• Overview
• How Is It Taken?
• Fast Hydromorphone Facts
• Effects on the Body
• On Opiates/Off Opiates
• Treatment for Habitual Users
• The Law

What Kind of Drug Is It?

Hydromorphone is a prescription painkiller made by chemically altering morphine molecules. Morphine is an organic, or carbon-containing compound, extracted from opium, a strongly addictive drug that is made from the opium poppy. (Entries on morphine and opium are also included in this encyclopedia.) Available in pill and injectable form, hydromorphone is about five to eight times stronger than morphine and is sometimes used instead of morphine to regulate pain from injuries, surgery, cancer, and severe migraine headaches. Doctors generally do not prescribe hydromorphone products as a first course for pain relief. Its use is restricted to longer bouts of pain that do not respond to weaker or over-the-counter (OTC) medicines.

Because hydromorphone is so addictive, doctors who prescribe it are careful to monitor their patients. Physicians also help their patients to gradually stop taking the drug when the medicine is no longer needed. For people who need help managing severe pain, hydromorphone carries few side effects beyond drowsiness and constipationAn inability to have a bowel movement..

Abuse of hydromorphone presents a completely different situation. Peddled on the street as "drug store heroin," the medicine, when crushed and snorted or injected, behaves like morphine in the brain. Since hydromorphone is stronger than morphine, however, its use as a can be deadly, even on the first dose. Abuse leads to addiction, a physical and psychological craving for the drug.

According to the Monitoring the Future survey conducted in 2004, most types of illegal drug use have declined since the 1990s. The exception is abuse of prescription drugs, especially painkillers such as hydromorphone. Interestingly enough, abuse of prescription drugs is not limited to young adults but can affect all segments of the populationeople of all ages, from teens to senior citizens. However, hydromorphone is not mentioned as frequently in the media as its related compound, oxycodone. (An entry on oxycodone is also

Purdue Pharma, maker of the painkiller Palladone, voluntarily recalled the new drug in July 2005 pending further research. The FDA asked for the withdrawal after receiving reports that Palladone's extended release mechanism could fail if the user took the drug with alcohol. This failure could result in dose-dumping, or the dangerous rapid release of the drug into the bloodstream. AP/Wide World Photos.

available in this encyclopedia.) Nevertheless, abuse of hydromorphone has killed or sickened many thousands of people, including those who obtain it illegally and legally.

Overview

Use of the opium poppy for medical purposes dates back more than 6,000 years. The first archeological record of poppy use can be found in the ancient cultures of the Fertile Crescent (now Iraq and Iran). The ancient Egyptians, Greeks, and Romans all sought opium products for relief of many ailments, from diarrhea to headaches. The Greeks and Romans also knew that opium could be used as a poison. The Greek god of dreams, Morpheus, is depicted in artworks holding opium poppies in his hands.

Between 1000 and 300 BCE, users had learned that the best way to experience from opium was to smoke it. By the Middle Ages (c. 500. 1500), opium use was widespread in Asia, the Middle East, and the Far East. The drug was mixed into wine or other stronger liquors and called laudanum, the Latin word for "to be praised."

Completely legal in the nineteenth century, opium was used and abused by poets such as Samuel Taylor Coleridge (1772834) and Elizabeth Barrett Browning (1806861), as well as wide segments of the general population. The drug was both cheaper and easier to get than alcohol. In fact, some doctors used it to treat alcoholism. In Europe during this era, opium-based medicines were liquids containing small doses of the drug. Taking such medicines orally further limited the drug's power. Thus, it was possible to use "tincturesCombinations of an active drug and a liquid alcohol." and "elixirs" containing opium for many years while maintaining a fairly ordinary lifestyle. However, it was also easy to take higher doses of the "tinctures" than recommended, leading to addiction and changes in behavior.

Morphine Is Introduced

Morphine, one of the active ingredients in the opium poppy, was first isolated in 1803 by German scientist Friedrich Sertürner (1783841). He named the substance after the Greek god Morpheus. By 1832 morphine salts could be obtained in most pharmacies without a doctor's order. The invention of the hypodermic needle in 1848 provided a whole new way to deliver morphine. The hypodermic needle is sharp and hollow and used for administering an injection into the skin. Surgeons used needles to deliver morphine to ease pain during the American Civil War (1861865), sending many soldiers home with healed woundsnd addiction problems. In the late 1800s, morphine addiction was called the "soldiers' disease."

After the Civil War, the medical profession set out to discover a way to keep morphine's pain-relieving qualities while removing its potential for addiction. In 1874 British chemist Alder Wright boiled morphine with acetic anhydride, a type of acid. The resulting drug, heroin, was at first thought to be that perfect painkiller. But heroin actually proved more habit-forming than morphine. (An entry for heroin is available in this encyclopedia.) Meanwhile, the growth of and the abuse of clearly addictive "tonics" raised new alarms about the hazards of morphine, opium, and heroin. The Harrison Narcotics Act of 1914 removed all opiatesAny drug derived from the opium poppy or synthetically produced to mimic the effects of the opium poppy; opiates tend to decrease restlessness, bring on sleep, and relieve pain. from over-the-counter medicines and made them available only by a doctor's prescription. In 1924 heroin was made illegal.

In an effort to keep powerful prescription drugs from falling into drug dealers' hands, the FDA announced plans to track such drugs by using radio frequency identification (RFID) tags. According to then-acting FDA commissioner Lester Crawford (pictured here), RFID technology allows drugs to be tracked from the manufacturer to the pharmacy to the consumer. AP/Wide World Photos.

Dilaudid Hits the Market

As of 2005, opiates are separated into two categories: completely illegal Schedule I substances, such as heroin, and regulated Schedule II substances, including morphine, codeine, and hydromorphone. Hydromorphone, a slight alteration of the morphine molecule, was first created and patented by Abbott Laboratories as the prescription pain-killer Dilaudid. Stronger than morphine and available in pill, injection, and form, Dilaudid quickly became popular as a pain reliever for patients in long-lasting, or chronic, pain. It could also be used safely by patients who had allergic reactions to morphine.

With the explosion of drug experimentation in the 1960s and 1970s, Dilaudid began to appear on the streets under a variety of names, including "dillies" and "drug store heroin." Other problems arose with the prescription painkiller. Some people did not use it correctly and became addicted to it. Others gave away their prescriptions, or sold them, or allowed family members to use the pills. Such tactics began occurring in the early twenty-first century with the popular painkillers OxyContin and Vicodin.

In 2005, Purdue Pharma introduced a new, extended-release hydromorphone capsule called Palladone. Stronger and more dangerous than OxyContin, Palladone was regulated by the most sophisticated tracking devices in an effort to keep it from falling into illegal use. Palladone is a Schedule II controlled substance.

In July 2005 Purdue Pharma voluntarily recalled Palladone after reports surfaced that the drug could prove fatal if combined with alcohol. Although the company warned people not to use the drug with alcohol, it withdrew Palladone pending further investigation. Alcohol can affect the extended-release mechanism in the drug, causing the contents of the pill to be released rapidly rather than slowly. This dose dumping could prove fatal, hence the recall.

What Is It Made Of?

Hydromorphone is called a "semi-synthetic" drug, meaning that it is a chemically altered version of the naturally occurring opiate morphine. By weight it is five to eight times more powerful than morphine. In its most basic form it is a fine, white (or nearly white) powder. Because the substance is so closely related to morphine, urine tests for the presence of opiates will detect it.

In prescription pill form, Dilaudid appears as a pale yellow pill, and Palladone as a capsule containing pellets of various colors. Dilaudid is also available in suppositories and in a liquid formula, which is occasionally prescribed for persistent coughs. Dilaudid is dispensed in five strengths: 1 milligram, 2 milligrams, 3 milligrams, 4 milligrams, and 8 milligrams per dose. Palladone extended relief capsules come in 12 milligram, 16 milligram, 24 milligram, and 32 milligram doses.

How Is It Taken?

Dilaudid and Palladone are the prescription names for hydromorphone hydrochloride. Both are made as pills. Dilaudid is a powder-based pill that immediately dissolves in the stomach. Palladone is a time-release capsule. The capsule's shell dissolves in the stomach and the medicine moves on into the intestines in the form of small pellets coated with substances that dissolve over time. Some pellets have more coating than others, allowing for a continuous release of the medicine into the bloodstream.

In the past, doctors used injections of hydromorphone during and after surgery for pain relief. In more recent decades fentanyl has replaced hydromorphone for use in surgeries and also as a time-release painkiller. (An entry for fentanyl is available in this encyclopedia.)

Abusers of dilaudid have been known to crush the pills and snort or inject the powder. Injection can be dangerous because the powder-form pills contain fillers that do not always dissolve completely. The injection of these particles into the blood can damage veins.

Doctors who issue legal prescriptions for hydromorphone are ordered to stress the medication's potential for abuse. Patients needing the medicine are told to take it only as prescribed. They are not to double-up on doses. Also, they are told to flush any leftover medicine down the toilet so that it cannot be stolen. Patients who take the medication for more than a few weeks will need "taper down" doses to avoid symptoms.

Are There Any Medical Reasons for Taking This Substance?

Many Americans will need treatment for pain at some point in their lives. Hydromorphone is considered a "last resort" medication for pain that has not responded to other drugs, for those who have already developed a for opiates such as morphine, and for terminally ill cancer patients. Victims of serious traffic crashes or difficult and painful surgical procedures may be given prescriptions of hydromorphone to help them through the first weeks of recovery. Occasionally, the drug is prescribed for severe back pain, but only after the existence of the pain is proven with X rays or a Magnetic Resonance Imagery (MRI).

Hydromorphone was developed, in part, to provide opiate-grade pain relief to people who have allergies to pure opiates such as morphine and codeine. With other syntheticMade in a laboratory. and semi-synthetic drugs available, use of hydromorphone has dropped in the hospital setting.

Usage Trends

According to the Monitoring the Future study, theft and abuse of prescription drugs is one area of growth in the illicit, or illegal, drug market. Abusers seeking a rush of euphoria will open OxyContin tablets, crush the contents, and swallow the ground-up particles. Dilaudid also has a history of being ground into a powder and snorted or injected. How the drug Palladone will enter this illegal arena remains to be seen. Palladone is stronger than OxyContin. Purdue Pharma has issued strict warnings that crushing the contents of a Palladone capsule and swallowing the powder could be immediately fatal. For that reason, the drug may not appeal to thieves and dealers.

A Prescription for Abuse

Opiate abuse and addiction is a problem not just for the young. Men and women of all ages have been killed by, or treated for, prescription opiate abuse. Some people resort to "." They visit more than one doctor and describe the same symptoms in order to double up on prescriptions. Doctor shoppers are more likely to be adults than teenagers. And no matter how careful doctors and patients are with their pain management, some legal users will become addicted to the drug.

According to the U.S. Drug Enforcement Administration's Diversion Control Program, Dilaudid was one of the "leading opioid products for abuse and diversion during the 1970s and 1980s." The DEA has prosecuted people who forged prescriptions, criminally minded doctors and pharmacists, and thieves who rob hospitals, drugstores, and nursing homes in search of hydromorphone. On its Web site in October of 2004, the DEA noted: "Recently the diversion of Dilaudid has been reported by a number of DEA field offices including, New York, Chicago, St. Louis, San Antonio, Atlanta, Boston, Dallas, Detroit, Houston, Los Angeles, and Washington, DC." The problem also exists in suburban areas. In October of 2002, a South Florida Sun-Sentinel feature story confirmed "almost 400 deaths during the past two years in seven South Florida counties from prescription drug abuse, many ordered by doctors to control discomfort."

Middle-aged and upper- or middle-class people are far more likely to abuse prescription painkillers than to smoke marijuana or buy illegal street drugs. Even the doctors who prescribe such medications can fall victim to them. On November 30, 2003, the South Florida Sun-Sentinel reported on a doctor who died just two days prior to his forty-seventh birthday from an overdose of cocaine, oxycodone, and a muscle relaxant. He had been working as a pain specialist at a local clinic. Nurses have been prosecuted for stealing hydromorphone from their workplaces as well.

One of the stranger stories reported in the press is a 2002 case in Brighton Beach, New York. Two elderly womenne seventy-nine, the other seventy-sevenere arrested for selling their prescription hydromorphone tablets on the street. Their customers, who were willing to pay as much as $10 for a single pill, included local teenagers. Both women were charged with possessing and selling a controlled substance.

Effects on the Body

In the book Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy, Cynthia Kuhn and her coauthors wrote: "Opiates act on specific receptor molecules for the endorphin/enkephalin class of in the brain." This means that hydromorphone enters the brain and floods nerves that are searching for endorphinsA group of naturally occurring substances in the body that relieve pain and promote a sense of well-being. and . The human brain produces its own endorphins and enkephalins, allowing people to experience happiness and peaceful feelings. Hydromorphone and its related compounds stimulate all of the endorphin/enkephalin receptors at once. These receptors serve several functions. They control the "fight or flight" response, govern the amount of pain a person feels, and suppress coughing.

After taking a normal dose of hydromorphone, a patient in severe pain will receive relief within forty-five minutes. The drug's effects last several hours. Continuous release capsules last even longer. Taken in the proper amounts, as prescribed, hydromorphone promotes pain relief with side effects of drowsiness, dizziness, slower breathing, and constipation. Usually the patient will not feel the rush of euphoria that characterizes abuse. The drug simply relieves pain and allows a patient to move about or interact without constant distress.

Healthy people who abuse hydromorphone do so for the high. This is a brief but intense rush of enhanced happiness, feelings of well-being, loss of anxiety, and relaxation. In Illegal Drugs: A Complete Guide to Their History, Chemistry, Use and Abuse, Paul M. Gahlinger noted: "Opiates affect almost every part of the body The muscles are relaxed: speech becomes slurred and slowed, the eyelids droop, and the head may begin to nod. It may become difficult to walk. The pupils of the eyes become pinpointed and do not react to light." The natural opiates such as morphine also cause nausea and vomiting. Hydromorphone can also cause nausea, but it does not affect the stomach as severely as morphine or heroin.

Hydromorphone Abuse

When the effects of a dose of recreational hydromorphone begin to wear off, the user will experience a "rebound" that includes heightened anxiety, muscle tension, and diarrhea. It becomes highly tempting to take another pill to relieve these uncomfortable symptoms. Over timeays or weekshe body builds a tolerance to the pleasurable effects of hydromorphone abuse, while the uncomfortable symptoms of withdrawal become worse.

A woman identified only as "Sadie" told Cosmopolitan magazine that she began using her father's Dilaudid while caring for him as he battled terminal cancer. After two months of moderate use, she suffered severe withdrawal symptoms. "It had a vise grip around me," she said of the drug. "I couldn't [quit]." The Cosmopolitan story also stated that women are more likely to receive prescription pain relievers than men, and that women also become addicted to them more easily than men. Culture may play a part in this: Men tend to view pain as something they can live through. Biology may play a role as well. Women are more likely to suffer from anxiety and depressionnd to find relief in prescription medicines.

Suffocation and Death

Hydromorphone shares the dangers of the other opiates in terms of breathing. The drug works on the part of the brain that automatically orders the body to breathe. Pain patients and drug abusers alike have been known to stop breathing after a dose of hydromorphone. If found in time, these users can be revived using the drug naloxone (Narcan), a substance that quickly rids the body of opiates. Many victims are not found in time, however, and they die of .

In a hospital setting, first-time users of hydromorphone are monitored closely until their tolerance level is established so that they do not quit breathing and die. Doctors may also prescribe some sort of laxative, a drug that brings on a bowel movement, to help with the constipation brought on by the drug's action on the muscles in the intestines.

Reactions with Other Drugs or Substances

Since it is a powerful central nervous system depressant, hydromorphone will enhance the effects of other drugs and alcohol. Drinking alcohol while taking hydromorphone will increase the likelihood of breathing problems and loss of muscle control. The

Addiction to narcotics is extremely difficult to overcome. Abusers of powerful opiates often need to be hospitalized in a rehabilitation clinic. Photograph by Leitha Etheridge-Sims.

drug also should not be combined with such as Benadryl; drugs for nervous disorders such as Nembutol, Restoril, Thorazine, Valium, or Xanax; or antidepressants such as Elavil and Tofranil. Persons taking other opiate painkillers such as Vicodin, Demerol, Percocet, or fentanyl should not use hydromorphone.

Because it reacts so strongly with other drugsnd because it is a powerful painkiller with potentially dangerous side effectsydromorphone is not prescribed to be taken on an "as needed" basis. People receiving valid, legal prescriptions for hydromorphone need to take it on a daily schedule, sometimes for a prolonged period of time. Patients receiving hydromorphone need to tell their doctors about any other medications they are taking. The medicine must be kept out of reach of children. Palladone was not prescribed for anyone under eighteen.

After taking hydromorphone for a period of weeks, patients will need to gradually lower the dosage slowly to avoid withdrawal symptoms. This is done under a doctor's supervision.

Treatment for Habitual Users

Narcotics addiction is extremely difficult to overcome. Abusers of powerful opiates such as hydromorphone often need to be hospitalized in a rehabilitation clinic, sometimes for as long as thirty days. Attempting to quit the drug without medical assistance can lead to a host of withdrawal symptoms, including uncontrolled muscle spasms, cramps, diarrhea, sweating, clammy skin, anxiety and panic attacks, nausea, and a prolonged period of depression. Often the addict just caves in and goes looking for the drug again.

Under a doctor's care, the hydromorphone abuser might receive methadone, another opiate that controls withdrawal symptoms without producing a "high." (A separate entry on methadone is available in this encyclopedia.) Patients should also undergo counseling. Some are prescribed anxiety-relieving medications. Nonprofit organizations like Narcotics Anonymous (NA) provide support from other recovering addicts through a twelve-step program of regular meetings, a telephone hotline, and a "buddy system" that pairs newcomers with successfully drug-free members.

Many recovering addicts discover that the drug abuse has so altered their lifestyles that they literally need to "begin again" with a new life. Drug abusers trying to go straight are always counseled to end friendships that developed around the abusive lifestyle, to avoid the places they went to purchase or steal drugs, and to seek new social and professional contacts. This can prove particularly difficult for those in the health care industryhe doctors, nurses, and other medical support staffho abuse painkillers.

Addiction to opiates does not end when the withdrawal symptoms ease. The brain rebounds from its altered chemistry by undergoing a lengthy period of adjustment. Recovering addicts may feel badepressed, anxious, joylessor months or even years. It is this ongoing that sends some addicts back into drug abuse. Also, it is this syndrome that self-help groups such as Narcotics Anonymous try to combat.

Consequences

Studies have shown that prolonged use of opiates such as hydromorphone cause little damage to the human body in and of

In 2005 the FDA launched a pilot program using radio frequency identification (RFID) tags to track the movement of bottles of the most addictive prescription painkillers. AP/Wide World Photos.

themselves. Nevertheless, the drug can wreak havoc on a person's health. In pursuit of the next dose, the addict might resort to criminal behavior such as theft, robbery, or prostitution. Trading sexual favors for drugs can lead to numerous diseases, from syphilis to AIDS (acquired immunodeficiency syndrome). Shared needles also expose the user to AIDS and . Since opiates produce nausea and vomiting, users tend to eat less, wasting away as the habit consumes their lives. While high on opiates, users may not be able to drive or operate machinery with the proper amount of control.

Hydromorphone depresses the region of the brain that controls breathing. Taken in large doses, or in strange settings, or in combination with other drugs, hydromorphone can make the user stop breathing. Drug abusers are sometimes found dead in bed or on the bathroom floor by those who love them most.

The Law

Hydromorphone is a Schedule II controlled substance, overseen by the DEA. It is illegal to possess the drug without a valid prescription from a licensed physician. Doctors face possible legal sanctions if they over-prescribe painkillers to their patients. Although doctors are allowed to assess each individual case, many tend to be very conservative when treating pain. The illegal abuse of hydromorphone has made it more difficult for truly needy patients to obtain it.

Once a patient has received a prescription, it is illegal to alter that prescriptionor instance, to change a "30" to a "300" by adding a zero. In 2004, a thirty-seven-year-old woman was caught altering a Dilaudid prescription that she received from a doctor in Tampa, Florida. Her bail was set at $10,000.

"Doctor Shopping" and Pharmaceutical Theft

It is also illegal to "doctor shop." Patients who doctor shop typically move from physician to physician, reporting the same symptoms to each doctor. They receive the same prescriptions from each doctor. Of course, the doctors do not know that the patient has already seen someone else and received a prescription for the same complaint. Doctors, too, have been arrested for running "pill mills." This occurs when doctors prescribe painkillers to patients with vague symptoms, no X rays or other evidence of the reported pain, or feeble reasons for seeking more medicine, such as having lost the first prescription.

The DEA reported in 2004 that robberies of pharmacies, hospitals, and nursing homes were on the rise. In some cases, thieves have posed as safety inspectors or other hospital personnel in attempts to snatch pharmaceuticals. In 2005, strangers entered a hospital under false pretenses and the incident was investigated by the U.S. Department of Homeland Security as a possible terrorist attack. Needless to say, theft of prescription drugs carries very serious penalties, usually including jail time.

Radio Frequency Identification (RFID)

In 2005 the Food and Drug Administration (FDA) launched a pilot tracking program for the most addictive prescription painkillers, including Palladone. The new system, called Radio Frequency Identification (RFID), places a small tracking tag on each individual bottle of pills. The electronic tag can be scanned as the bottle of medicine moves from the factory where it is made, to the package it is shipped in, to the pharmacy where it will be sold, and ultimately to the legal consumer. Acting FDA commissioner Lester Crawford told the Chain Drug Review: "These actions are designed with one goal in mind: to increase the safety of medications consumers receive by creating the capacity to track a drug from the manufacturer all the way to the pharmacy."

Penalties for illegal use and sale of hydromorphone vary from state to state and become more severe for each repeat offense. The burden of keeping illegal hydromorphone off the falls on the federal government, doctors, nurses, hospital staff, and ultimately patients who really need it.

See also: Codeine; Fentanyl; Heroin; Meperidine; Methadone; Morphine; Opium; Oxycodone