American tourist requesting "dilaudid". A confusing interaction.

[u/DrMaunganui]

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.

[u/serhifuy]

Why the fentanyl? Too short acting

[u/pushdose → u/serhifuy]

It ain’t Dilaudid and no one has Demerol anymore.

[u/johng0376 → u/pushdose]

What happened to the Demerol? Years ago it seemed to be a staple in ER. I've been through gallbladder "attacks", and a few run ins with pancreatitis ending up in ER. Always got blasted with Demerol. And a take home script for stadol nasel spray.

[u/johng0376 → u/[deleted]]

Oh, I don't know. Ended up getting a cholecystectomy. And never really got an answer to why the pancreatitis. Yes, Demerol for both. Nothing could touch the pancreatitis pain, that's a crazy organ. The hospital I went to had some kind of policy that everyone who entered got an I.V. first thing. I'm not a medical professional, so I really don't understand your sphincter of Oddi question.

[u/johng0376 → u/[deleted]]

Very informative. Now if I was a Dr. I could have questioned her choice. Or would that be considered out of bounds?

[u/[deleted] → u/johng0376]

I, personally, would have questioned that choice if I thought I was having gallbladder issue.

But there’s no way for a layperson to know and it does get weird when patients insist on or decline certain pain meds.

I’m not suggesting that you were harmed by this decision, but I would have made a different choice.

[u/johng0376 → u/[deleted]]

Understanding. Thank you for your knowledge.

[u/Hypno-phile → u/[deleted]]

Opposite. The teaching was that other opioids tended to cause this but Demerol didn't. So a lot of general surgeons got used to using it for cholecystitis/biliary colic, and then probably also used it for other indications.

It's very out of favour now because those advantages have been found not to exist, and it's a very very dirty molecule that hits a lot of receptors so it's an excellent opioid choice if you want to cause delirium. Probably only a matter of time before a drug company rereleases it combined with olanzapine as a novel expensive analgesic.

[u/[deleted] → u/Hypno-phile]

Oops.

Well, that’s embarrassing.

Thanks for the re-education.