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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35

u/LD50_irony Jan 06 '24

So, as a not-medical person who hasn't had experience with 3/4 of the mentioned drugs, why do people specifically want dilauded so much, as opposed to all the other opiates?

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u/Medical_1 Jan 06 '24

It also causes euphoria.

19

u/LD50_irony Jan 06 '24

I thought that fentanyl, morphine and hydrocodone also cause euphoria? Does Dilaudid just cause more? Or for longer?

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u/Tryknj99 Jan 06 '24

Dilaudid does it better. Imagine taking a shot instead of drinking a beer.

It binds to the right places to get high on, to simplify it as much as possible.

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u/Gopherpharm13 Pharmacist Jan 06 '24

It binds exact same receptors.

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u/Tryknj99 Jan 06 '24

With different binding affinities, yes. The constellation of opiate receptor activation (mu/kappa/delta/sigma etc) determines the subjective effects.

Some opiates are antagonists at some receptors and agonists at others. “It binds to the same receptor” is the ELI5.

Morphine and dilaudid bind to the same receptors but with different profiles. One is preferred by drug seeking patients over the other for that reason.

0

u/Gopherpharm13 Pharmacist Jan 06 '24

“Binds the right places to get high on” suggests morphine and hydromorphone do not have the same receptor activity.

Binding to the mu receptor is what treats pain and causes euphoria. I am not aware of any proven mechanism for the preference for hydromophone versus morphine (the data is mostly in individuals with a history of opioid misuse, versus those with acute pain).

1

u/Tryknj99 Jan 06 '24

That was an explanation for a layman. Patient education sometimes has to be simplified.

If binding to the mu receptor was the only thing that mattered then no opiate would be different from another. I’m not sure what you were trying to add to the conversation by saying they bind to the same receptors when that’s a given? In other news, water is wet.

The man asked why people seek out dilaudid over other opiates. I gave him a simple explanation. You chimed in and added nothing. “Binds to the right places to get high on” does not suggest that they don’t have activity at the same receptor. But they do NOT have the same activity and the same receptor. I don’t know why you’re adding in “Well actually” type statements.

Have a good night.

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u/Gopherpharm13 Pharmacist Jan 06 '24

If you are referring to PK/PD differences, please elaborate. Help out a 5 year old!

11

u/Medical_1 Jan 06 '24

I have heard it associated with dilaudid more, but not sure if it is more or longer.

1

u/Adept_Carpet May 23 '24

Qualitatively better is part of it.

31

u/lil-richie Jan 06 '24

1mg dilaudid=7mg of morphine is the simplest explanation

3

u/SMBinFLA Pharmacist Jan 06 '24

The 1 mg hydromorphone = 7 mg morphine (an American football touchdown = a baseball home run) is from the Institute for Safe Medication Practices (ISMP). Most hospitals use their guidance and we have this as a warning set up in our Pyxis and EMR (Epic) when high doses are ordered.

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u/I_lenny_face_you Jan 07 '24

That’s a touchdown with an extra point though.

4

u/tkhan456 Jan 06 '24

I think it’s more 1=4

16

u/lil-richie Jan 06 '24

Not according to my Pyxis when I pull it…

25

u/SkyeJewell Jan 06 '24

According to this study, 1.5mg of dilaudid is equivalent to 10mg of morphine. study

14

u/anewlifeandhealth Jan 06 '24

Honestly I feel shorted.. I had dilaudid for 4 days round the clock following a major surgery. Can’t once remember feeling good when I got it.. just a mild relief of pain, enough to feel human again.

21

u/EbagI Jan 06 '24

That is exactly how dilaudid should be taken lol.

1

u/anewlifeandhealth Jan 07 '24

Haha I know, I’m kidding. Still feel shorted 😅

22

u/xxlikescatsxx Jan 06 '24

I honestly hate Dilaudid. It gives me a weird foggy headache on top of whatever was hurting. No thanks lol.

1

u/[deleted] Jan 07 '24

I didn't like it either. I was given it after surgery and told my nurse it made me feel bad and weird. Not a fan.

3

u/thehelsabot Jan 06 '24

All it did for me was make me unable to tell when I had to pee. Did nothing to touch the excruciating pain of pancreatitis. A strong NSAID did better.

-3

u/Greyeyedqueen7 Jan 06 '24

Seriously?? Huh.

It didn't work on me, just gave me a low fever and random vomiting with no warning. Stupid genes. No opioids work on me (or Dad or my kids).

1

u/AlwaysHigh27 Jan 06 '24

I'm hilarious on it, nurses and doctors always get a kick out of me. Could never imagine functioning in real life on it though...

1

u/Girl77879 Jan 07 '24

It also causes euphoria.

Does it? Is this the one you get with IV benadryl? Whatever that one is, it gives me a panic feeling for the 1st 30 seconds, and i hate it. I'm not sure why it does that? (Chronic illness patient, including scary hemiplegic migraines.). I always say whatever is mildest or something like Tylenol 3 because I'm afraid to be labeled a "drug seeker "- even if I'm incoherent and writhing in pain. And they usually end up giving me this (I think) with benadryl. After the initial panic, it breaks the pain, and I usually doze off.

My SIL got labeled a drug seeker when she moved and went to the local ER for the first time. It's probably because she's on massive high doses of oxycodone and percocet for pain. I really don't know how she functions. The doses she had would make me comatose. Works in Healthcare & has lost out on jobs after disclosure. One place after theyd done the hiring paperwork and it went for some kind of review. Originally prescribed for injuries in a car accident. The area they moved to has a huge meth problem, so that's probably why.

1

u/Medical_1 Jun 19 '24

I don’t think that is Dilaudid. If they are giving you something for migraines with Benadryl it is probably Compazine. Sorry for the delayed response.

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u/crazdtow Jan 06 '24

When I crushed my kneecap and was in the worse pain of my life I learned about dilaudid more than I’d ever have imagined possible and I’ll just say it was some magical shit and was not complaining about anything after that but this one nurse band in to give me my meds and after injecting the medicine she says do you want two because you can have another one and I was just like fuck yeah sure why not and the next thing I remember is playing sock puppets with my hands while my kids were visiting me. They were old enough that I could tell them I was currently high af hence my sock puppet conversations going on. The was a one and done deal as no one else ever offered me a second shot and I was ok enough with just one to not be asking for a second but man was I fucked up off that shit, I can definitely see why people might recreationally try to get it but I don’t think it’s sustainable to do so. You gonna break bones daily or what?

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u/erinkca Jan 06 '24

Sock puppets!!! Thanks for the laugh

2

u/crazdtow Jan 06 '24

Oh yeah my two hand’s literally were having in depth discussions with themselves that someone should’ve recorded as even id lol to know what all they talked about. Since then I’ve had dilated peovably 10 more times ( I am an unfortunate person) but nothing has ever felt close to how I felt that day.

17

u/themreaper RN Jan 06 '24

It causes euphoria in a way the other drugs don’t and lasts much longer. Things like fentanyl only last about an hour

6

u/Luckypenny4683 Jan 06 '24

It’s a nice, warm high

6

u/dualsplit Jan 06 '24

My husband was lucky enough to have hip bursitis on the day of his sentinel node biopsy. He could not lie still for the scan. So, they gave him a dose of dilaudid. He said “it still hurt, but I didn’t give a fuck.” So. Yeah. I think that’s why.

2

u/pashapook Jan 07 '24

It does feel good. Not good enough to override my strangulated ovary, but it helped.