August Intro: The Dilaudid® Debacle

Hydromorphone produces more prominent euphoria than morphine in some studies, but whether that translates into greater ED abuse risk is unsettled. When opioids are needed for acute pain, the real bedside question is usually route and sequencing: start oral when possible, use IV selectively, and avoid reflexive repeat IV dosing.

Hydromorphone Versus Morphine in Acute Pain

• Higher likability signal: Hydromorphone has shown higher subjective “likability” and “feeling high” scores than morphine in healthy volunteers, a pharmacologic distinction that keeps surfacing in bedside opioid choice.
• Abuse liability uncertainty: More likable does not automatically mean more abuse-prone; the link between positive subjective effects and real-world misuse remains uncertain, and that distinction is worth hearing in the episode.
• Migraine return-visit data: In ED migraine patients randomized to hydromorphone 1 mg versus prochlorperazine 10 mg plus diphenhydramine 25 mg IV, medication likability was not associated with higher return visits.
• Pain relief versus euphoria: Higher likability scores may track with better analgesia rather than a simple drug “high,” which complicates the common shorthand that hydromorphone is just “hospital heroin.”},{

Practical Opioid Route Strategy

• Oral first approach: When patients can take medications enterally, starting with PO or SL opioids may control pain adequately and can make discharge easier by avoiding a second round of IV analgesia.
• Morphine conversion pearl: Oral morphine is roughly 3:1 compared with IV dosing, with a typical starting PO dose around 15 to 20 mg when escalation beyond non-opioids is needed.
• Sublingual route advantages: Sublingual morphine and oxycodone can act faster than standard oral dosing and last longer than IV dosing, a route choice with useful bedside nuance we get into in the chapter.
• Selective IV fentanyl use: IV fentanyl is best reserved for severe acute pain, with a plan to transition after one or two doses to SL, PO, or another longer-acting option.
• Hydromorphone practice split: Some clinicians have stopped using hydromorphone entirely, while others still value its analgesic effect; the divide often reflects concerns about euphoria, nursing preferences, and repeat dosing patterns.

References:

1. Hill JL, Zacny JP. Comparing the subjective, psychomotor, and physiological effects of intravenous hydromorphone and morphine in healthy volunteers. Psychopharmacology (Berl). 2000;152(1):31-39. PMID: 11041313
2. Wightman R, et al. Likeability and abuse liability of commonly prescribed opioids. J Med Toxicol. 2012;8(4):335-340.  PMID: 22992943
3. Friedman BW, et al. Opioid-Induced "Likeability" and "Feeling Good" Are Not Associated With Return Visits to an ED Among Migraine Patients Administered IV Hydromorphone. Headache. 2018;58(5):750-754. PMID: 29516486