Anesthesiologists at Massachusetts General Hospital, in Boston, have documented the positive results from a mid-2013 switch to a “morphine first” policy, which they implemented in the wake of mounting reports of serious adverse events from hydromorphone that were highlighted in a 2012 alert by the Massachusetts State Board of Medicine.
At the end of June 2013, Padma Gulur, MD, director of pain services at Massachusetts General, and colleagues implemented a protocol in which morphine became the first-line, first-choice analgesia, and hydromorphone was the second choice for patients with moderate to severe perioperative pain. They documented a 2.7% reduction in hydromorphone use in the first six months of protocol implementation compared with the previous six months, which was accompanied by a nearly 40% fall in adverse events.
“In adult hospitals there has been a significant shift to using hydromorphone as a first-line, first-choice agent over the last few years, irrespective of etiology or patient condition,” Dr. Gulur told Anesthesiology News. “Evidence in the literature has not shown hydromorphone to be any more effective or well tolerated than morphine, and it appears to be associated with more serious adverse events and emergency room visits.”
The protocol included education of anesthesiologists about the drawbacks of hydromorphone and the safety and efficacy of morphine, use of equianalgesic conversion cards, access to support whenever needed from pain specialists and feedback to frequent prescribers of hydromorphone.
The use of hydromorphone fell slightly, and morphine use rose significantly after protocol implementation: The oral morphine equivalents (OMEs) for hydromorphone fell 2.7% from 2,260,135 in the first six months of 2013, to 2,199,305 OMEs in the last six months of 2013. In those same time periods, the OMEs for morphine rose 60.4%, from 903,754 to 1,449,683, respectively.
Concurrently, adverse-event reports to the internal quality and safety reporting event system fell for both medications: There were 2.8 safety events per 100,000-mg OMEs for hydromorphone before implementation and 1.7 safety events per 100,000 mg after implementation (a 39.3% reduction); for morphine the respective numbers were 2.7 and 2.15 (a 20.4% drop; Figure 2). Naloxone, the rescue agent for side effects from opioids, was used in 1.23% of cases before implementation and 1.13% after implementation.
Dr. Gulur said that although they did not document the associated cost savings, they assumed they were significant because other studies have quantified the cost of opioid-related adverse events (e.g., J Pain Palliat Care Pharmacother 2013;27:62-70). Findings were presented at the 2015 Regional Anesthesiology and Acute Pain Medicine annual meeting.
The patients appeared satisfied with the switch. Average scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey were similar for those who said their pain was controlled (64% both before and after implementation), those who believed that staff helped with pain control (79% before and 82% after) and in the composite of all three domains (72% before and 73% after).
Tarun Bhalla, MD, vice chairman of comprehensive pain services at Nationwide Children’s Hospital and clinical associate professor of anesthesiology at The Ohio State University Wexner Medical Center, both in Columbus, commented that he would prefer to see more data before considering whether the “morphine first” policy is clinically applicable. Anesthesiologists at his institution individualize their decisions on hydromorphone versus morphine according to the surgery the patient has undergone and the individual patient characteristics.
“They don’t mention cost savings in the poster. And they don’t give specific details related to the adverse events related to hydromorphone and morphine, including the proportion of serious adverse events. Regardless, it’s an interesting topic, and it’s certainly worthwhile to investigate it,” Dr. Bhalla said.