Hydromorphone Injections Can Quickly Relieve Intractable Pain

By Dr. Forest Tennant

I recall the time over a decade ago when Anazao Laboratory in Tampa, Florida informed me they had developed ultra-high potency (50 mg/ml) hydromorphone for palliative pain care. Anazao Labs was well aware of my patients’ needs, since they formulated my endocrine medicinals. 

In contrast to the other injectable opioids, Anazao’s hydromorphone formulation could be injected subcutaneously under the skin rather than intramuscularly.  The injection required a very small amount of fluid (.1 to .2 ml) that was administered with an allergy or insulin syringe.

My patients’ pain was called “intractable” to meet California’s Medical Board guideline and legal definitions.  The criteria for patients to enter my clinic was a determination that there was a high risk of death within one year unless opioid treatment could be administered. The top causes of intractable pain were adhesive arachnoiditis, traumatic brain injury, severe neuropathies (CRPS), autoimmune disease, and post-cancer care.

I recall the first patient to whom I prescribed ultra-high potency hydromorphone.  She was not receiving adequate pain relief with long-acting and breakthrough opioids, so she was referred for an intrathecal implanted device (pain pump) for opioid administration.  Due primarily to its cost and insurance reasons, she could not obtain this expensive treatment, so I chose to experiment with the new ultra-high potency hydromorphone. 

It worked remarkably well.  In fact, she soon found she didn’t require a long-acting or breakthrough opioid. Using the new hydromorphone formulation, she dropped her daily morphine milligram equivalent (MME) dosage from over 500 to less than 100 MME per day.

After success with this patient, I prescribed the hydromorphone formulation to other patients on high dose oral opioids, who could not obtain intrathecal opioids or an implanted electrical stimulator.  All the patients tolerated and adjusted well to it.  Ultra-high dose hydromorphone became an alternative to intrathecal opioids at my pain clinic.

When I later prescribed the hydromorphone formulation to other patients with intractable pain, I found that I could eliminate or reduce their use of high dose opioids through oral, patch or sublingual administration, and obtain equal or superior pain relief.

I have since retired from clinical practice, but still believe this is a major reason for using ultra-high potency hydromorphone for patients in severe pain.  My initial experience told me that the hydromorphone formulation could be an alternative to standard intractable pain care, which is the combined use of a long-acting opioid with a short-acting opioid for breakthrough pain. That therapy has shortcomings, because long-acting opioids suppress endocrine levels, which can lead to a wide range of health problems.

My procedure in prescribing hydromorphone was to instruct both the patient and a live-in family member on proper injection technique, secure storage, and maintaining sterility.  At the time I closed my clinic, I probably had about 2 dozen patients who successfully used this innovative formulation.

I have come to some conclusions that go against common beliefs about opioid therapy.  First and foremost, high potency hydromorphone can usually substitute in most cases for long-acting opioids such as OxyContin, transdermal fentanyl, and methadone.  Effective pain relief occurs within minutes after the injection, so the patient doesn’t have a proclivity to follow the opioid dose with a sedative or neuropathic drug such as a benzodiazepine. 

Seldom did my patients use over 3 to 4 injections a day.  To date, I know of no overdoses occurring.  I attribute this to hydromorphone’s rapid, potent, short-acting activity, which doesn’t invite the use of other drugs (including alcohol), to help the patient achieve pain relief.  Blood levels of the hydromorphone don’t stay elevated longer than about two hours, which protects against overdose. Pain relief remains much longer, however, likely because it is hydrophilic in neurologic tissues.

In summary, I have found ultra-high potency hydromorphone to be a significant advance in palliative pain care for intractable pain patients.  It has proven to be a bonafide alternative to intrathecal opioid delivery and to high opioid dosages necessary when combining the use of long and short acting opioids.  Its unique properties seem to reduce the risk of overdose. 

Families and patients can be trained to safely and effectively use this medicinal to relieve suffering from the most severe forms of intractable pain.  Unfortunately, it is an under-recognized and underused treatment for the palliative care of intractable pain patients.

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. Readers interested in learning more about his research should visit the Tennant Foundation’s website, Arachnoiditis Hope. You can subscribe to its research bulletins here.   

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.