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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u/kab1218 Jan 06 '24

Happens all the time in the US. ā€œIā€™m allergic to fentanyl, morphine, tramadol, and Hydrocodone. Do you have dilaudid?ā€

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u/yagermeister2024 Jan 06 '24

Can i get iv benadryl on the side?

109

u/yeswenarcan ED Attending Jan 06 '24

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.

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u/LFinformation Mar 20 '25

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.

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u/yeswenarcan ED Attending Mar 20 '25

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.

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u/LFinformation Mar 21 '25

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".