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  5. Pain medicines / analgesics
  6. Hydromorphone
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description: Potent opioid.
Fourth-line opioid: only for use with specialist advice.

 

Tables are best viewed in landscape mode on mobile devices

Route Preparation Available strengths
Oral Immediate release hydromorphone Palladone® capsules 1.3mg, 2.6mg
Modified release (long acting) hydromorphone Palladone SR® capsules 2mg, 4mg, 8mg, 16mg, 24mg

Immediate release† hydromorphone liquid

10mg/ml (other strengths can be made on
request)

Unlicensed preparation but can be made to order (contact local non-sterile pharmacy production
unit via specialist pharmacist)
Injection

Palladone injection®

Used as a subcutaneous infusion or as a subcutaneous bolus injection.

2mg/ml 10 mg/ml 20 mg/ml 50 mg/ml

Licensed preparation available via wholesalers (made by NAPP Pharmaceuticals)

Non formulary in some NHS boards

Must have specialist input. Fourth-line oral and injectable analgesic for moderate to severe opioid responsive pain in patients unable to tolerate oral morphine/oxycodone, subcutaneous diamorphine/morphine or oxycodone due to persistent side effects (for example sedation, confusion, hallucinations, itch).

 

  • Immediate release and modified release capsules have similar names. Some NHS boards recommend prescribing by brand name to avoid confusion.
  • Frail or elderly patients need smaller doses less frequently and slower titration.

 

  • Liver impairment:
    • Reduced clearance (may need reduced dosing frequency). Note that the summaries of product characteristics (SPC) list hepatic impairment as a contra-indication, but this would not preclude its use in palliative care. Patients with moderate hepatic impairment should be started at a lower dose and closely monitored during dose titration.
  • Renal impairment:
    • Reduced excretion (may need reduced dosing frequency). Titrate slowly and monitor carefully in mild to moderate renal impairment. Avoid in chronic kidney disease stages 4 to 5 (eGFR less than 30ml/min). Check renal handbook.
  • Drug interactions:
    • Similar to other strong opioids such as morphine/oxycodone. Hydromorphone may be expected to have additive effects when used in conjunction with alcohol, other opioids, or drugs that cause central nervous system (CNS) depression (for example sedatives, hypnotics, general anaesthetics, phenothiazines, tranquilisers). Respiratory depression, hypotension and profound sedation or coma may occur. 
  • Side effects:
    • Opioid side effects similar to morphine/oxycodone - monitor for opioid toxicity.
    • Constipation: prescribe a laxative to be taken regularly and anti-emetic as needed (for example metoclopramide).
    • Drowsiness: hydromorphone may cause drowsiness, impairing mental and/or physical ability. If affected do not drive or operate machinery. Avoid alcohol.

 

Immediate release oral hydromorphone

  • Prescribe 4 hourly regularly and use the same dose as required for breakthrough pain.

  • The capsules can be opened and the contents sprinkled on cold, soft food.

Modified release (long acting) oral hydromorphone (Palladone SR®)

  • Prescribe 12 hourly, with a 1/6th to 1/10th of the 24-hour dose as immediate release oral hydromorphone for breakthrough pain.

  • Palladone SR® capsules can be opened (if difficulty when swallowing the SR capsules) and the contents sprinkled on cold, soft food, but the granules should NOT be broken, chewed, dissolved or crushed as this could lead to a rapid release of the drug and a potential overdose. Seek pharmacy advice if the patient has a feeding tube.

Hydromorphone injection

  • Continuous subcutaneous infusion in a syringe pump over 24 hours.

  • In addition, prescribe 1/6th to 1/10th of the 24-hour infusion dose subcutaneously, 1 to 2 hourly as required for breakthrough pain (max 6 doses in 24 hours).

  • Diluent: water for injection.

  • Refer to stability and compatibility tables in Syringe pump guideline.

  • Sodium chloride 0.9% can also be used as a diluent. Seek specialist palliative care/pharmacy advice.

Hydromorphone is approximately 7.5 times more potent than morphine.

Tables are best viewed in landscape mode on mobile devices

Morphine dosage Hydromorphone dosage
Oral morphine 10mg ≈oral hydromorphone 1.3mg
Oral hydromorphone 10mg ≈subcutaneous hydromorphone 5mg
Subcutaneous morphine 30mg ≈subcutaneous hydromorphone 4mg
Subcutaneous diamorphine 20mg ≈subcutaneous hydromorphone 4mg
  • As with all opioid conversions, these are approximate (≈) doses.
  • Dose conversions should be conservative and doses rounded down.
  • Monitor the patient carefully so that the dose can be adjusted if necessary.
  • If the patient has opioid toxicity, reduce the dose by 1/3rd when changing opioid.

 

  • The GP, community pharmacist, district nurse and unscheduled care service should be informed that the patient is receiving this fourth-line opioid, for example via eKIS.
  • Hydromorphone can be prescribed by the patient’s GP for the indications/uses listed in liaison with local palliative care specialists.
  • Patients should receive an initial supply on discharge to allow adequate time for the community pharmacist to order the preparation(s) required.
  • At high background maintenance doses of long acting hydromorphone, the burden of the number of immediate release hydromorphone capsules for the breakthrough analgesic dose should be considered.

 

Ashley C, Currie A.  Renal Drug Handbook.  3rd Edition. Radcliffe Publishing. 2009.

Dickman A, Schneider J. The Syringe Driver. 4th ed: Oxford University Press; 2016.

Summary of Product Characteristics (SPC) http://www.medicines.org.uk/emc/search

Twycross R, Wilcock A, Howard P. Palliative Care Formulary PCF6. 6th ed. England: Pharmaceutical Press; 2017.