Sergey M. Motov, MD, FAAEM

Twitter @painfreeED

Dr. Motov is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is an Associate Research Director who is passionate about safe and effective pain management in the ED.  He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally

Missed Episode 011? Low Dose Ketamine for Pain – Administration Explained! Click Here

Missed Episode 018? Deep Dive on Continuous Sub-Dissociative Dose Ketamine Infusions, Ketamine in Geriatrics?, Ethics & More Click Here

A Candid Conversation on having a Hydromorphone-Free ED with Sergey Motov, MD FAAEM

This episode was recorded earlier in the year at the same time as the Deep Dive Continuous Sub-Dissociative Dose Ketamine discussion.

Are people forgetting how powerful hydromorphone is?

Some people do forget, majority have not been educated.

Why are we now using so much hydromorphone?

This medication was basically thrown at us. “Use it. It’s a great and safe medication alternative to morphine.” Without actual explanations of equi-analgesic conversion, potency, or lipophilicity (lipid solubility) in comparison to morphine.

Morphine 8mg or Hydromorphone 1mg?

• There’s something mental about giving a single digit dose of an opiod versus double digit.
• It’s much easier to prescribe 1mg, 2mg, 3mg…6mg of hydromorphone than let’s say 10mg of morphine without understanding that hydromorphone 2mg = morphine 16mg.

Opioid-Naive Patients

• First-line medication – should NOT be hydromorphone
• Initial hydromorphone dose should be 0.2-0.4mg (If you must, for opioid-naive patients)
• Conversion: Morphine 2-4/5mg dose

How to administer opioids? Titrate at Specified Intervals *Clinical Pearl

• Single dose of opioids will not do the trick. No matter how you dose it (weight based or fixed).
• Start with a lower dose. Reeval every 10-15 minutes. Ask the patient if they need more. Give another dose as needed. Repeat.
• No need to wait 4 hours for the next opioid dose.
• Morphine peak time ~20 minutes
• Hydromorphone peak time ~15 minutes
• Morphine, hydromorphone and fentanyl are pure mu receptor agonists with no analgesic ceiling.

• Titrate opioids up until one or two things will happen: Pain is optimized or they stop breathing

• Clinical Example:
  • Patient received 3 doses of morphine: 4mg, 4mg, 4mg. Still has pain. Now what? You want to give an opioid. Which one?
  • Some may switch to hydromorphone. But why?
  • Hydromorphone is not any different than morphine except for potency.
  • The most potent opioid is fentanyl. Problem is fentanyl has a shorter half life so will have to re-dose more often.
  • Consider adding non-opioid analgesic modalities
  • If you do switch to hydromorphone – remember to add previous morphine doses and convert equianalgesia for total dosage. i.e. Morphine 12 mg (4mg x3) + Hydromorphone 1mg (Morphine 8mg) = Morphine 20mg

Opioid-Induced Hyperalgesia

Hydromorphone has a Higher Abuse Potential than Morphine

Hydromorphone is 10x more lipophilic than morphine.

• Penetrates the blood brain barrier significantly faster and saturates the mu receptors faster.
• It translates to a euphoria, a high. It’s especially present when administered as an IV push dose.

Morphine penetrates the blood brain barrier more slowly

• Saturates the mu receptors slowly so patients will experience nausea, vomiting.
• Will become dysphoric before euphoria.
• Morphine has less abuse potential than hydromorphone.

Hydromorphone + Diphenhydramine

Background

• Initial studies showed that hydromorphone at higher dose >1.5-2mg will be associated with pruritus.
• Hydromorphone doses below <1mg will have less pruritus (still releases histamines). Both hydromorphone and morphine release histamines.
• Morphine releases histamines at a greater extent.

• Is centrally mediated and related to activation of mu receptors in ~85-90% cases.
• 10% cases may be histamine related. Diphenhydramine may be helpful in these cases.
• The problem with diphenhydramine, it’s a sedative + hydromorphone is a sedative analgesic. Your patients will become loopier and more comatose.
• In 90% of the cases it doesn’t work.

• The first subjective feeling from diphenhydramine is euphoria or a “high”.
• Add that to the high from hydromorphone and your patient has a double high.
• Subsequently your patient becomes loopier, altered, respiratory depression, and CNS depression (double whammy from both hydromorphone and diphenhydramine) = problems with both Respiratory and CNS systems.

Treat Opiod-Induced Pruritis with Nalaxone (super low dose)

• 0.1-0.25mcg/kg/hr
• Will preserve analgesic efficacy and treat opioid-induced pruritus

Ween Off Chronic Opioid Users

• Increasing opioid dose will worsen side effects and ultimately won’t work and just make the situation worse for these patients.
• Non-opiod analgesic modalities come into play
• Alternative and complementary medicine
• Counseling and acknowledge they are in pain and suffering from a disease like an addiction

Reserve hydromorphone only for intractable breakthrough pain related to cancer

“We have been a hydromorphone-free ED for 2 years.”

Palliative care is consulted and prescribes hydromorphone for intractable breakthrough pain related to cancer

Sickle Cell Patients benefit from multiple modality treatment

• Intranasal or nebulized fentanyl
• Nebulized morphine at triage
• Subcutaneous morphine
• Subcutaneous ketamine or Subdissociative continous ketamine iv infusions
• NSAID
• Multiple modality treatment 

Are your sickle cell patients walking out of your ED discharged?

• Some patients are successfully discharged with subcutaneous morphine.
• The hardest part is to have a conversation that there is another way aside from hydromorphone alone.
• Admitted patients are a dilemma – they will get hydromorphone IV and on a PCA pump
• Opioids are indicated in sickle cell patients.
• We need to find a safe and judicious way in using opioids to help patients. More effective, less addictive, less euphoric in combination with non-opioid analgesic medications

Shared Decision Making for Pain Control and Realistic Expectation

• Numeric pain scale is not a good marker for pain control
• Unrealistic expectations for pain control. Not everyone will achieve a pain level of 0/10.
• Zero pain or pain free is unrealistic and harmful to patient
  • Patients may have a natural trajectory of a painful condition and having zero pain is not possible without consequences.
• Functional improvement or restoration is a better marker of pain control
  • Ex: Pt was in a wheelchair but now can tolerate standing after therapeutic/medication intervention. Pain may still be present but tolerable – no need for additional pain management.
  • If your patient is ready to go back to daily ADLs – you’ve achieved your goal for pain control.

How to Re-Assess Pain (Yun Cee’s formula)

• Ask your patient, We have given your pain medication 30 minutes ago, are you still in pain?
• “No.” That’s great. I’m glad that the pain medication helped. Do you feel like you are ready to go home?
• “Yes.” Acknowledge your patient’s pain whether it is acute or chronic.
  • Would you say it is a lot, in the middle, or a little? Did the previous pain medication make any change in your pain (a little change or moderate change)?
  • Remind patient that they have a condition that causes pain (acute or chronic) and we may not be able to remove all of the pain but we can take the edge off so you are more comfortable.
  • Ask the patient, “Even though you still have pain, is it something you can handle or tolerate right now? Or do you need more pain medication at this time?”
    • Pain may be 8/10 but tolerable – no more medication required at this time. Remind patient that if the pain creeps back, that they can always ask for more later.
    • Pain not tolerable and need a little more. Administer pain medication as indicated.
• Repeat above steps until pain is optimized.
• Acute exacerbation of Chronic pain
  • Ask patient if they are willing to try multiple medication modality that has been shown to help other patients in their condition. Concern that patient’s pain will just keep coming back and want to help patient to manage pain at home.
  • Most are willing to try with a little convincing. Remind patient that they can try these medications together and “let’s see what happens.” They are still in the ED and can always receive more if it doesn’t work.

Pain Education Awareness

• 85% patients come into the ED annually with complaints of pain.
• Re-educate ourselves and our patients in how to approach patients’ pain.
• Use shared decision making, expectations, natural trajectory, analgesics, risks and benefits, etc.

Every attempt should be made to keep opioid-naive patients opioid-naive. -Nelson

Keep opioid-naive patients hydromorphone-naive. -Motov

• Do not routinely use hydromorphone in the ED.
• Reserve hydromorphone in situations when patients are suffering from intractable, multianalgesic-resistent painful condition, and when the benefits of using hydromorphone outweigh the risks.
• If you ought to use hydromorphone, use in significantly lower doses that you are accustomed to use.

Now listen to the episode….

1. D’Arrigo, T. (2016). Pharm.D.-M.D. Team Successfully Enacts Opioid-Free ED Shift. [online] Ashpintersections.org. Available at: http://www.ashpintersections.org/2016/02/pharm-d-m-d-team-successfully-enacts-opioid-free-ed-shift/.
2. Cohen, V., Motov, S., Rockoff, B., Smith, A., Fromm, C., Bosoy, D., . . . Marshall, J. (2015, December 01). Development of an opioid reduction protocol in an emergency department. Retrieved from http://www.ajhp.org/content/72/23/2080
3. Motov, MD FAAEM, S., Strayer, MD FRCP FAAEM, R., Hayes, PharmD, B., Reiter, MD MBA FAAEM, M., Rosenbaum, MD FAAEM, S., Richman, MD FAAEM, M., Repanshek, MD FAAEM, Z., Taylor, MBBS, S. and Friedman, MD FAAEM, B. (2017). AAEM White Paper on Acute Pain Management in the Emergency Department. [online] Aaem.org. Available at: https://www.aaem.org/UserFiles/file/WhitePaperAcutePainManaginED102417.pdf
4. Motov, S. (2016). Lectures. [online] Painfree-ed.com. Available at: http://www.painfree-ed.com/lectures.
5. Nicholas Genes, P. and Sergey Motov, M. (2018). Dilaudid in Detail: The Problem with Hydromorphone – Emergency Physicians Monthly. [online] Emergency Physicians Monthly. Available at: http://epmonthly.com/article/dilaudid-detail-problem-hydromorphone/.
6. Scott Weingart. Podcast 139 – Opioid-Free ED with Sergey Motov. EMCrit Blog. Published on December 14, 2014. Available at [https://emcrit.org/emcrit/opioid-free-ed/ ].
7. Trescot, MD, A., Datta, MD, S., Lee, MD, M. and Hansen, MD, H. (2008). Opioid Pharmacology. [online] Painphysicianjournal.com. Available at: http://www.painphysicianjournal.com/current/pdf?article=OTg3&journal=42

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