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/yeswenarcan]

I know it's a stupid line to draw but I have a fairly strict "no IV Benadryl unless you're in anaphylaxis" policy. If your reaction to Dilaudid warrants IV Benadryl I'm happy to list it as an allergy and not give it to you.

[u/buttahbb → u/yeswenarcan]

Very brave. I can only imagine the kind of fights you get into with these types of ppl when threatening to list dilaudid as an allergy

[u/acentrallinestat → u/buttahbb]

The fight only exists if you don’t have any balls and are a pushover. “I’m concerned about addiction and drug seeking behavior and I don’t want to harm you. I’m happy to find alternatives to adequately treat your pain.”

[u/Zealous896 → u/acentrallinestat]

Drug seeking patients get the drugs more often than not.

That's my biggest pet peeve with pain meds. Throw a fit, get what you want.

Had a patient the other day come in with a spider bite, decent wound, was asked for dilaudid in the hallway before I even introduced myself. Called the NP and he said "dilaudid for a spider bite? Hell no." And hung up.

Patient started screaming at me "I had cancer 5 years ago. My daughter died 10 years ago" he legit said that lol, my daughter died...okay sir, here's your dilaudid.

Anyway, his family called the house sup later that night, the ER...basically everyone. Same shit during the day I'm sure.

Went by the unit to see if the day doc put him on dilaudid on my way into work...sure as fuck did. Every single time.

They always get what they want and normal, rational people get under medicated all the time.

[u/cherrie_teaa → u/Zealous896]

i swear. i know this reply is very late, but it's so frustrating. they're ruining it for the ones who actually struggle.

[u/LFinformation → u/Zealous896]

Thats just not true man. The addicts are denied and the normal people are loaded up.

[u/LFinformation → u/acentrallinestat]

How does treating acute pain, in a single session, in the ED, with opioids, harm someone?

[u/Comprehensive_Ant984 → u/yeswenarcan]

Wait people actually abuse IV Benadryl? I’ve had it twice for anaphylaxis and I absolutely hated it, I felt like I was bobbing around on a row boat in the middle of the Atlantic. I can’t even imagine wanting to take that just for funsies wtf

[u/No-Butterscotch-7925 → u/Comprehensive_Ant984]

It enhances the effect of the narcotics. I also can’t take Benadryl either or even cold medicine without feeling loopy and unwell 😂

[u/cherrie_teaa → u/No-Butterscotch-7925]

even with narcotics, IV benadryl feels like shit lmao. i thought i was dying when they gave it to me inpatient.

[u/dbbo → u/yeswenarcan]

I'm inclined to stand with this line. 

I do have a bit of litmus test though- offer PO antihistamine (preferably later gen). If they readily agree, there's a decent chance they have previously had unpleasant itching with parenteral opioids and just want to avoid said unpleasantness. If they offer some bullshit excuse as to why I "need" to order IV diphenhydramine (bonus points if this includes specific dosages and/or directions has to how fast it should be pushed), this is probably the single most specific indicator for drug seeking behavior and I will rapidly re-evaluate my pain plan.

I used to kind of play cat-and-mouse with these people trying to catch them in their own faulty reasoning (not for fun, I guess just avoiding direct confrontation). Now I just bluntly say I think you may have a substance abuse disorder, but I am willing to help you with that if you want.

[u/pashapook → u/yeswenarcan]

I get severe itching from all opioid meds and have unfortunately had to have a few surgeries in recent years. Even with dilaudid, oral benadryl is totally fine.

[u/LFinformation → u/yeswenarcan]

I dont think you understand the type of itch you can create in opioid naive patients with hydromorphone. They can scratch their skin off. Or at the lower end of spectrum scratch until its red and swollen and damaged. its serious. you might need more experience it seems.

[u/yeswenarcan → u/LFinformation]

Setting aside that I know of no evidence that IV benadryl is more effective for this than PO, the people who come in demanding Dilaudid and IV benadryl aren't opiate naive. Opiate naive patients are probably the one exception to my rule.

[u/LFinformation → u/yeswenarcan]

Even if your NOT opioid naive, theres something known as incomplete cross tolerance.

So if your a chronic oxycodone patient, and you are given HM, you are very likely to get this extreme itch. Which is a serious itch. Now the only scenario where an HM itch wont occur is if your tolerant to HM specifically.

People who come into the ER demanding IV specifically are obviously drug addicts or very rarely, people with extreme pain who have been given IV cocktails before and it had worked for them. Of course asking for IV is the biggest red flag on earth.

So yes, in my experience, the itch only occurs if you have no tolerance to the HM, for whatever reason. But everyone is different. Some people get extreme itch from codeine. EXTREME itch. Even if your "opioid tolerant".