg/day) = potential 16 mg/day additional 2
• Total potential daily dose: 52 mg oral hydromorphone 2

Key Observations About This Regimen:

The prescription structure is problematic because it provides excessive PRN dosing relative to the scheduled baseline dose. 1, 3

• The PRN doses (up to 16 mg/day) represent 44% of the total daily dose, which exceeds the recommended 10-20% for breakthrough dosing 1, 3
• Patients requiring more than 3-4 breakthrough doses daily should have their scheduled baseline dose increased rather than relying on frequent PRN dosing 1, 3, 4
• The current structure suggests either inadequate baseline dosing or inappropriate prescribing patterns 1

Immediate Management Strategy

Step 1: Initial Continuation (First 1-2 Visits)

Continue the current prescription initially without changes to establish trust and assess actual usage patterns. 1

• Verify the prescription history through pharmacy records to confirm actual dispensing patterns 1
• Document the patient's current pain levels, functional status, and quality of life 1
• Assess for signs of opioid-induced hyperalgesia, which can occur with chronic hydromorphone use 5
• Screen for concurrent benzodiazepine or carisoprodol use, which is common in this population (35% and 9.2% respectively) and increases overdose risk 6

Step 2: Comprehensive Pain Assessment

Conduct a thorough evaluation focusing on pain intensity, functional capacity, and treatment goals rather than simply continuing prescriptions. 1

Pain Assessment Components:

• Current pain intensity, worst pain in past 24 hours, and usual pain levels 1
• Pain at rest versus pain with movement 1
• Functional limitations: ability to perform physical, cognitive, vocational, and social activities 1
• Document whether the current regimen provides adequate pain relief throughout dosing intervals 2

Red Flags to Evaluate:

• Opioid-induced hyperalgesia: increased pain sensitivity despite opioid therapy 1, 5
• Pseudo-opioid resistance: reporting persistent severe pain to prevent dose reduction 1
• Signs of inadequate pain control versus tolerance development 1

Step 3: Optimize the Regimen Structure

Restructure the prescription to emphasize scheduled dosing with appropriate breakthrough coverage. 1, 3, 2

Recommended Restructuring Approach:

If the patient is actually using most of the PRN doses regularly, consolidate into a higher scheduled dose with appropriate breakthrough coverage. 1, 3

• Calculate total average daily hydromorphone consumption from pharmacy records 1
• Convert 80-90% of total daily dose to scheduled extended-release formulation 1, 2
• Provide breakthrough doses of 10-20% of the 24-hour total, available every 4 hours as needed 1, 3, 4

Example restructuring if patient uses 50 mg daily:

• Hydromorph Contin 24 mg BID (48 mg scheduled) 2
• Hydromorphone IR 6 mg every 4 hours PRN for breakthrough (10-12% of daily dose) 3, 4

If the patient rarely uses PRN doses, maintain current scheduled dose but reduce PRN availability. 1

• Continue Hydromorph Contin 18 mg BID 2
• Provide hydromorphone IR 4 mg every 4 hours PRN (approximately 10% of 36 mg daily dose) 3, 4

Monitoring and Safety Measures

Mandatory Concurrent Interventions

Institute a prophylactic bowel regimen immediately, as constipation is universal with chronic opioid therapy and does not develop tolerance. 7, 2

• Prescribe stimulant laxatives (senna, bisacodyl) or osmotic laxatives (polyethylene glycol) 7
• This is non-negotiable for all patients on sustained opioid therapy 7

Monitor for neuroexcitatory symptoms, particularly given the chronic high-dose hydromorphone use. 7

• Watch for myoclonus, tremors, or agitation 7
• These can occur even with normal renal function but are more common with renal impairment 7
• If present, consider dose reduction or opioid rotation 7

Ongoing Assessment Schedule

Reassess pain control, functional status, and adverse effects at every visit during the first 3 months. 1

• Document pain intensity ratings at each contact 1
• Evaluate whether benefits (pain relief, improved function) continue to exceed risks 1
• Monitor for signs of tolerance, requiring dose escalation 1

When Tapering May Be Indicated

Consider tapering only if specific indications are present, not simply because the dose seems high. 1

Clear Indications for Tapering:

• Patient requests dose reduction 1
• Diminishing analgesia despite dose increases (suggesting tolerance or opioid-induced hyperalgesia) 1, 5
• Intolerable adverse effects that cannot be managed 1, 7
• Lack of functional improvement despite adequate pain control 1
• Development of aberrant drug-related behaviors 1

Tapering Protocol If Needed:

If tapering is indicated, reduce the dose gradually by 25-50% every 2-4 days while monitoring for withdrawal symptoms. 2

• If withdrawal symptoms develop, return to the previous dose and taper more slowly 2
• Never abruptly discontinue hydromorphone in physically dependent patients 2
• Increase the interval between decreases or decrease the amount of change per step 2

Special Considerations for Spine Injury Pain

Neuropathic pain from spine injury may require adjunctive medications beyond opioids alone. 1

• Consider adding gabapentin (100-1200 mg TID) or pregabalin (100-600 mg/day divided BID-TID) 1
• Trial of antidepressants: duloxetine (30-60 mg/day) or nortriptyline (10-150 mg/day) 1
• These adjuvants may allow for lower opioid doses while maintaining pain control 1

Common Pitfalls to Avoid

Do not refuse to prescribe or demand immediate dose reduction simply because the dose seems high or you are uncomfortable with opioids. 1

• Abandoning patients on LTOT creates serious harm and violates ethical obligations 1
• High doses may be appropriate if functional benefits are documented and side effects are manageable 1

Do not maintain the current PRN-heavy structure long-term. 1, 3

• Excessive reliance on PRN dosing suggests inadequate baseline coverage 1
• Restructure to emphasize scheduled dosing with limited breakthrough coverage 1, 3

Do not assume the patient is misusing medication without evidence. 6

• The majority of patients on LTOT were initiated and maintained by primary care physicians, not pain specialists 6
• Most patients on chronic opioids do not have current illicit drug use (only 7.9%) 6

Do not order hydromorphone PRN "every hour" for chronic pain management. 4

• Breakthrough doses should be available every 4 hours, not hourly 4
• More frequent dosing increases peak-to-trough fluctuations without improving analgesia 3