Intrathecal hydromorphone for chronic nonmalignant pain: A retrospective study

Objective. Ten percent to 15% of patients with chronic pain experience intolerable side effects or inadequate analgesia with continuous intrathecal morphine therapy. Although clinical experience suggests that rotation to hydromorphone (Dilaudid) can reduce side effects and recapture analgesia, there have been only scattered reports of long-term intrathecal hydromorphone use in patients with nonmalignant pain. The purpose of this study is to review the safety and effectiveness of continuous intrathecal hydromorphone in the management of patients with nonmalignant pain in whom continuous intrathecal morphine therapy has failed. Design. A retrospective review of 3 7 patients with chronic nonmalignant pain managed with intrathecal hydromorphone after failure of intraspinal morphine. Results. The mean age of patients was 64 years +/-12 SD. All patients suffered from severe nonmalignant pain, most from failed lumbosacral spine operations (19/37; 51%). Morphine was replaced with hydromorphone because of pharmacological complications (21/37; 57%) or inadequate analgesic response (16/37; 43%) after an average of 11 months +/- 11 SD of intrathecal therapy. Pharmacological complications, particularly nausea and vomiting, pruritus, and sedation were reduced by hydromorphone in most patients. Peripheral edema was improved by hydromorphone but tended to recur with prolonged hydromorphone exposure. Analgesic response was improved by at least 25% in six of 16 patients who were switched to hydromorphone because of poor pain relief. Conclusions. Hydromorphone can be a safe, analgesic alternative for long-term intrathecal management of nonmalignant pain among patients in whom morphine fails because of pharmacological side effects or inadequate pain relief.