UMEM Educational Pearls

A recent, randomized study evaluated two approaches for treating acute pain in an inner-city ED.

  • Group 1 received hydromorphone 2 mg. Group 2 received hydromorphone 1 mg (with the option of a second 1 mg dose 15 minutes later).
  • 1 hour after the dose, patients were asked if they wanted more pain medication.
  • Both groups had an equal proportion of patients decline more pain medication at one hour (67%). 61% of patients in the 1 + 1 group only needed the initial dose of hydromorphone!
  • Secondary outcomes and safety measures were also similar between the groups.
  • Patients with chronic pain, age >64, weight <150 pounds, or opioid use within last 7 days were excluded. 

Application to clinical practice: For most patients with acute, severe pain in the ED, start with hydromorphone 1 mg. It may be all the patient needs and can potentially avoid giving them extra opioid they don't need.


Chang AK, et al. Randomized clinical trial of the 2 mg hydromorphone bolus protocol versus the "1 + 1" hydromorphone titration protocol in treatment of acute, severe pain in the first hour of emergency department presentation. Ann Emerg Med. 2013 May 16. [Epub ahead of print]. PMID 23694801

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