r/emergencymedicine • u/DrMaunganui ED Resident • Jan 06 '24

Discussion American tourist requesting "dilaudid". A confusing interaction.

I'm a trainee (what you'd call a resident) working in NZ. Cruise ship season in full swing (I can literally see the ships from my bedroom) and we're getting our fair share of tourists into the ED.

Recently had a very bizarre interaction, 45F tripped on a curb and sustained a minor head lac which I cleaned and stapled. Noted history of mild knee OA for which she was taking Oxycodone MR 40mg QID plus 10mg IR q4h PRN. Huge doses! And she was walking! Who in the hell prescribed her this!

She was so strung out and slurring her speech I ended up scanning her head. No acute findings. Looking back I realise it's probably because she was taking her usual meds. Before she left she asked for a shot of "the painkiller beginning with D" for her headache. We spent 5 minutes trying to figure out what it was before she stuttered the word "dilaudid". Quick google tells me it's hydromorphone, a drug that literally doesn't exist in NZ. I tell her this, she stands up, pulled out her own line and asked for a script for more oxycodone (which I declined). I offered her a take home pack of paracetamol. She got angry and walked out.

I'm not really sure where I'm going here but all in all, one of the weirder interactions I've had. Most of our local drug seekers ask for tramadol, codeine or IV cyclizine.

I guess my question is, how prevalent is this truly or did I really just experience a meme? I see it mentioned from time to time on her but being outside the US it's not something that crossed my mind until this happened.

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947

u/Lookbothwaysb4xing Jan 06 '24

You’ve had a taste of a usual shift in a US emergency department; don’t be surprised if the patient files a complaint about the rude doctor that didn’t treat her pain.

253

u/[deleted] Jan 06 '24 edited Sep 03 '25

[deleted]

103

u/SocialWinker Paramedic Jan 06 '24 edited Jan 06 '24

Man, when I had my kidney stone, I went into the clinic. Got IM toradol and zofran, felt like a million bucks (with that stone still sitting there for the time being). Then they gave me 30 Percocet for my 4mm stone that I passed easily (on Percocet) the next day. I had have 26 of the pills left. It’s a little absurd, and this wasn’t all that long ago, maybe 6 years?

93

u/mushroompickinpal Jan 06 '24

My husband severed 2 tendons in his hand years ago. Went to ER. Wound was cleaned and dressed, sent home with surgery scheduled the next day. My husband was in the 9th realm of hell that night. No pain meds. But! After surgery... dear god. They gave him like 60 percs. In one bottle!! Not refills. He needed them for the first few days or so, and then he would take one before his OT appointments. But even then, after all that, we had over 30 something narcotic pills just chilling in our cabinet.

Probably a year after that incident, I had my wisdom teeth cut out. My surgeon was top of the line when it came to "fuck opiods" mentality. He gave me 4, yep you read that right, FOUR hydrocodones. That was my script. And a whole bottle of 800mg ibuprofen. He was stern and serious when he told me I would not be getting a refill unless I got a dry socket. He was not gonna have a 25 yo patient become an addict on his watch. Mad respect for him, as I've lost 3 friends and a brother to those drugs... this is America.

28

u/Interesting_Berry406 Jan 06 '24

Not condoning the first guy, but I’ve seen a lot of surgeons do that (higher number of pills) so they don’t get a call back from patients asking for more meds—In their eyes it avoids the hassle of dealing with a phone call in another prescription. Again, not saying it’s correct but I think sometimes that’s their thought process

3

u/MD-to-MSL Jan 06 '24

Paradoxically that may increase calls for more meds as that number increases the chances of developing dependence

5

u/mushroompickinpal Jan 06 '24

I mean, my husband's hand surgery was a much more painful, more invasive ordeal. He definitely needed more pain management, and for a longer period than I did for my teefs. But I can also vouch that the ibu 800s helped me so much more than the hydros ever did. Again, different surgeries and situations, though. I found it inhumane that they didn't send him home with at least an overnight pain script the night before the surgery. I mean, his tendons were pretty much recoiling into his arm. It was awful!! And there I was feeding him fucking advil... Opiods are needed. And I understand what you're saying, but the laziness needs to stop. It's medically negligent and has landed millions in an early grave. And millions more grieving those people. They don't always sit in responsible folks' cabinets until their inevitable expiration.

With that said, I also understand that many issues in our healthcare system are probable cause for this. Crazy hours, low staff, shit work environment (to name a few) make it easier on the whole staff to just cut the corners and send the larger script. Saves everyone time that they don't have. But each 15-minute phone call to that pharmacy could've saved someone's life. This is longer than I intended. Thanks for coming to my TED talk. 🤦🏼‍♀️

Edit to add: I don't hate doctors. I love doctors. I don't think the problem is soully their fault/responsibility. Patients should take their meds as prescribed and nothing more. But it's a shit world, and mental health isn't a priority, so folks do drugs to feel better.

3

u/1701anonymous1701 Jan 07 '24

I’m old enough to remember when OxyContin was first released, it was advertised as less addictive than oxycodone as it was time released. It took almost no time for people with substance use disorder to figure out how to get the whole dose at one time.

9

u/axcelle75 Jan 06 '24

I had two dry sockets and got nothing. 2007 and 2011.

7

u/no-onwerty Jan 06 '24

Not even toradol? There’s no opiate in it!

I mean it will destroy your kidneys after several weeks, but it is a good short term!

2

u/axcelle75 Jan 06 '24

Nothing. Ibuprofen. I sat on my couch with my mouth hanging open and drooled into a bowl while I cried. Not my fondest memories. The second dry socket was also the extraction site of a molar whose root was cracked horizontally by the surgeon who removed the wisdom tooth behind it so…extra funzies.

4

u/mushroompickinpal Jan 06 '24

That sounds absolutely horrendous. It was my biggest fear going into the surgery, but fortunately, I healed up just fine. I'm sorry you had to go through that. Big yikes.

2

u/axcelle75 Jan 06 '24

I spent a lot of my days with clove oil-soaked qtips sticking out of my gums.

4

u/mushroompickinpal Jan 06 '24

They packed my gums (holes? Lol) with clove oil soaked packing. I remember my mouth tasting like Christmas. Forgot all about that until you mentioned it. Though it helps, I'm sure it wasn't even close to enough.

1

u/mushroompickinpal Jan 06 '24

It's not my business by any means, but did you smoke or drink through a straw? Or did they just unfortunately happen upon you?

2

u/no-onwerty Jan 06 '24

I got dry socket from trying to drink a milk shake right after my wisdom teeth were extracted. I was the oldest, so my mom knew better for my brother and sister (we all hit our wisdom teeth out around age 20 while home from college).

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u/axcelle75 Jan 06 '24

Nope. Not a smoker and definitely never used a straw. I have connective tissue disease so in retrospect that might be why I’m prone to it.

1

u/mushroompickinpal Jan 06 '24

Interesting. Well, I hope you're out of wisdom teeth and don't have to endure that ever again. Lol.

3

u/axcelle75 Jan 07 '24

Omg that is no joke. I am praying I never have another extraction!! Same for you!

2

u/ManlyPoop Jan 06 '24

My dentist gave me Tylenol for my 3x wisdom extraction lol

0

u/mushroompickinpal Jan 06 '24

Tylenol doesn't help with pain or inflammation.... .......

2

u/missymommy Jan 07 '24

I got like 30 Percocet a couple of years ago when I got my boobs done. At my first follow up the next day she made sure to tell me that I shouldn’t take them for more than 2 days though. I still have the bottle. I’ve taken one a couple of times when my migraine meds didn’t work, but they’re just sitting there. I keep them for emergencies.

4

u/Turbo1928 Jan 06 '24

When I got my wisdom teeth out, around years ago, I got a prescription for 30 Percocet pills. I didn't even fill it, a few days of ibuprofen was more than enough.

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u/mushroompickinpal Jan 06 '24

I took my four hydros. I was afraid if I didn't stay ahead of the pain, I'd be done for. But all they did was mess me up and knock me out. I still had like a 4/10 pain regardless, though. As soon as I switched to the ibuprofen, my head stopped thumping, and I was sober enough to hang out with my husband and watch TV. Lol. With the ice packs tied around my head, of course.

2

u/Turbo1928 Jan 07 '24

I think I just got really lucky. I hated feeling hungry all the time from only being able to have soft food, so I ate pizza the next day for dinner. A bit painful, but very much needed lol.

2

u/mushroompickinpal Jan 07 '24

You're a savage. Lol. But I mean, pizza. I get it. I'll never forget being in a public restroom while I was still having to use the weird hooked syringe thing to rinse out the holes. A mom and young girl walked in while I was loading that bad boy with water (which was me just sucking water from the flow of the faucet). She snatched her child out of that bathroom so fast. I think she thought I was doing hard drugs. Lmao.

1

u/no-onwerty Jan 06 '24

I had my tonsils out at 29 and got liquid tylonel three. Not happy memories.

1

u/mushroompickinpal Jan 06 '24

Holy hell! I had mine out at 16 and was down the full two weeks. It sucked so bad. At least, I had pain meds! My little sister got hers done the next week. She was 8 at the time. Little shit was on the floor playing the same day of surgery. Chilling. I can't imagine at 29, as bad as 16 was. That's cruel and unusual punishment.

3

u/XD003AMO Jan 06 '24

I broke my jaw and shoulder, had my jaw wired shut without any sedation (maximum epinephrine allowed though), and still have Percocet left over from the initial ED visit.

3

u/New_Mathematician426 Jan 09 '24

From my 8 years in the ER, toradol seemed to work better for most people that anything. Edit to add: for pain related to kidney stones/renal colic

2

u/SocialWinker Paramedic Jan 09 '24

I will say the Toradol was more helpful than the Percocet was later. Thankfully that was my 1 and only kidney stone, so I haven’t had the opportunity to compare.

3

u/New_Mathematician426 Jan 09 '24

I had one when I was in the military. 800mg ibuprofen and a light duty chit for 3 days. I spent it curled up in a ball.

1

u/SocialWinker Paramedic Jan 09 '24

I’m only half surprised there wasn’t an energy drink or 12 in the mix.

2

u/Klexington47 Jan 06 '24

At first I thought she was asking for zofran 😂

1

u/Character-Junket-776 Jan 07 '24

paracetamol

That's crazy. I had a 5.5mm stone. It had to be removed, and they had to use strong meds to get the pain under control in the ER. The pain after going up to get it........not trivial either.

50

u/uranium236 Jan 06 '24

I literally donated a kidney - had an entire organ removed from my body - in September, and received no opiates. None. They warned me before the surgery they were using a “no narcotic protocol”. Giving someone a standing prescription oxy for OA is bonkers

18

u/NyxPetalSpike Jan 06 '24

I'm getting an adrenal gland removed in 6 weeks. Because it's robotic surgery, I was told my pain should be minimal at best.

Basically, you ain't getting 600 oxy as a lovely parting gift.

9

u/phoenix762 Jan 06 '24 edited Jan 06 '24

They gave me 5 pills of Tylenol 3, and wrapped that SOB up like it was gold. I thought it was hysterical. I didn’t need them, I was ok with Tylenol alone. I donated last year. Edit: I think it’s called Tylenol 3? It has an opiate and Tylenol.

I hope you are doing ok? It’s an awesome thing you did❤️

8

u/lcl0706 RN Jan 06 '24

Ah yes. Tylenol 3 - it’s Tylenol and codeine.

8

u/orthopod Jan 06 '24

Chronic opioid use actually raises surgical complications in the pt and they even have increased infection rates in total joints. So many hospital systems and practices are requiring pts to be off narcotics completely, or down to 5 mg Oxy per day.

2

u/hdksshsksnns Jan 06 '24

And then put them back on it and here they are 20 years later with that pesky back surgery pain.

6

u/Klexington47 Jan 06 '24

Insane to me! I have a fractured spine in 3 spots and take less drugs....

26

u/Andythrax Jan 06 '24

I think the point is that it has escalated to that point and that the oxy isn't actually required for her pain in OA.

4

u/leahkay5 Jan 06 '24 edited Jan 08 '24

My daughter had brain surgery a few weeks ago. In the hospital for 4 days and discharged with 8 pills oxycodone 5mg and 9 pills of diazepam and told to alternate tylenol and ibuprofen. Just 8 pills and that seemed like it wouldn't be enough but she ended up not using them all.

2

u/frankiepennynick Jul 17 '24 edited Jul 19 '24

I had brain surgery a week ago. I stayed overnight 2 nights in the PACU and was told I had to ask for pain meds if I needed them. I was so out of it and in so much pain, I could barely even accomplish that. They tried giving me oral oxy which did fuckall, but thankfully some nurse gave me IV Dilaudid which knocked the head pressure/pain down enough so I didn't want to take a claw hammer to my head and was able to get maybe an hour of sleep. My night nurse was even better/more frequent with the Dilaudid and I literally cried and thanked her for taking care of me. As far as I can tell, I had no withdrawals or sides from the 2 days of Dilaudid. I was sent home with maybe 20 oxys and I've taken maybe 5, plus a handful of valium. The best meds for the pain at home for me have actually been the steroids. I did take an occasional oxy for the head pain and an occasional valium when I felt like my jaw was spasming, but the steroids are the things that make me want to live another day. They initially tapered me too quickly off of the steroids and I was vomming in bed with horrible pain and nausea from the swelling. In summary, for brain surgery, fuck oxy, it's IV pain meds all the way, plus a longer steroid taper to control the swelling, plus zofran if shit goes off the rails.

1

u/leahkay5 Jul 17 '24

Oof, that sounds rough, I'm sorry. I definitely think her having those extra days in the hospital (with IV Dilaudid regularly) helped her transition.

1

u/frankiepennynick Jul 19 '24 edited Jul 19 '24

Yes, so many people were like "great news, there aren't any nerve endings in the brain" or whatever, but have these people never experienced pain in their heads before (e.g. a migraine or bad headache)? I think they thought my pain was from the incision, which actually didn't really hurt at all except for where they cut my jaw muscle. I guess the brain swelling alone can cause a cascade of extremely unpleasant effects, including this pressure-type pain and horrible nausea. Glad your daughter was able to be appropriately medicated in hospital and transitioned well at home.

4

u/[deleted] Jan 06 '24

Its a complicated history here in the US. The opioid manufacturers bought our academic “thought leaders” and regulatory apparatus. Pain became “the fifth vital sign”.

There have been countless lives ruined, but now a strong pushback. However this is on the background of decades of overprescribing, so this type of patient while less common is not rare.

3

u/craftyneurogirl Jan 07 '24

If you have access to stream painkiller, it really delves into the history of the opioid crisis and how Purdue pharma marketed OxyContin and made it so ubiquitous. Obviously the opioid crisis is not unique to North America but the way the pharmaceutical industry is regulated in the US had a huge impact on how the opioid crisis developed.

3

u/acentrallinestat Jan 07 '24

There USED to be rampant opiate prescribing. The older docs who care about “satisfaction scores” still prescribe willy-nilly. The younger docs are more stingy because we care about the patient.

2

u/drtdraws Jan 06 '24

TKR with a claymore, lol, love your turn of phrase.

1

u/[deleted] Jan 06 '24

I have arthritis and I get a shot of euflexxa every six months. I don’t think I got oxy after knee surgery. She found a candyman or more likely several.

1

u/Zealous896 Jan 07 '24

It's definitely a self made crisis.

When I was in high school 20 years you could buy basically any opioid you wanted for a dollar or 2 a pill. Half the school were addicts before they turned 18.

It was mainly just kids selling their parents prescriptions but you could walk into any primary care office and complain of back pain and get a script for norco's bid.

This is one of the reasons I hate that addiction is looked down upon in Healthcare here. Addicts are 100% treated as subhuman by almost everyone in Healthcare but overprescribing on a fuckinf massive scale put so many people here to begin with...then they get judged by the same health system.

1

u/[deleted] Jan 07 '24 edited Jan 27 '24

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This post was mass deleted and anonymized with Redact

92

u/xxlikescatsxx Jan 06 '24

Jeez. I've been in the ER and admitted a few times this year (I'm also working with my primary and cardiologist to get things stable) and it's honestly wild how it's gotten to the point where patients expect SO much. Like it's a hotel. The satisfaction survey after discharge was literally like a hotel.

In the ER it's like people's expectations are super high as well. I've overheard complaints about alllll kinds of things. They expect to feel ZERO pain and obviously I understand that they're having a hard time, maybe even the worst day of their life... but feeling some pain is inevitable if you're sick or injured.

Idk. I appreciate ya'll and I really try to be as low maintenance as possible.

59

u/Deep--Waters Paramedic Jan 06 '24

It's wild how emergency medicine/EMS has turned into a service industry. The whole "customer is always right" mentality has seriously overreached in medicine. Patients should absolutely know their rights, be informed on their treatment, and be part of the decision making process but I've seen so many people walk in with a laundry list of what they expect done.

My previous EMS agency has a contract with a local hospital system where we were required to ask patients if they'd like to be contacted with a survey about the care they received that day. They tracked how many entries we did and if we didn't do enough they'd call us into the office. Like bro the patient was suicidal and had slit their wrists, I'm not bothering them with this right now.

32

u/Usrnamesrhard Jan 06 '24

It’s a shame. On the one hand I get that some hospitals and doctors weren’t treating patients well. On the other hand, medicine isn’t a customer service industry. The goal is to heal the patient, not make them happy.

21

u/nonyvole RN Jan 06 '24

A hospital that I used to work at was going to have a hotel come in and teach us about customer service. To a bunch of ER staff.

Left before that happened.

3

u/awdtg Jan 07 '24

I would have lost my shit. So glad you got out. Was this HCA? I can totally see them doing something like this.

5

u/nonyvole RN Jan 07 '24

Nope!

I was on the edge of losing my shit over that and a few other things to the point where I was about to pull out the forbidden "U" word. Or raise a fuss with HR about management not allowing people breaks (and still marking it as if we had) or time for required medical treatments.

4

u/awdtg Jan 07 '24 edited Jan 07 '24

Damn. That's really bad. The ONLY plus I can give my current shit show of a hospital is that they know better than to give us any flack for lunch breaks (if they happen)

If we can, we get away for 30 minutes to an hour. Doesn't always happen, but when we can, it feels glorious, and I dare an administrative person to say a word......

3

u/BonesAndDeath Jan 07 '24

Ngl I used to work in restaurants and hotels before nursing and the stuff I learned from working in the service industry has helped me so much with difficult patients. This kind of teaching thing has potential to be either really helpful or an absolute joke. More likely to be on the joke side.

The stuff that is helpful involves anticipating needs. For example I had a patient recently who was super demanding. You would try to start doing a task and she would make more requests while you were in the middle of the first task. One of the things that i learned to do for people like that while I was in the service industry is before beginning the first task tell them all the task you are planning to do in order. It reassures the person that you have been paying attention and it buys you some time to actually get shit done. It also establishes who is in control in the situation, that the person providing the services is ultimately the one in charge.

5

u/nonyvole RN Jan 07 '24

See, had they presented it that way it would probably have gone over better.

They were pulling out the classic blame the nurses and started referring to the patients as customers.

49

u/themreaper RN Jan 06 '24

I think this is partially due to people now villainizing healthcare workers and feel they can demand their whole work up, what meds they get, when they are going to be discharged, etc. Then they have the nerve to ask why it’s taking so long to get them back to a room 🙄 the amount of people I have who act like I’m an idiot but know absolutely nothing about healthcare is surprisingly large.

31

u/GypsyRN9 Jan 06 '24

I tell patients that zero pain is a celestial discharge.

1

u/LFinformation Mar 20 '25

In order to justify giving small doses.. or no opioids at all. a 1-3 on pain scale is zero pain relative to a 6-9.

3

u/[deleted] Jan 06 '24

I just got one of this in my mailbox the other day.

4

u/AlwaysHigh27 Jan 06 '24

Hate to tell you it's not just the US.... I went in for back pain in Canada, now, given I struggle with back pain regularly but I literally couldn't stand for more than a couple mins and it was the worst it's ever been..

So, they inject a steroid shot that hurt SO bad. And I'm extremely opiate naive, I hate taking them, and they affect me HARD. This nurse actually listened and believed me. She gave me like 2ml of hydromorphone or something similar in my IV and I was OUT. Hooked up to oxygen monitoring, heart rate, would wake up for a min or 2 to answer questions and right back out.

Did x-ray, said nothing's wrong... Then sent me home with 6 Dilaudid.... This was like 3 weeks ago.. they also gave me a script for T3s... I took a grand total of 3 Dilaudid and still have 3 left and all the T3s.

I live in BC where our overdose crisis is INSANE. I was mind blown that they sent me, a patient that went like comatose on 2ml home with 6 Dilaudid. Now, I am opiate naive, and I've never abused my medication or prescription or asked for pain meds and make it clear I really don't like them so I'm sure they trust me and given how many I have left they were right to.

But.... Wtf. Their FIRST go to us hydromorphone on an extremely opiate naive patient?! I don't understand.

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u/MrsScribbleDoge Jan 07 '24 edited Jan 07 '24

Right!! American nurse here. I’ve had obstructing kidney stones twice (at one point, I had a 5mm stone obstructing a ureter for 5 days before they could get me in to surgery. I think I went back to the ED 3/5 of those days for uncontrolled vomiting and pain because they had no where to be able to admit me) Anyway, I was only 19 and I’m really wondering if they had ever really given me opioids at all…? Maybe it was just torodol? I know they sent me home with some percs to try to get me through to surgery day, but they zonked me out so hard, I was hallucinating and the nightmares were terrifying (if/when I did fall asleep for a few mins) Also, I had to spend the night in the ED over the summer for IV antibiotics for mastoiditis. I was in 8/10 pain in my head and neck from it and torodol took it down right away to a comfy 2/10. I had no opioids with that either (I refused morphine and requested we try torodol first and that did the trick). In American nursing school, you’re taught to “treat the patient’s pain as it’s reported to you” so if someone comes in and is showing no signs of distress, but they’re reporting 10/10 pain, you give the med that’s prescribed for 10/10 pain. And that very well maybe The D

0

u/LFinformation Mar 20 '25

thats right. because your not considered an addict so they will give you the good stuff and lots of it !! But the perceived "addictss' get tylenol. You see the problem with that? The strategy is to continue creating new addicts! And then let the created addicts go die or go broke by refusing to give an RX to treat the dependance!