title: 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.
abstract: OBJECTIVE
  We compare a high initial dose of 2 mg intravenous hydromorphone against titration of 1 mg intravenous hydromorphone followed by an optional second dose.
  
  
  METHODS
  Patients aged 21 to 64 years with severe pain were randomly allocated to 2 mg intravenous hydromorphone in a single bolus or the "1+1" hydromorphone titration protocol. 1+1 Patients received 1 mg intravenous hydromorphone followed by a second 1 mg dose 15 minutes later if they answered yes when asked, Do you want more pain medication? The primary outcome was the between-group difference in proportion of patients who declined additional analgesia at 60 minutes.
  
  
  RESULTS
  Of the 350 enrolled patients, 334 had sufficient data for analysis. The proportion who declined additional analgesics was 67.5% in the 2 mg bolus arm and 67.3% in the 1+1 titration arm (difference 0.2%; 95% confidence interval -9.7% to 10.2%). The between-group difference in numeric rating scale pain scores was 0.4 numeric rating scale units (95% confidence interval -0.3 to 1.1). The incidence of adverse effects was similar; 42.3% of 1+1 patients achieved satisfactory analgesia at 1 hour with only 1 mg hydromorphone.
  
  
  CONCLUSIONS
  A hydromorphone 1+1 titration protocol provides similar pain relief to an initial 2 mg bolus dose, with no apparent clinical advantage to the latter. The 1+1 titration protocol had an opioid-sparing effect because 50% less opioid was needed to achieve satisfactory analgesia for 42.3% of patients allocated to this protocol.
authors.affiliation: Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY. Electronic address: achang@montefiore.org.
authors.forename: Andrew K
authors.initials: AK
authors.lastname: Chang
authors.forename: Polly E
authors.initials: PE
authors.lastname: Bijur
authors.forename: Jason B
authors.initials: JB
authors.lastname: Lupow
authors.forename: E John
authors.initials: EJ
authors.lastname: Gallagher
mesh_terms: D059787:Acute Pain / Q000188:drug therapy*; D000328:Adult; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000627:therapeutic use*; D002985:Clinical Protocols; D004334:Drug Administration Schedule; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D004091:Hydromorphone / Q000008:administration & dosage / Q000627:therapeutic use*; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged; D059408:Pain Management / Q000379:methods*; D010147:Pain Measurement; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D004091:Hydromorphone