Randomized clinical trial of the 2 mg hydromorphone bolus protocol versus the "1+1" hydromorphone titration protocol in treatment of acute, severe pain in the first hour of emergency department presentation

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Abstract

Study objective: We compare a high initial dose of 2 mg intravenous hydromorphone against titration of 1 mg intravenous hydromorphone followed by an optional second dose. Methods: Patients aged 21 to 64 years with severe pain were randomly allocated to 2 mg intravenous hydromorphone in a single bolus or the "1+1" hydromorphone titration protocol. 1+1 Patients received 1 mg intravenous hydromorphone followed by a second 1 mg dose 15 minutes later if they answered yes when asked, Do you want more pain medication? The primary outcome was the between-group difference in proportion of patients who declined additional analgesia at 60 minutes. Results: Of the 350 enrolled patients, 334 had sufficient data for analysis. The proportion who declined additional analgesics was 67.5% in the 2 mg bolus arm and 67.3% in the 1+1 titration arm (difference 0.2%; 95% confidence interval -9.7% to 10.2%). The between-group difference in numeric rating scale pain scores was 0.4 numeric rating scale units (95% confidence interval -0.3 to 1.1). The incidence of adverse effects was similar; 42.3% of 1+1 patients achieved satisfactory analgesia at 1 hour with only 1 mg hydromorphone. Conclusion: A hydromorphone 1+1 titration protocol provides similar pain relief to an initial 2 mg bolus dose, with no apparent clinical advantage to the latter. The 1+1 titration protocol had an opioid-sparing effect because 50% less opioid was needed to achieve satisfactory analgesia for 42.3% of patients allocated to this protocol.

Original languageEnglish (US)
Pages (from-to)304-310
Number of pages7
JournalAnnals of Emergency Medicine
Volume62
Issue number4
DOIs
StatePublished - Oct 2013

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Hydromorphone
Acute Pain
Clinical Protocols
Hospital Emergency Service
Randomized Controlled Trials
Analgesia
Pain
Opioid Analgesics
Confidence Intervals
Analgesics
Incidence

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

@article{1eb6440e7ed74d529e64040d097326ca,
title = "Randomized clinical trial of the 2 mg hydromorphone bolus protocol versus the {"}1+1{"} hydromorphone titration protocol in treatment of acute, severe pain in the first hour of emergency department presentation",
abstract = "Study objective: We compare a high initial dose of 2 mg intravenous hydromorphone against titration of 1 mg intravenous hydromorphone followed by an optional second dose. Methods: Patients aged 21 to 64 years with severe pain were randomly allocated to 2 mg intravenous hydromorphone in a single bolus or the {"}1+1{"} hydromorphone titration protocol. 1+1 Patients received 1 mg intravenous hydromorphone followed by a second 1 mg dose 15 minutes later if they answered yes when asked, Do you want more pain medication? The primary outcome was the between-group difference in proportion of patients who declined additional analgesia at 60 minutes. Results: Of the 350 enrolled patients, 334 had sufficient data for analysis. The proportion who declined additional analgesics was 67.5{\%} in the 2 mg bolus arm and 67.3{\%} in the 1+1 titration arm (difference 0.2{\%}; 95{\%} confidence interval -9.7{\%} to 10.2{\%}). The between-group difference in numeric rating scale pain scores was 0.4 numeric rating scale units (95{\%} confidence interval -0.3 to 1.1). The incidence of adverse effects was similar; 42.3{\%} of 1+1 patients achieved satisfactory analgesia at 1 hour with only 1 mg hydromorphone. Conclusion: A hydromorphone 1+1 titration protocol provides similar pain relief to an initial 2 mg bolus dose, with no apparent clinical advantage to the latter. The 1+1 titration protocol had an opioid-sparing effect because 50{\%} less opioid was needed to achieve satisfactory analgesia for 42.3{\%} of patients allocated to this protocol.",
author = "Chang, {Andrew K.} and Bijur, {Polly E.} and Lupow, {Jason B.} and Gallagher, {E. John}",
year = "2013",
month = "10",
doi = "10.1016/j.annemergmed.2013.02.023",
language = "English (US)",
volume = "62",
pages = "304--310",
journal = "Annals of Emergency Medicine",
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T1 - Randomized clinical trial of the 2 mg hydromorphone bolus protocol versus the "1+1" hydromorphone titration protocol in treatment of acute, severe pain in the first hour of emergency department presentation

AU - Chang, Andrew K.

AU - Bijur, Polly E.

AU - Lupow, Jason B.

AU - Gallagher, E. John

PY - 2013/10

Y1 - 2013/10

N2 - Study objective: We compare a high initial dose of 2 mg intravenous hydromorphone against titration of 1 mg intravenous hydromorphone followed by an optional second dose. Methods: Patients aged 21 to 64 years with severe pain were randomly allocated to 2 mg intravenous hydromorphone in a single bolus or the "1+1" hydromorphone titration protocol. 1+1 Patients received 1 mg intravenous hydromorphone followed by a second 1 mg dose 15 minutes later if they answered yes when asked, Do you want more pain medication? The primary outcome was the between-group difference in proportion of patients who declined additional analgesia at 60 minutes. Results: Of the 350 enrolled patients, 334 had sufficient data for analysis. The proportion who declined additional analgesics was 67.5% in the 2 mg bolus arm and 67.3% in the 1+1 titration arm (difference 0.2%; 95% confidence interval -9.7% to 10.2%). The between-group difference in numeric rating scale pain scores was 0.4 numeric rating scale units (95% confidence interval -0.3 to 1.1). The incidence of adverse effects was similar; 42.3% of 1+1 patients achieved satisfactory analgesia at 1 hour with only 1 mg hydromorphone. Conclusion: A hydromorphone 1+1 titration protocol provides similar pain relief to an initial 2 mg bolus dose, with no apparent clinical advantage to the latter. The 1+1 titration protocol had an opioid-sparing effect because 50% less opioid was needed to achieve satisfactory analgesia for 42.3% of patients allocated to this protocol.

AB - Study objective: We compare a high initial dose of 2 mg intravenous hydromorphone against titration of 1 mg intravenous hydromorphone followed by an optional second dose. Methods: Patients aged 21 to 64 years with severe pain were randomly allocated to 2 mg intravenous hydromorphone in a single bolus or the "1+1" hydromorphone titration protocol. 1+1 Patients received 1 mg intravenous hydromorphone followed by a second 1 mg dose 15 minutes later if they answered yes when asked, Do you want more pain medication? The primary outcome was the between-group difference in proportion of patients who declined additional analgesia at 60 minutes. Results: Of the 350 enrolled patients, 334 had sufficient data for analysis. The proportion who declined additional analgesics was 67.5% in the 2 mg bolus arm and 67.3% in the 1+1 titration arm (difference 0.2%; 95% confidence interval -9.7% to 10.2%). The between-group difference in numeric rating scale pain scores was 0.4 numeric rating scale units (95% confidence interval -0.3 to 1.1). The incidence of adverse effects was similar; 42.3% of 1+1 patients achieved satisfactory analgesia at 1 hour with only 1 mg hydromorphone. Conclusion: A hydromorphone 1+1 titration protocol provides similar pain relief to an initial 2 mg bolus dose, with no apparent clinical advantage to the latter. The 1+1 titration protocol had an opioid-sparing effect because 50% less opioid was needed to achieve satisfactory analgesia for 42.3% of patients allocated to this protocol.

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DO - 10.1016/j.annemergmed.2013.02.023

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JO - Annals of Emergency Medicine

JF - Annals of Emergency Medicine

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