Hydromorphone use in ED

Due to concerns over the high addictive potential of oxycodone, hydromorphone is preferable as a discharge analgesic for strong pain in most groups (other than the elderly where oxycodone’s stimulatory effects may be beneficial).


Hydromorphone intravenous and tablet form has been added to the S8 cupboard for use in management of acute pain. It has a similar spectrum of action and potential adverse reactions to other members of the opioid class. It should be considered an alternative opioid for those reporting a reaction to morphine, rather than the shorter acting fentanyl (unless rapid onset and short duration is desired). We recommend you consider using it instead of oxycodone because of concern regarding oxycodone’s addictive potential. It is available at community pharmacies and can be prescribed to patients being discharged from ED. Oxycodone may still be a reasonable choice in the elderly, where its stimulant effect on the CNS may be beneficial.

Rosen’s Emergency Medicine (7th ed. Part V, Chapter 186 – Pain Management);

Hydromorphone is a semisynthetic derivative of morphine that is a potent analgesic agent, increasingly used in the management of acute pain in the ED. Hydromorphone is seven times more potent than morphine when given parenterally and has a similar duration of action to morphine……. Pruritis, nausea, and vomiting may occur less frequently than with morphine at equianalgesic doses. It is conjugated primarily into hydromorphone-3-glucuronide (H3G) in the liver and is excreted renally. H3G is for the most part inactive, so hydromorphone is better tolerated than morphine in elderly patients and those with hepatic impairment. Patients with renal insufficiency may be at some risk of neurotoxicity after prolonged exposure due to H3G accumulation. True allergy to opioids is rare, but patients allergic to morphine do not always have cross-reactivity with hydromorphone. Hydromorphone can be given IV or PO.

Intravenous Opioids for acute pain relief in ED

NameEquipotent IV Dose*Duration Of Action
morphine10 mg3 – 4 hr
hydromorphone1.5 – 2 mg2 – 4 hr
fentanyl150 – 200 µg0.5 –1.5 hr

* given in one quarter increments, titrating to effect

Oral Opiods for acute pain relief in ED

Initial DoseDuration of Action
hydromorphone2 – 4 mg2 – 4 hr
oxycodone5 – 10 mg3 – 4 hr
codeine60 mg2 – 4 hr
buprenorphine200 – 400 mcg6 – 8  hr
tramadol50 – 100mg3 – 6 hr

Hydromorphone Immediate Release, Oral;

  • Trade name is dilaudid 2mg
  • For acute severe pain as an alternative to Endone or Oxynorm (Oxycodone IR)
  • Chart as “2 – 4 mg 2 hourly”, start with the lowest possible dose

Hydromorphone for IV use;

  • An alternative to IV morphine and fentanyl
  • Chart as “hydromorphone 0.5 – 2 mg IV”
  • Will be dilute 2 mg of hydromorphone with normal saline up to 10 mls
  • Will be administered as 2.5 ml (0.5 mg) boluses using the same procedures as the administration of intravenous morphine and fentanyl

Date implemented – 04/2015
Review date – 04/2018
Author – Dr Roger Swift

Dr James Wheeler
Dr James Wheeler

Emergency Physician, SCGH, WA, Australia

Articles: 500

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