Fixed Dose of Intravenous Hydromorphone in the Treatment of Acute Pain

This study has been completed.
Sponsor:
Information provided by:
Montefiore Medical Center
ClinicalTrials.gov Identifier:
NCT01006850
First received: October 30, 2009
Last updated: July 19, 2011
Last verified: July 2011
  Purpose

Research question: In adult emergency department (ED) patients to whom the attending ED physician has decided to administer intravenous opioid pain control:

  1. What is the incidence of serious adverse events, defined as the use of naloxone, up to a total of 2 hours after infusion of 2 mg IV hydromorphone?
  2. What is the incidence of other side effects (respiratory depression, hypotension, oxygen desaturation, nausea, vomiting, and pruritus) at 5, 15, 30 and 120 minutes post infusion of 2mg IV hydromorphone?
  3. What is the speed of onset of 2 mg IV hydromorphone? This will be measured by asking the patient for his NRS pain score at 1, 2, 3, 4, and 5 minutes post infusion of 2 mg IV hydromorphone.
  4. What is the incidence of administration of rescue medications?
  5. For those patients who decline to enter the study, what are their reasons for refusal (e.g. fear of becoming addicted)? The investigators believe this is yet another barrier to providing adequate pain relief for patients with acute severe pain.

Condition Intervention Phase
Acute Pain
Drug: Hydromorphone
Phase 4

Study Type: Interventional
Study Design: Allocation: Non-Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Single Group Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Safety and Speed of Onset of a Fixed Dose of Intravenous Hydromorphone in the Treatment of Adult Patients Presenting to the Emergency Department With Acute Severe Pain

Resource links provided by NLM:


Further study details as provided by Montefiore Medical Center:

Primary Outcome Measures:
  • The incidence of a serious adverse event by 120 minutes post infusion, which is defined as the use of naloxone as a reversal agent. [ Time Frame: 120 minutes ] [ Designated as safety issue: Yes ]

Secondary Outcome Measures:
  • Respiratory depression: RR < 12 breaths per minute will be considered a less serious adverse event. [ Time Frame: 120 minutes ] [ Designated as safety issue: Yes ]
  • Oxygen desaturation: The RAs will note the presence of oxygen desaturation, defined as a pulse oximeter reading less than 90% or a decrease of 5% or more from baseline, at the following time points: baseline, 1, 2, 3, 4, 5, 15, 30 and 120 minutes. [ Time Frame: 120 minutes ] [ Designated as safety issue: Yes ]
  • Hypotension: Systolic BP less than 90 mg Hg will be counted as a less serious adverse event. [ Time Frame: 120 minutes ] [ Designated as safety issue: Yes ]
  • Vomiting: Patients will be asked whether they vomited during the following time intervals: pre-baseline, baseline-5 minutes, 6 minutes to 15 minutes, 16 minutes to 30 minutes, and 31 minutes to 2 hours. [ Time Frame: 120 minutes ] [ Designated as safety issue: No ]
  • Nausea: We will use the recently validated quantitative nausea visual analog scale (VAS) (Hendey 2005). [ Time Frame: 120 minutes ] [ Designated as safety issue: No ]
  • Pruritis: Patients will be asked whether they experience pruritus at the following time intervals: pre-baseline, baseline-5 minutes, 6 minutes to 15 minutes, 16 minutes to 30 minutes, and 31 minutes to 2 hours. [ Time Frame: 120 minutes ] [ Designated as safety issue: No ]
  • The RAs will assess the incidence of other adverse events such as falling by observation and by reviewing the nursing notes and chart, as well as by asking the patient's providers. [ Time Frame: 120 minutes ] [ Designated as safety issue: Yes ]
  • Speed of onset of analgesia: Speed of onset of analgesia will be assessed by eliciting self-reported pain scores every minute for 5 minutes post infusion of hydromorphone. [ Time Frame: 120 minutes ] [ Designated as safety issue: No ]
  • A numerical rating scale ranging from 0 = no pain, to 10 = worst pain possible will be used to measure self-reported pain. [ Time Frame: 120 minutes ] [ Designated as safety issue: No ]
  • Speed of onset of analgesia will also be assessed by a 5-point pain relief scale. [ Time Frame: 120 minutes ] [ Designated as safety issue: No ]
  • Patient Satisfaction Scale: Assessed using a 6-point patient satisfaction scale. [ Time Frame: 120 minutes ] [ Designated as safety issue: No ]
  • Supplementary dose of opioid and non-opioid analgesics: The number of patients who receive supplementary pain medications as well as the total additional amount (mg) received. [ Time Frame: 120 minutes ] [ Designated as safety issue: No ]
  • All medications administered to the patients and the time of administration will be recorded. Data from any patients who are given other opioids will be used up until the time the second opioid is administered [ Time Frame: 120 minutes ] [ Designated as safety issue: No ]

Enrollment: 300
Study Start Date: July 2005
Study Completion Date: May 2007
Primary Completion Date: May 2007 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: 2 mg IV hydromorphone
2 mg IV hydromorphone
Drug: Hydromorphone
2mg IV hydromorphone
Other Name: Dilaudid

  Show Detailed Description

  Eligibility

Ages Eligible for Study:   21 Years to 65 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   Yes
Criteria

Inclusion Criteria:

  1. Age greater than 21 years: Patients under the age of 21 are automatically triaged to the Children's Hospital at Montefiore Emergency Department, and hence cannot be enrolled in this study.
  2. Age less than 65 years of age: Patients age 65 and over will be excluded in this study as the effects on opioids on the elderly may be different than in the non-elderly.
  3. Pain with onset within 7 days: Pain within seven days is the definition of acute pain that has been used in ED literature.
  4. ED attending physician's judgment that patient's pain warrants use of morphine: The factors that influence the decision to use parenteral opioids are complex and extensive. An approach that is commonly taken to address the issue of patient selection in drug trials is to use a specific condition (e.g., renal colic) or treatment (e.g., post-hysterectomy) that would generally be thought to be appropriately treated with an opioid analgesic, thereby eliminating individual judgment about eligibility for the study. However in order to assess the role of hydromorphone with the widest generalizability in the ED setting, we decided to enroll patients with a variety of diagnoses, all with a complaint of acute pain. Opioids are not an appropriate treatment for all patients who present with a complaint of pain (e.g., gastroenteritis, migraine). Therefore, unless there is a restriction to patients with a specific diagnosis, either a comprehensive list of diagnoses and situations in which opioids are indicated must be specified, or clinical judgment needs to be used. We have opted for the latter alternative.

    The use of patients with a variety of diagnoses, and therefore heterogeneous painful stimuli, risks masking a treatment effect because of large inter-individual variability. There are several design and analytic factors (detailed below) that attenuate this risk: 1) a sufficiently large number of patients will be randomly assigned to each group so that the variety of painful stimuli will be equally distributed between treatment groups; 2) change in pain intensity and pain relief will be analyzed rather than absolute pain intensity or pain relief therefore reducing variability.

  5. Normal mental status: In order to provide measures of pain experienced the patient needs to have a normal mental status. Orientation to person, place and time will be used as an indicator of sufficiently normal mental status to participate in the study.

Exclusion Criteria:

  1. Prior use of methadone: the effect of methadone use on the perception of acute pain is unknown and suspected to be altered. We feel that the needs of patients on methadone may exceed the dosage ceiling of 2mg that will be used for this study. Similar to sickle cell patients and chronic cancer patients, patients on methadone usually require significantly higher doses of opioids to control their pain. Thus, we feel that it would be unethical to restrict the dose that this subset of patients can receive.
  2. Use of other opioids or tramadol within past seven days: to avoid introducing bias related to opioid tolerance that may alter the response to the study medication thereby masking the medication's effect.
  3. Prior adverse reaction to hydromorphone.
  4. Chronic pain syndrome: frequently recurrent or daily pain for at least 3 months result in alteration in pain perception which is thought to be due to down-regulation of pain receptors. Examples of chronic pain syndromes include sickle cell anemia, osteoarthritis, fibromyalgia, migraine, and peripheral neuropathies.
  5. Alcohol intoxication: the presence of alcohol intoxication as judged by the treating physician may alter perception, report, and treatment of pain.
  6. SBP <90 mm Hg: Hydromorphone can produce peripheral vasodilation that may result in orthostatic hypotension or syncope.
  7. Use of MAO inhibitors in past 30 days: MAOs have been reported to intensify the effects of at least one opioid drug causing anxiety, confusion and significant respiratory depression or coma.
  8. C02 measurement greater than 46: In accordance with a similar study (04-12-360), three subsets of patients will have their CO2 measured using a handheld capnometer prior to enrollment in the study. If the CO2 measurement is greater than 46, then the patient will be excluded from the study. The 3 subsets are as follows:

    1. All patients who have a history of COPD
    2. All patients who report a history of asthma together with greater than a 20 pack-year smoking history
    3. All patients reporting less than a 20 pack-year smoking history who are having an asthma exacerbation
  Contacts and Locations
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Please refer to this study by its ClinicalTrials.gov identifier: NCT01006850

Locations
United States, New York
Montefiore Medical Center
Bronx, New York, United States, 10467
Sponsors and Collaborators
Montefiore Medical Center
Investigators
Principal Investigator: Andrew Chang, MD Montefiore Medical Center
  More Information

No publications provided

Responsible Party: Andrew Chang, MD, Montefiore Medical Center
ClinicalTrials.gov Identifier: NCT01006850     History of Changes
Other Study ID Numbers: MMC05-11-307
Study First Received: October 30, 2009
Last Updated: July 19, 2011
Health Authority: United States: Institutional Review Board

Keywords provided by Montefiore Medical Center:
Acute pain hydromorphone emergency department

Additional relevant MeSH terms:
Acute Pain
Nervous System Diseases
Neurologic Manifestations
Pain
Signs and Symptoms
Hydromorphone
Analgesics
Analgesics, Opioid
Central Nervous System Agents
Central Nervous System Depressants
Narcotics
Peripheral Nervous System Agents
Pharmacologic Actions
Physiological Effects of Drugs
Sensory System Agents
Therapeutic Uses

ClinicalTrials.gov processed this record on October 23, 2014