The opiate drug Dilaudid (hydromorphone hydrochloride) is a full opioid agonist similar to drugs like morphine and heroin. Dilaudid is significantly more potent than morphine and may be used clinically when morphine does not effectively control a patient’s pain. All of the opiate drugs are primarily developed for the control of pain, and Dilaudid is most often used to control postoperative pain after drugs like morphine are not effective.
The mechanism of action of Dilaudid is similar to other narcotic drugs, such that it readily attaches to the endogenous opioid receptors in the brain and alters the individual’s subjective pain threshold. This results in a diminished experience of one’s perception of pain.
The drug has a relatively short half-life and quick onset of action. This means that the drug typically works quickly and remains in the system relatively less time than some of the other narcotic drugs used to control pain.
The drug is classified as a Schedule II controlled substance by the United States Drug Enforcement Administration (DEA), indicating that while it does have significant medical uses, it is also a drug that has a strong potential to be abused and to induce physical dependence. Dilaudid can only legally be obtained with a written prescription by a physician. It is administered either via intravenous injection, in an oral solution, or in tablet form.
Abuse of Dilaudid
Prescription medication abuse is a major concern in the United States, and abuse of central nervous system depressants, such as opiate drugs and benzodiazepines, has become a serious issue.
Data from the Substance Abuse and Mental Health Services Administration (SAMHSA) indicates the following:
- According to figures collected in 2015, over 12 million people reported abuse of opiate drugs; however, only 261,000 people reported some abuse of hydromorphone products (the active substance in Dilaudid).
- The rate of prescriptions written for hydromorphone increased from 2004 to 2011.
- Emergency department admissions for issues related to hydromorphone also increased from 2004 to 2011; however, the rate of this increase has declined over this period.
- Hydrocodone overdose has serious and even fatal ramifications. For example, the drug has been approved for use in federal executions even though its use in this capacity is rare.
There are number of risk factors associated with the abuse of prescription medications like Dilaudid.
These risk factors represent situations that can increase the probability that one may develop a substance use disorder, but the presence of one or more of these does not guarantee that an individual will abuse drugs. In addition, research looking at the motivations of individuals who misuse prescription medications suggests that other variables can contribute to the risk. One interesting study published in the Journal of Drug and Alcohol Dependence compared different groups of college students who admitted to prescription medication abuse and did not have a prescription for the drug they used.
The different groups were designated as:
- Recreational subtype users: This group reported primarily using prescription medications for their psychoactive effects. Individuals in this group would use the drugs in a number of different ways, such as taking them orally, grinding up tablets and snorting them, or grinding up tablets, mixing the powder with liquid, and then injecting them. This group was far more likely than the other groups to mix different types of prescription medications or to mix prescription medications with other drugs.
- Self-treatment users: This group typically used the medication for some type of therapeutic reason. For example, this group would be inclined to use narcotic medications like Dilaudid for pain control, even though they did not have prescriptions for the drugs. This group was far less likely to use the drug in a manner inconsistent with its prescribed use, such as snorting or injecting it, and was far less likely to mix drugs.
- Mixed subtypes: This group of individuals, which was the largest group, displayed different motivations and different methods of administration. Sometimes, they would use the medication for its intended purposes and other times for recreational purposes.
Individuals in the recreational use group and the mixed use group were far more likely to develop substance use disorders than individuals in the self-treatment use group. The researchers suggested that individuals abusing prescription medications for their psychoactive effects are far more likely to develop substance use disorders than those using them for medicinal reasons, even among people who take these drugs without a prescription. SAMHSA also reports that the majority of individuals who are prescribed these medications do not develop substance use disorders related to them.
Dilaudid and Physical Dependence
All of the opiate drugs carry a significant risk for the development of physical dependence. Physical dependence consists of two syndromes: tolerance and withdrawal. Tolerance occurs when an individual no longer gets the same effects from a specific dosage of the drug and needs more of it to achieve effects that were once achieved at lower doses. Withdrawal occurs when an individual’s system adjusts itself to account for the presence of the drug in its tissues. When the levels of the drug drop sharply because the individual has stopped taking the drug or significantly lowered the amount taken, the person develops a number of adverse reactions.
Because Dilaudid is most commonly used for the treatment of postoperative pain, and the majority of users who are prescribed the drug are given it in a hospital setting, few individuals who take the drug with a prescription are likely to develop physical dependence. Physical dependence is a syndrome that develops over time. Typically, individuals need to use the drug for 2-3 months on a consistent basis before even low-level physical dependence is developed. Individuals who do develop physical dependence as a result of medicinal use of the drug would not be considered to have a substance use disorder.
The development of physical dependence (or even just developing tolerance) in individuals who abuse Dilaudid would be considered a sign that the individual may have a substance use disorder. The development of physical dependence in individuals who abuse substances becomes a significant contributor to escalating substance abuse. This is because these individuals will often begin using the drug more frequently and in higher amounts in order to avoid the uncomfortable withdrawal syndrome that accompanies opiate drugs, such as Dilaudid.
The actual experience of the withdrawal syndrome will vary from individual to individual based on the number of different factors that include how much of the drug is used, how long they use it for, how they used it, individual differences in metabolism, and the individual’s psychological makeup.
A general timeline associated with withdrawal from Dilaudid follows:
- Symptoms of withdrawal may appear in a relatively short time after the person has stopped using the drug due to its relatively short half-life (the time it takes an individual’s system to reduce the concentration of the drug by half). People who abuse Dilaudid may begin to experience issues with anxiety, irritability, nausea, restlessness, jitteriness, and cravings within several hours of discontinuation. The symptoms may occur within 4-8 hours after the person has stopped using the drug. Initially, they will be mild but will increase in their intensity if the person does not use the drug.
- The symptoms will often reach their peak within 12-24 hours but may continue to be quite distressing for 48-72 hours. Symptoms listed above will continue along with a number of other symptoms, such as aches and pains, muscle spasms, sweating, chills, fever, increased nausea, vomiting, headaches, severe anxiety, confusion, and the sensation of uncontrollable urges to use Dilaudid. Individuals may become confused and disoriented as the symptoms peak. As a result, they may be vulnerable to accidents, issues with judgment, and even suicidal behaviors.
- Following the peak of the symptoms, which for most individuals is after 48-72 hours, the symptoms will slowly begin to decline in their intensity. However, individuals will still experience some level of distress that can include aches and pains, nausea, anxiety, irritability, depression, and cravings. These symptoms may continue for several days and even for several weeks in some.
- For most individuals, the symptoms will be significantly diminished within 5-7 days following discontinuation. Some individuals may continue to experience residual symptoms, such as mild anxiety, nausea, irritability, cravings, etc., for several weeks following discontinuation. In some cases, individuals may continue to experience intermittent issues with mood swings and cravings for months to years following discontinuation.
The potential to relapse is extremely high, especially in the early stages of withdrawal, but it continues to be high at all stages. People who attempt to discontinue use of the drug without undergoing medical assistance relapse at extremely high rates that approach 100 percent. Although the withdrawal process from Dilaudid is not considered to be potentially fatal in the same way that withdrawal from alcohol or benzodiazepines is, individuals are at risk for harm due to accidents or potential suicidality and should be monitored by a medical professional. These individuals are also at risk for overdose because they may use an extremely high dose of the drug in an attempt to rid themselves of their distress or may lose track of how much of the drug they have used.
Withdrawal Management
Withdrawal management, or medical detox, refers to a targeted strategy aimed at reducing withdrawal symptoms associated with alcohol or drugs. Physician-assisted withdrawal management describes formal medical treatment of the withdrawal process where a physician trained in addiction medicine assists the individual in safely withdrawing from drugs. The use of a physician-assisted withdrawal management strategy is strongly recommended as this strategy will significantly decrease the probability of relapse, ensure that the individual safely withdraws from their drug of abuse, and deals with any complications that can occur throughout the withdrawal process.
Medical detox for withdrawal from Dilaudid may include the use of an opioid replacement medication, such as Suboxone. A replacement medication will significantly decrease or totally eliminate the symptoms of withdrawal and can be administered safely by a physician. As time goes on, the physician will slowly use a tapering strategy and decrease the dosage at specific intervals to allow the person’s system to slowly adjust to decreasing levels of the medication.
This will reduce any withdrawal symptoms, lessen cravings, and assist the individual in safely withdrawing from the drug while at the same time engaging in substance use disorder treatment to prepare for the future.
Physicians can also address any co-occurring mental health issues that can increase the probability that the person will relapse. This can be done through the use of medications and therapy, depending on the individual’s needs. Other medications can be administered for symptoms that are not controlled by the opioid replacement medication or for other co-occurring physical symptoms, such as pain.
Withdrawal management, or medical detox, can be performed on an inpatient or outpatient basis, depending on the needs of the individual and on the specific factors associated with the case. Often, inpatient programs are preferred in the initial stages to allow for 24-hour monitoring and immediate attention to any complications that may occur.
Withdrawal management is only the initial step in recovery, and completing a withdrawal management program is not sufficient to recover from a substance use disorder. Individuals need to be involved in a long-term treatment program that includes substance use disorder therapy to allow them to explore and understand their reasons for abusing drugs, develop coping strategies, and create a long-term program of recovery that supplies them with the skills needed to address stress and other issues in their lives. Participation in adjunctive forms of treatment, such as social support groups (e.g., 12-Step groups) and other interventions, is also highly recommended.
Success in recovery is highly associated with the length of time one remains in recovery. Many individuals find that they continue to participate in some form of recovery-related activity for many years following the discontinuation of drugs or alcohol, and many continue this participation for the rest of their lives.
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