What’s the difference between hydromorphone, morphine, Dilaudid® and fentanyl patches? When would each of these be used?

All these medications are opioids. This is a group of medications that target certain receptors in the body in order to relieve pain.

When treating pain with opioids it’s typical to start with a low dosage, monitor to see how it’s working, and gradually increase the dosage until the person is comfortable. The monitoring is needed to check for side effects. Sometimes the medication is switched. Commonly people have some additional medication prescribed, called breakthrough medication. This is an extra dose for any flare-up of pain, that is, an occasional period when the pain is worse than usual and “breaks through” the regular level of pain relief.

Morphine is the most commonly known pain medication. Hydromorphone (brand name Dilaudid®), sometimes called hydromorph, is chemically similar to morphine. Hydromorphone is more potent than morphine, which simply means that a smaller quantity of hydromorphone has the same pain relieving effect as a larger quantity of morphine. If someone is switched from morphine to hydromorphone it’s important to realize this. For example, someone taking 10 mg of morphine may be switched to 1 or 2 mg of hydromorphone. The degree of pain relief is the same.

Both morphine and hydromorphone are used to treat moderate to severe pain. Morphine is often the first medication used. For some patients, however, hydromorphone may be a better first choice. People who are older may have less trouble with side effects such as sleepiness or confusion with hydromorphone. People whose kidneys are not fully functioning may also do better with hydromorphone, because it is removed from the body by the liver not the kidneys. A physician takes these factors into account when deciding which medication to use.

Usually when people have become adjusted to a short-acting medication, they are switched to the slow-release form. Both forms typically take effect within half an hour. The short-acting form typically lasts for four hours and the slow-release usually lasts eight. So the slow-release form doesn’t have to be taken as frequently. Sometimes people with stable pain are switched to a fentanyl patch, which lasts even longer. People with a fentanyl patch continue to have oral pain medication for breakthrough pain.

The fentanyl patch (Duragesic®) is used for people who have stable, chronic pain and require strong pain medication. It should only be used once a person has been on another opioid for several days and the pain is well managed. It is not used when people have intermittent pain, acute pain such as the pain following surgery, or need a lower level of pain relief. It’s useful for people who have difficulty swallowing, because the medication is absorbed through the skin. It’s also helpful for people who sometimes forget to take their medications, as it only needs to be applied every three days instead of being taken orally several times daily. It’s important to ensure the patch is always disposed of properly, as it may contain some medication when it’s taken off. The medication in the patch could harm a pet or child.

Many factors need to be considered when deciding which pain medication is best for a given situation. Often there’s more than one option. The most important thing is to match the dosage to the level of pain, and to monitor closely to make sure the person is consistently comfortable. People may say the opioid medication isn’t working. This usually means the person isn’t getting an adequate dosage. No matter which medication people use, if they’re not comfortable, they need to talk with the health care team so medications can be changed to give better pain relief.