What methods can be used to wean a patient with chronic abdominal pain due to chronic pancreatitis off intravenous (IV) hydromorphone, who has been tried on adjuvants like fluoxetine, gabapentin, naproxen, tramadol, ketorolac, Tylenol (acetaminophen and codeine) 3, and suboxone (buprenorphine and naloxone), with no evidence of opioid use disorder (OUD) and a clear computed tomography (CT) scan of the abdomen?

From the Guidelines

To wean this patient off IV hydromorphone, I recommend implementing a structured opioid tapering plan combined with multimodal pain management, starting with a conversion to oral opioids and a 20-30% dose reduction, as well as optimizing non-opioid medications and non-pharmacological approaches. The patient's history of chronic abdominal pain from chronic pancreatitis and intermittent alcohol use, despite having no opioid use disorder (OUD) according to addictions services, requires a careful approach to tapering opioids while managing pain effectively.

Opioid Tapering Plan

The plan should involve converting IV hydromorphone to oral opioids using an equianalgesic chart, typically at a 20-30% dose reduction to account for incomplete cross-tolerance, as suggested by 1. Establishing a clear tapering schedule, reducing the dose by 5-10% every 1-2 weeks, and adjusting based on the patient's response is crucial.

Multimodal Pain Management

Simultaneously, optimizing non-opioid medications is essential. This can include acetaminophen 1000mg four times daily, celecoxib 100-200mg twice daily (if not contraindicated), and considering increasing gabapentin to therapeutic doses (1800-3600mg daily in divided doses). For neuropathic pain components, adding or optimizing pregabalin (starting at 75mg twice daily) or duloxetine (60-120mg daily) can be beneficial. A tricyclic antidepressant like amitriptyline 10-25mg at bedtime may help with pain and sleep.

Addressing Psychological Factors and Non-Pharmacological Approaches

Addressing psychological factors by screening for depression, anxiety, and trauma, which can amplify pain perception, is vital. Considering a pain psychology referral and establishing clear boundaries with a written pain contract specifying goals, expectations, and consequences can help. Regular urine drug screening and pill counts can monitor adherence. Non-pharmacological approaches, including cognitive behavioral therapy for pain, physical therapy, and referral to a comprehensive pain management program, should be implemented.

Alternative Considerations

Given the patient's complex situation, an alternative approach could involve a trial of buprenorphine/naloxone, as suggested by 1, especially if the patient has not responded well to high opioid doses and has experienced poor outcomes with tapering. This option may reduce urges for dose escalation and is demonstrably safer than high doses of mu agonists. However, this should be considered on a case-by-case basis, taking into account the patient's specific needs and responses to previous treatments.

Prioritizing Patient Safety and Well-being

Ultimately, the goal is to prioritize the patient's safety and well-being, minimizing the risk of opioid dependence while effectively managing chronic pain. A multimodal approach that combines opioid tapering with optimized non-opioid medications and non-pharmacological strategies is likely to yield the best outcomes in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

Do not abruptly discontinue Hydromorphone Hydrochloride Injection in a physically-dependent patient. (2.6) The patient should be weaned off iv hydromorphone slowly and carefully to avoid withdrawal symptoms.

• A conservative approach would be to gradually taper the dose of hydromorphone,
• monitoring the patient closely for signs of withdrawal or increased pain. 2

From the Research

Methods to Wean Off IV Hydromorphone

To wean a patient off IV hydromorphone, the following methods can be considered:

• Gradual dose reduction: This involves gradually reducing the dose of IV hydromorphone over a period of time to minimize withdrawal symptoms 3.
• Conversion to oral opioids: The patient can be converted to oral opioids, such as oral hydromorphone or morphine equivalent daily dose (MEDD), using a conversion ratio 3.
• Opioid rotation: Rotating to a different opioid, such as oxycodone or morphine, may be considered if the patient is experiencing inadequate pain control or side effects 3, 4.
• Use of adjuvant medications: Adjuvant medications, such as gabapentin or pregabalin, can be used to manage neuropathic pain and reduce the need for opioids 5.
• Non-pharmacological interventions: Non-pharmacological interventions, such as cognitive behavioral therapy, meditation, or music therapy, can be used to manage pain and reduce the need for opioids 5.

Conversion Ratios

When converting from IV hydromorphone to oral opioids, the following conversion ratios can be used:

• 1 mg of IV hydromorphone is equivalent to 2.5 mg of oral hydromorphone 3.
• 1 mg of IV hydromorphone is equivalent to 11.46 mg of MEDD 3.

Alternative Opioids

If IV hydromorphone is not available, alternative opioids, such as nalbuphine or buprenorphine, can be considered 6. However, it is essential to carefully evaluate the advantages and disadvantages of these alternatives and outline potential dosing strategies.