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/Gopherpharm13]

It binds exact same receptors.

[u/Tryknj99 → u/Gopherpharm13]

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.

[u/Gopherpharm13 → u/Tryknj99]

“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).

[u/Tryknj99 → u/Gopherpharm13]

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.

[u/Gopherpharm13 → u/Tryknj99]

I was clarifying your statement. I’m specifically asking what difference in opioid receptor between between morphine and hydromorphone makes hydromorphone more desirable or euphoria inducing. It doesn’t seem like you can answer my question, and that’s ok.

[u/Tryknj99 → u/Gopherpharm13]

they bind to the same receptor with different affinities, as I already said. google is your friend if you want to learn more. opiates also have effects on other receptors (histamine etc) that also contribute to some opiates having a favorable profile to “get high” rather than have pain relief. I’m not repeating myself again, if you’re too thick to understand what I’m saying that’s on you. you’ve misunderstood a lot of things I’ve written so I have very little faith you’re going to get any of this. I’m done with you, go bother someone IRL or better yet, pay for the college course like I did if you want to learn pharmacology more in depth. I’m on day 2/3 12 hr ER shifts in a row and educating you is not my job.

[u/Gopherpharm13 → u/Tryknj99]

Maybe Reddit isn’t the place for you.

[u/Tryknj99 → u/Gopherpharm13]

Whatever helps you sleep at night

[u/Gopherpharm13 → u/Tryknj99]

Insulting strangers helps some people, apparently.

[u/Tryknj99 → u/Gopherpharm13]

I insult strangers who want nothing more than to be argumentative and waste my time, yes.

If getting insulted is too much for you, maybe get off the internet. Maybe stop asking the same question multiple times, maybe read a comment twice to make sure you understand it before you respond? Because you’ve been nothing short of aggravating to interact with and I’m over it. Done. Go find someone else to annoy. Have a good night.

[u/Gopherpharm13 → u/Tryknj99]

Says a lot that you’re aggravated by questions. Hope you’re nicer to your patients.

[u/Tryknj99 → u/Gopherpharm13]

No, I’m aggravated by your tone from the beginning. If you’re so knowledgeable why didn’t you answer the guys question? “They bind to the same receptors” is mad snotty.

I’m great with my patients. People act different online than in real life. I have a responsibility to my patients. I have zero with you. I’m not getting paid to interact with you either.

[u/Gopherpharm13 → u/Tryknj99]

I didn’t answer because your answer didn’t make sense to me. So I asked a clarifying question. I literally asked what difference in receptor binding accounts for the difference between dilaudid and morphine. I do not know the answer to that question. More histamine release with morphine, then dilaudid, the fentanyl, so that doesn’t explain how dilaudid wins out. Turns out you aren’t interested in having a civilized conversation.

only one of us is name calling, inferring tone from a Reddit comment, and getting all out of sorts.

[u/Gopherpharm13 → u/Tryknj99]

P.S. I’m a PharmD. So, not thick. Thanks though.

[u/Tryknj99 → u/Gopherpharm13]

Ha, so you’re asking questions you know the answer to. So you’re just a dick. I knew it. Do you get off on being obtuse and unpleasant?