HYDOMORPHONE (DILAUDUD) IS MORE POTENT THAN YOU THINK
By Amy Rosenberg, PharmD, and Robert Hurley, MD
Scenario: A patient is admitted to the hospital following a procedure and has an order for hydromorphone (Dilaudid) 1-2 mg IV every 2 hours prn for severe pain. That evening the patient complains of severe pain rated 7/10 and receives 2 mg of IV hydromorphone. The patient’s nurse returns to the room 30 minutes later and finds the patient difficult to arouse, with a respiratory rate of seven breaths per minute and an oxygen saturation of 70 percent.
Respiratory depression from opioid analgesic administration is one of the most common causes of medication-related harm for hospitalized patients in the United States and can lead to death. In particular, hydromorphone has been associated with harm, presumably due to a lack of knowledge among all clinicians regarding hydromorphone potency as related to morphine. In this case, 2 mg of IV hydromorphone (Dilaudid) is equivalent to 14 mg of IV morphine. Two milligrams is a high initial dose to administer to an opioid-naïve patient. A commonly used morphine dose of 2 mg IV is equivalent to 0.3 mg IV hydromorphone (Dilaudid).
In many cases, prescribing errors that are not intercepted result in an overdose of opioid analgesic. Although there are other safeguards in place to help protect patients from harm due to opioid analgesics at SUF, below are some of the more reliable strategies that have been put in place in the Epic electronic medical record system to help prevent prescribing errors:
- Standardization of default doses for IV opioid analgesics. These default doses are appropriate initial doses for opioid patients just starting on opioids.
- Opioid dosing equivalents and initial dosing recommendations listed in ordering instructions for all parenteral morphine, hydromorphone and fentanyl products. These are highly visible for clinicians during medication order entry.