Randomized Clinical Trial of Efficacy and Safety of a Single 2-mg Intravenous Dose of Hydromorphone Versus Usual Care in the Management of Acute Pain

Objectives The objective was to test the efficacy and safety of 2mg of intravenous (IV) hydromorphone (Dilaudid) against usual care in emergency department (ED) patients with acute severe pain. Methods This was a randomized clinical trial. Patients allocated to 2mg of IV hydromorphone received their medication in a single dose. Those randomized to usual care received any IV opioid, with type, dose, and frequency chosen by the ED attending. All patients received 2 L/min. nasal cannula oxygen. The primary outcome was the difference in the proportion of patients who achieved clinically satisfactory analgesia by 30minutes. This was defined as the patient declining additional analgesia when asked the question, Do you want more pain medicine? A 10% absolute difference was chosen a priori as the minimum difference considered clinically significant. Results Of 175 subjects randomized to each group, 164 in the 2mg hydromorphone group and 161 in the usual care group had sufficient data for analysis. Additional pain medication was declined by 77.4% of patients in the 2mg hydromorphone group at 30minutes, compared to 65.8% in the usual care group. This difference of 11.6% was statistically and clinically significant (95% confidence interval [CI]=1.8% to 21.1%). Safety profiles were similar and no patient required naloxone. There was more pruritus in the hydromorphone group (18.3% vs. 8.7%; difference= 9.6%, 95% CI=2.6% to 16.6%). Conclusions Using a simple dichotomous patient-centered endpoint in which a difference of 10% in proportion obtaining adequate analgesia was considered clinically significant, 2mg of hydromorphone in a single IV dose is clinically and statistically more efficacious when compared to usual care for acute pain management in the ED. ACADEMIC EMERGENCY MEDICINE 2013; 20:185-192 (C) 2013 by the Society for Academic Emergency Medicine