Dilaudid

Dilaudid, the brandname for hydromorphone, is a popular and much sought after street drug. It is highly addictive and is still prescribed by many doctors. Amazingly, as best I can tell, Dilaudid has only been compared to non-narcotic pain relievers in one scientific study. Dilaudid has one loss, no wins, and no ties. If there were more studies, it is virtually certain that it would fail miserably. The corrupt FDA has let manufacturers sell this drug without requiring research comparing it to non-addictive alternatives. Like heroin, morphine, oxycodone, and all of the others, it is an inferior pain killer and the little added benefit it might give is far outweighed by its extremely addictive nature. Something is very rotten in the State of Medicine.

If a doctor wants to give you hydromorphone (Dilaudid), print out this webpage and give it to him. If he still insists on giving you a narcotic, get another doctor. If a doctor gave you Dilaudid and you became addicted and suffered some unfortunate consequence, the doctor and the narcotic manufacturer could be liable for malpractice. Also, consider whether you should report the doctor to the state licensing board. In view of the extensive research on narcotics, prescribing Dilaudid is or at least should be ruled malpractice.

Renal Colic: Hydromorphine (Dilaudid) Inferior to IV Indomethacin: In a DB study of 50 patients with acute ureteral-stone pain, IV indomethacin 50 mg provided more rapid pain relief than SC 2 mg hydromorphine chloride-atropine (Dilaudid-atropine 1 ml). Patients in the latter group also received a suppository of prochlorperazine 25 mg. The side-effects of indomethacin had a tendency to be milder and of shorter duration. Uden P, Rentzhog L, Berger T. A comparative study on the analgesic effects of indomethacin and hydromorphine chloride-atropine in acute, ureteral-stone pain. Acta Chirurgica Scandinavica 1983;149(5):497{9. 6637313.

"Small," Fixed Doses of Morphine or Hydromorphone Don't Give Adequate Relief After Surgery: In a poorly design study of intravenous patient-controlled analgesia (PCA) in 60 patients after surgery, the PCA was programmed to deliver morphine 1 mg or hydromorphone 0.1-0.2 mg, with a lockout interval of 10 and 6 minutes for 80% and 20% of the patients, respectively. During the first 12 hours of intravenous PCA use, 75% of the patients reported moderate-to-severe pain >/= 5 on a verbal numeric rating scale) at rest, 80% after activity. Corresponding values were 33% and 72% for the 12-24-hour period, 43% and 76% for the 24-36-hour period, and 36% and 64% for the 36-48-hour period of intravenous PCA use. Within 4 hours of stopping PCA, 30% and 58% of the patients had moderate-to-severe pain at rest and after activity. Pain control was rated as good or very good by 54% of patients during the first 12 hours of intravenous PCA. Ratings of pain control tended to improve with time. Pain evaluation in patients receiving intravenous patient-controlled analgesia after surgery. Larijani GE, Sharaf I, Warshal DP, Marr A, Gratz I, Goldberg ME. Department of Anesthesiology, Cooper University Hospital, Camden, New Jersey. Pharmacotherapy. 2005 Aug;25:1168-73. Ed: The study design could not prove opiates help, but it did prove that, if they helped at all, their benefit was certainly not very impressive. Another point worth noticing, many patients answered that their pain "control" was at least "good" even though they were still in at least moderate pain. Thus, the "good" rating considerably overestimated the actual amount of pain decrease. (I would avoid the word pain "relief" and prefer pain "decrease" since relief suggests that some outside agent is responsible for the decrease in pain and this can only be determined by a double blind study. Also, to determine whether medicine help at all, a placebo group is necessary. Otherwise, only if one active does better than another can you say that at least the better agent helped and only by the amount of difference between the two. Asking a patient to evaluate pain "control" is wrong, since it is impossible for an individual to tell how much, if any, their decrease in pain is due to a particular agent. Patients may feel an unconscious obligation to give a higher rating of "pain control" so as to be good patients and show that they are grateful for the efforts of the doctors and nursing staff.

Opiates Promoted for Chronic Arthritis in Bogus Open Trial with High Drop-out Rate, Poor Measures, and No Controls: In an industry-funded but totally unscientific 52-week, multicenter, open-label extension study supposed "to evaluate the safety, tolerability, and effectiveness of oxymorphone extended release (ER)," given to 153 patients with moderate to severe chronic osteoarthritis-related pain, only 40% completed the study. Common opioid-related side-effects caused most withdrawals. Mean pain scores decreased druing the first 6 weeks and then remained stable at mild levels throughout the remainder of the study (average pain, 20-25 mm on 100-mm Visual Analog Scale). Average daily dosing was 40 mg/d. At each assessment, at least 80% of patients rated their global satisfaction with oxymorphone ER as "excellent," "very good," or "good," although as noted above, the over-estimates how well the patients are doing. Oxymorphone ER provides a new 12-hour analgesic for the treatment of moderate to severe chronic osteoarthritis-related pain in patients who may require long-term opioid therapy. Safety, tolerability, and effectiveness of oxymorphone extended release for moderate to severe osteoarthritis pain: a one-year study. McIlwain H, Ahdieh H. Tampa Medical Group Research, 4700 N. Habana Avenue, Suite 303, Tampa, FL. . Am J Ther. 2005 Mar-Apr;12(2):106-12. Ed: There needs to be double-blind randomization with one or more active non-narcotic controls such as NSAIDs, glucosamine and chondroitin, and nortriptyline. Also, global satisfaction is a defective measure.

Low Back Pain: High Dose Opiates Had Somewhat Less Pain Than Those Thrown into Withdrawal: In an industry-funded DB PC study supposedly to compare the analgesic "efficacy and safety" of oxymorphone extended release (ER) and oxycodone controlled release (CR) in 213 out-patients with moderate to severe chronic low back pain, patients received either oxymorphone ER (10 to 110 mg) or oxycodone CR (20 to 220 mg) every 12 hours during a 7- to 14-day dose-titration phase. Only those patients having a reduction of pain while on a stable opioid dose entered an 18-day double-blind treatment phase and either continued opioid therapy or received placebo. Patients were then kept at their fixed dosages and those on oxymorphone ER (79 mg/day) and oxycodone CR (155 mg/day) were superior to placebo for change from baseline in pain intensity as measured on a visual analog scale; the LS mean differences were -18.21 and -18.55; P = .0001). Use of rescue medication was 20 mg more per day. The authors claimed, "Oxymorphone ER and oxycodone CR were generally safe and effective for controlling low back pain." Efficacy and safety of oxymorphone extended release in chronic low back pain: results of a randomized, double-blind, placebo- and active-controlled phase III study. Hale ME, Dvergsten C, Gimbel J. Gold Coast Research, LLC, Weston, FL. . J Pain. 2005 Jan;6(1):21-8. Ed: These researchers do a lot of work for the narcotic pain industry. Many of their patients have probably been on opiates before. In addition to this, some patients were elimated before the study began, either because their pain was too severe and not getting better or because of side-effects. Only after two weeks was the placebo introduced, meaning that the control patients were being thrown into withdrawal with access of no non-narcotic pain medications either. Even with all of the study design defects, the narcotics only made the equivalent of one step in pain difference, i.e., mild pain instead of moderate pain. To hook patients on highly addictive narcotics for probably the rest of their lives for such a small benefit which could easily be obtained in several other ways seem callous and irresponsible. Also, opiates do nothing to halt the progression of joint and bone deterioration which interventions like glucosamine, chondroitin, vitamin K, vitamin D, calcium, and others found on this website do slow or halt the deterioration and even lead to some healing.

Hydromorphone Has Never Been Compared to Non-Narcotic Pain Treatments, Yet English Oncologist Claims That It is "A Potent Analgesic:" Sadly, morphine is the gold standard for the management of severe cancer pain without any research to show that it is superior to non-narcotic pain treatments. Morphine has been found inferior in some studies of non-cancer pain and never superior to the best of my knowledge. In this review of double-blind hydromorphone studies through February 2000, out of 43 studies (2725 subjects), the author notes that half of the studies are of low quality. 11 (645 subjects) involved chronic pain conditions (cancer) and 32 (2080 subjects) acute pain. Only three studies were placebo-controlled. In the remainder, hydromorphone was compared with other opioids (morphine, fentanyl, sufentanyl, meperidine, oxycodone, diamorphine), bupivicaine and with itself, using different formulations. Despite not one single study ever comparing hydromorphone to any of the non-narcotic pain medication, medications which have repeated proven superior to opiates, the author proclaims, "Hydromorphone appears to be a potent analgesic." He admits that there is little difference between morphine and hydromorphone in analgesic efficacy. Hydromorphone for acute and chronic pain. Quigley C. Medical Oncology, Hammersmith Hospitals Trust, London, UK. . Cochrane Database Syst Rev. 2002;(1):CD003447. Ed: Morphine IV was no better than an IV relative of acetaminophen and orally no better than another non-narcotic.

Dear Dr. Quigley: Sept. 26, 2005

I am a psychiatrist dealing with numerous opiate addicts who got their first start with prescription narcotics. We are literally drowning in opiate addiction here in rural Pennsylvania. I saw your Cochrane 2002 review. I am puzzled how you can claim that hydromorphone is a potent analgesic for cancer pain when it has never once in a double blind study been compared to any of the non-narcotic pain medications.

I have found over 3 dozen double-blind studies comparing opiates to non-narcotic pain treatments and in every single study, the narcotic is either inferior or no better than the non-narcotic. These include hydrocodone, oxycodone, morphine, meperidine, codeine, and others. If all of these are on average inferior pain killers and if hydromorphone is no better than they are, can't one conclude that, until proven otherwise, in patients not already subjected to narcotics, that hydromorphone is likely to be inferior or at least no better than non-narcotic pain medications. Doesn't the cancer community owe the patients of the world at least one such study?

Tom Radecki, M.D., J.D.
Clarion, Pennsylvania.

Because of the enormous global issue of cancer related pain, the World Health Organisation devised the 3 step analgesic ladder in 1982. This has revolutionised the management of cancer pain. Step 3 involves the use of strong opioids such as morphine, which remains the gold standard for the management of moderate to severe cancer pain.

The ladder also recommends the use of non-opioid analgesics, either alone, for mild pain, or in conjunction with strong opioids. Different analgesics work in different ways, and cancer pain can be complex and multi-factorial, hence the value of combinations of analgesics for some patients.

From both animal and clinical studies, strong opioids have been proven to be potent analgesics. In addition, there have been many studies comfirming their efficacy in the management of cancer pain, and in improving quality of life. Ethically, one could not justify withholding strong opioids from patients with severe cancer pain in order to perform a clinical trial.

Dear Dr. Quigley: September 27, 2005

Thank you very, very much for your recent letter.

You state that "Ethically, one could not justify withholding strong opioids from patients with severe cancer pain in order to perform a clinical trial." I would like to point out that in many double-blind trails, according to published reports themselves, many and often most cancer patients in those studies, according to the patients own self-ratings, were not suffering from severe pain, but were suffering from only moderate pain.

In view of dozens of studies (attached) showing that opiates are no better than and usually inferior to non-narcotic pain relievers for acute pain, are you still willing to say that it is unethical for one study somewhere in the world to delay starting powerfully addictive narcotics to cancer patients suffering from only moderate cancer pain for several weeks in order to determine for the first time ever what benefit, if any, potent opiates add to non-narcotic pain relievers like NSAIDs and nortriptyline.

I would point out that the 3 dozen studies (see attachment) which I have found have in every instance shown that non-narcotic pain relievers are as powerful and usually more powerful pain relievers than narcotics. Yet I have read many cancer pain studies and other pain studies in which cancer patients and other patients with severe pain are deprived from these more powerful non-narcotic pain relievers, to be treated unconscionably with opiates alone. I admit that it is probable that opiates add a little to pain relief, although I personally think (and many patients agree with me) the small benefit falls far short of justifying the common addiction problem which arises. However, In my opinion, it is an unethical research practice to deprived cancer patients of NSAIDs, yet many uninformed doctors routinely do this, instead relying, often unsuccessfully on opiates alone. Even according to WHO guidelines, with which I don't agree because of the total absence of scientific justification, opiates are to be added to NSAIDs, not used instead of NSAIDs.

I truly appreciate this discussion. While I do personally treat many pain patients with moderate and severe pain, I am concerned by the many patients whom I admit to our psychiatric hospital who are addicted to opiate pain relievers. By the time they get to us, some are getting their medicines from the streets, but others only from physicians. It certainly looks like a human tragedy to everyone working in our hospital.

Sincerely,

Tom Radecki

Hi!

This is clearly something you feel very passionate about, and I can see you encounter serious and intractable issues amongst your patients with opioid dpendency and addiction.

I do, infrequently, see patients with chronic noncancer pain, and in this population, the use of strong opioids can be very problematic (The Pain Society UK has guidelines on this).

Fortunately, these issues, ie drug dependency and abuse, are currently extremely rare in those patients we manage with advanced cancer and severe pain, so the use of opioids in this clinical context is rarely problematic, and in most cases successful.