Hydromorphone withdrawal

Epidural analgesia is frequently used for lower extremity procedures and pain (e.g., knee surgery, labor pain, and some abdominal procedures). Intermittent bolus or continuous infusion of preservative-free opioids (morphine, hydromorphone, or fentanyl) and local anesthetics (bupivacaine) may be used for epidural analgesia. Opiates given by this route may cause pruritus that is relieved by naloxone. Adverse effects including respiratory depression, hypotension, and urinary retention may occur. When epidural routes are used in narcotic-dependent patients, systemic analgesics must also be used to prevent withdrawal since the opioid is not absorbed and remains in the epidural space. Doses of opioids used in epidural analgesia are 10 times less than intravenous doses, and intrathecal doses are 10 times less than epidural doses (i.e., 10 mg of IV morphine is equivalent to 1 mg epidural morphine and 0.1 mg of intrathecally administered morphine).45... 

In rats, naloxone-induced withdrawal is just as severe for butorphanol as for morphine95 Nasal spray Very little abuse liability in male opioid abusers134 i.m. In 2-choice discrimination butorphanol more like hydromorphone than like saline withdrawal both morphine-like and kappa-like but subjects choose sedative, not more butorphanol, for relief increases liking, but not MBG sometimes identified as barbiturate135... 

Patients who have received hydromorphone for long periods of time or those with confirmed opioid dependency should not receive the so-called agonist/antagonist analgesics, such as nalbuphine, pentazocine, butorphanol, dezocine, and buprenorphine. The use of these drugs in these patients can intensify withdrawal symptoms. 

Hydromorphone Hydrochloride Formulations containing hydromorphone with either minocycline hydrochloride or tetracycline hydrochloride were found incompatible and manifest as a color change from pale yellow to light green. Concentration-dependent incompatibilities are reported in formulations containing hydromorphone hydrochloride with dexamethasone sodium or phosphate,59 and fluorouracil.60 Visual incompatibility, such as haziness or precipitation, developed 4 hours after mixing thiopentone sodium and hydromorphone hydrochloride.61 Dependence, withdrawal, and interactions are similar to those of opioid analgesics. 

Hydromorphone has the potential for abuse. Chronic users may develop tolerance, thus necessitating larger doses for the desired effect. Abrupt cessation can cause withdrawal, yielding restlessness, insomnia, hypertension, tachycardia, tachypnea, vomiting, and diarrhea. 

As an oral drug, codeine is much less effective as an analgesic due to its large first-pass hepatic metabolism compared to morphine, hydrocodone and oxycodone. The plasma half-life of codeine is also shorter than many other orally available opiates such as morphine, hydromorphone, and oxymorphone. Like all opioids, continued use of codeine may result in tolerance development and physical dependence. However, when compared to potent mu agonists, codeine is less addictive and is associated with mild withdrawal symptoms. 

---