Oldenmenger, W.H., Lieverse, P.J., Janssen, P.J., Taal, W., van der Rijt, C.C., & Jager, A. (2012). Efficacy of opioid rotation to continuous parenteral hydromorphone in advanced cancer patients failing on other opioids. Supportive Care in Cancer, 20, 1639–1647.

To describe the analgesic efficacy and side effects of parenteral hydromorphone among patients with severe cancer-related pain

Medical records were reviewed and data were collected retrospectively for patients admitted to a palliative care unit for pain management because of uncontrolled pain or severe side effects from their current pain regimens. Patients were started on parenteral hydromorphone. After starting the intervention, pain intensity and side effects were recorded twice daily. All patients had previously received opioids.

• N = 104      
• MEAN AGE = 57 years (SD = 13.5 years)
• MALES: 55%, FEMALES: 45%
• KEY DISEASE CHARACTERISTICS: 88% had metastatic disease and nociceptive pain
• OTHER KEY SAMPLE CHARACTERISTICS: Some patients were receiving chemotherapy or palliative radiation therapy. Some patients also were receiving ketamine during the study. Eighty-eight percent had had two or more previous opioid rotations. Median effective dose was 600 mg per day (range = 72–2592 mg per day).

• SITE: Single site    
• SETTING TYPE: Inpatient    
• LOCATION: Netherlands

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

• Retrospective, descriptive

• Numeric rating scale for pain
• Effectiveness determined as change in mean pain intensity at rest and with movement
• Time of adequate control was defined as first of at least two consecutive days with mean pain score of 4 or less, or physician was satisfied that pain was controlled

Adequate pain control was reported for 83% of patients, and among those who had improvement, the decline in mean pain score was significant (p < .001), ranging from a 2.7–3.1-point reduction. Seventeen percent had no response. Survival analysis showed continued effect of hydromorphone for 150 days for those who continued on the study (35 patients).

Switching to parenteral hydromorphone was effective for pain control in some patients who had either uncontrolled pain or severe side effects with previous pain medication regimens.

• Baseline sample/group differences of import
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias(sample characteristics) 
• Unintended interventions or applicable interventions not described that would influence results
• Key sample group differences that could influence results
• Measurement/methods not well described
• Measurement validity/reliability questionable
• Other limitations/explanation: Differences in pain scores were used to show statistical significance, but the timing of measures used is not described, and authors state that where measurements were not available, physician satisfaction with control was used to show efficacy. It was stated that some patients were on ketamine, but it was not clear how much, who, or the potential impact on findings. A variety of coanalgesics were used, with no relevant subgroup analysis. There was extreme variability in baseline opioid dosages, suggesting highly varied baseline pain levels as well–range of baseline levels is not provided. Some patients also were receiving other palliative therapies, and analysis did not consider this.

Findings suggest that opioid rotation to parenteral hydromorphone was effective for some patients who had either uncontrolled pain or unacceptable opioid side effects. This study provides rather weak evidence because of numerous study limitations, but, for those patients at the end of life with intractable pain or significant adverse effects on current pain regimens, alternative approaches that may be effective are important to consider. Parenteral hydromorphone may be an appropriate alternative for these patients.