My best friend is aussie and she loads up on Canadian cold meds every time she visits because apparently ours are better 😂 (she also brings me a butt ton of salbutamol so I can have a little stash just in case I can't get to the pharmacy for whatever reason)
You’ve had a taste of a usual shift in a US emergency department; don’t be surprised if the patient files a complaint about the rude doctor that didn’t treat her pain.
Little wonder there’s an opioid crisis if that level of prescribing is for everyday, ambulant OA of the knee. I’d only expect that sort of regime only if the orthopod had attempted a TKR with a claymore mine or there was some sort of comorbidity leading to hyperalgesia.
Man, when I had my kidney stone, I went into the clinic. Got IM toradol and zofran, felt like a million bucks (with that stone still sitting there for the time being). Then they gave me 30 Percocet for my 4mm stone that I passed easily (on Percocet) the next day. I had ~~have~~ 26 of the pills left. It’s a little absurd, and this wasn’t all that long ago, maybe 6 years?
My husband severed 2 tendons in his hand years ago. Went to ER. Wound was cleaned and dressed, sent home with surgery scheduled the next day. My husband was in the 9th realm of hell that night. No pain meds. But! After surgery... dear god. They gave him like 60 percs. In one bottle!! Not refills. He needed them for the first few days or so, and then he would take one before his OT appointments. But even then, after all that, we had over 30 something narcotic pills just chilling in our cabinet.
Probably a year after that incident, I had my wisdom teeth cut out. My surgeon was top of the line when it came to "fuck opiods" mentality. He gave me 4, yep you read that right, FOUR hydrocodones. That was my script. And a whole bottle of 800mg ibuprofen. He was stern and serious when he told me I would not be getting a refill unless I got a dry socket. He was not gonna have a 25 yo patient become an addict on his watch. Mad respect for him, as I've lost 3 friends and a brother to those drugs... this is America.
Not condoning the first guy, but I’ve seen a lot of surgeons do that (higher number of pills) so they don’t get a call back from patients asking for more meds—In their eyes it avoids the hassle of dealing with a phone call in another prescription. Again, not saying it’s correct but I think sometimes that’s their thought process
At the moment, my shop will do a take home pack of Oxycodone IR 5mg x4, and that’s it - if you need more, you need either a full script or a GP review and I don’t think many of our docs write up more than about a ten-pack of 5mg tabs unless there’s a comorbidity and always with a GP review for tapering or management. We can also do a 20-pack of paracetamol forte (500mg/30mg paracetamol/codeine IR) but this has become significantly less popular over the last few years due to both changes in scheduling (removed from OTC formulary due to the risk of paracetamol OD) and non-superiority to other agents that lack codeine’s variable metabolism or else just provide more effective pain relief. But it’s always 5mg right from the get-go unless they’re a million years old (and even then, if they’re on normal opioid therapy it often reverts back up to 5mg) even though 2.5mg would often be sufficient (and certainly if one had been considering using paracetamol forte…). And say nothing of the “magic little pill” approach people seem to take with oxycodone, throwing it at everything from headaches (for which opioids are last line therapy and generally ineffective), to renal colic (your toradol is our standard management alongside paracetamol) to neuropathic pain (variable demonstration of effect and certainly not first line treatment…)
I literally donated a kidney - had an entire organ removed from my body - in September, and received no opiates. None. They warned me before the surgery they were using a “no narcotic protocol”. Giving someone a standing prescription oxy for OA is bonkers
I'm getting an adrenal gland removed in 6 weeks. Because it's robotic surgery, I was told my pain should be minimal at best.
Basically, you ain't getting 600 oxy as a lovely parting gift.
They gave me 5 pills of Tylenol 3, and wrapped that SOB up like it was gold. I thought it was hysterical. I didn’t need them, I was ok with Tylenol alone. I donated last year. Edit: I think it’s called Tylenol 3? It has an opiate and Tylenol.
I hope you are doing ok? It’s an awesome thing you did❤️
My daughter had brain surgery a few weeks ago. In the hospital for 4 days and discharged with 8 pills oxycodone 5mg and 9 pills of diazepam and told to alternate tylenol and ibuprofen. Just 8 pills and that seemed like it wouldn't be enough but she ended up not using them all.
Its a complicated history here in the US. The opioid manufacturers bought our academic “thought leaders” and regulatory apparatus. Pain became “the fifth vital sign”.
There have been countless lives ruined, but now a strong pushback. However this is on the background of decades of overprescribing, so this type of patient while less common is not rare.
Jeez. I've been in the ER and admitted a few times this year (I'm also working with my primary and cardiologist to get things stable) and it's honestly wild how it's gotten to the point where patients expect SO much. Like it's a hotel. The satisfaction survey after discharge was literally like a hotel.
In the ER it's like people's expectations are super high as well. I've overheard complaints about alllll kinds of things. They expect to feel ZERO pain and obviously I understand that they're having a hard time, maybe even the worst day of their life... but feeling some pain is inevitable if you're sick or injured.
Idk. I appreciate ya'll and I really try to be as low maintenance as possible.
It's wild how emergency medicine/EMS has turned into a service industry. The whole "customer is always right" mentality has seriously overreached in medicine. Patients should absolutely know their rights, be informed on their treatment, and be part of the decision making process but I've seen so many people walk in with a laundry list of what they expect done.
My previous EMS agency has a contract with a local hospital system where we were required to ask patients if they'd like to be contacted with a survey about the care they received that day. They tracked how many entries we did and if we didn't do enough they'd call us into the office. Like bro the patient was suicidal and had slit their wrists, I'm not bothering them with this right now.
It’s a shame. On the one hand I get that some hospitals and doctors weren’t treating patients well. On the other hand, medicine isn’t a customer service industry. The goal is to heal the patient, not make them happy.
A hospital that I used to work at was going to have a hotel come in and teach us about customer service. To a bunch of ER staff.
Left before that happened.
I think this is partially due to people now villainizing healthcare workers and feel they can demand their whole work up, what meds they get, when they are going to be discharged, etc. Then they have the nerve to ask why it’s taking so long to get them back to a room 🙄 the amount of people I have who act like I’m an idiot but know absolutely nothing about healthcare is surprisingly large.
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.
One time about 10 years ago a patient threatened me that they’ll report me to the board if I didn’t mix Benadryl and dilaudid in the same syringe and slam it real fast. I’ll never forget this persons face or sheer audacity.
One of our local hospital's pain services has adopted the practice that no one gets IV Benadryl to counteract itching from opioids, only PO. My hospital does not have a pain service, so I have borrowed this approach.
LOL!! Back in the day, 2002, my husband herniated L5-S1 while turning to lift a box at his job. I had to leave my ICU job to pick him up while they used a forklift to remove him from the trailer of an 18 wheeler. The ER doc gave him that combo AND 5 of Valium PO! He didn’t move for 24 hours. I had to keep checking on him to make sure he was breathing!😂
ETA the best part of this is I went back to work. (Same hospital). He woke up when one of his work buddies came to check on him. This was near Christmastime and he started singing loudly “I’m the happiest Christmas tree, hahaha, heeheehee.” There were other parts to the song which I can’t remember. I was asked to please come get him he was ready for discharge. I helped load him into his buddy’s car and the buddy took him home for me. He had no recollection of the event.
Oh man, this sounds like what they gave me for my migraine. Now I couldn't see, couldn't walk, was literally not functioning. Like 2 mins after they have me 3 pills to take (no idea what they were but they were all different) I was out, completely, woke up an hour or 2 later and was fine... So, yeah definitely works, and got a great nap but holy shit.
I used to cure so many migraines as a rural ED locum. I'd take a history, do a neurological exam and by the time I wrote the orders for 1L N/S Billy's, 10mg metoclopranide iv, ketorolac iv, 1g tylenol po...they'd have left the department as they hadn't yet had their usual IM Demerol/Gravol. I assume they felt better.
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.
I think pethidine was thought to be safer than other opioids, which was shown to be incorrect.
Some people clearly *really* like it - you still occasionally see alerts, or people caught for using forged prescriptions for it. Despite the fact that presenting a prescription for pethidine to a pharmacy is like holding up a big neon sign saying 'this is a forged/stolen prescription'. Somehow I still see pharmacies handing it out though...
It is less safe than other opioids.
One example: Demerol only works for a few hours, but it breaks down into other compounds that take days to leave the body. It was found that with repeated dosing, those breakdown products accumulate, and can cause severe problems like seizures.
Also, it doesn't work any better than other drugs of its class.
It used to be thought that Demerol worked better for pain in the gallbladder or the pancreas. That turns out not to be true. You can get exactly the same pain relief from an appropriate dose of some other drug, with fewer side effects.
It hasn't been a first-line medication i the US for something like 20 years. I have never given it in my entire career. My current hospital doesn't even keep it in stock.
Got one right now, chronic pancreatitis with a million allergies including zofran, droperidol and morphine. She’s getting haldol and phenergan. Sometimes I give one dose bc I’m not gonna fix this persons problem but I’m feeling spicy today.
And you know what? Those are the people who come to the floor and immediately ordered q2hr prn morphine and dilaudid. For which they sit around on their phones waiting for, just living it up watching tv. 10 mins till it’s “due”? Walk within 10ft of their door, now 5ft and rustle your papers “Whimper, moan whimper.” Oh the 10/10 pain is back. Time for their “pain shot”. Literally, so fuckin sick and tired of these people. And the docs who prescribe this shit all day every day, q2-q4 and thats in-between their scheduled PO oxys. These people are fuckin drain and it takes away from the actual patients, you know the ones who need actual medical attention. And god forbid pain relief for actual problems like, oh fresh fractures, acute spinal injuries and post-surgical pain. And here these assholes are, on the call light, like clockwork, for their “pain shot”… because it’s not oxy time yet and why the hell else are they here? This is a fuckin problem on the floors, it’s rampantly commonplace and I know I speak for us all when I say, we are utterly sick of these people. But they sit there, in 0/10 pain, ordered IVP narcs around the clock, to placate their asses. Why do we have to put up with shit? People in far worse pain, far more urgently acute of our time and licensed attention, and we walk back and forth to the Pyxis all fuckin, shooting drug addicts up for funnies, because they have a stomach ache. Yeah, it hurts somethin fierce. Rant over.
Our internal medicine service now has a chronic pain policy. If you have chronic pain, you are not placed on IV opioids for it when you are admitted. It's a fantastic policy. You remain on PO opioids. And when you are discharged, your prescriber of chronic opioids is informed IN WRITING that you were hospitalized and supplied with your PO opioids for X number of days, so this can be considered when refilling your script.
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?
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.
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.
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?
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.
Where I trained in the US there was a guy who presented to the ED more than 365 times per year (so on average more than once per day). He dressed like a TGIF manager with a flashy reflective light purple button up, large striped tie and pin stripe slacks. He came in with abdominal pain, pouring tears out of his eyes like faucets screaming "dilaudid, dilaudid DILAUDID!" It was honestly insanity.
Well I guess administration was on top of this dire situation without hesitation, contacted his GP and social services, made a treatment plan with a walk-in clinic, informed local law enforcement who would show up if requested and drive the patient home without escalating.
I work in a veteran’s hospital. We have our regulars. Sadly, they are sick enough to be admitted, and some of the veterans are just awesome, they are just horribly sick and not very compliant. Others….they drive the poor nurses bonkers.
I work with a hand surgeon from Spain and he says they don’t give opiates unless it’s severe trauma. They manage the pain with a acetaminophen drip after surgeries and it does the trick. Granted a acetaminophen drip is outrageously expensive but they don’t have anywhere near the opioid problem like here. They just don’t expect to get it there.
>Granted a acetaminophen drip is outrageously expensive
Most European governments price fix their drugs by law, so they're probably getting a significant discount.
You just witnessed a daily occurrence of what we see every day in the States. Addicts will come in demanding narcs for minor injuries like ankle sprains and lacerations. They'll say the only thing that works for them is, "da, di, did, the did... You know what it is!" I wonder what it's like to work in culture where there's not some angle for many ED visits.
It’s actually not available PR in the US. I had that argument with a British orthopedic surgeon who was demanding it for his daughter with a 2mm stone. Thing was so small that it fell out of her in the OR when they were moving her 🙄
Are you serious it's not available there? Ireland here and pr difene is very common here and works like magic for many things, it's standard for renal stones.
I like when explaining to the demanders that the surgery isn't to make them feel better, it's to protect their kidneys. The stent won't feel good at all.
Noooooooo! lmao I get flashbacks just seeing the word.
I had Droperidol back in August when I had a really bad gallbladder attack with vomiting, and it did stop the vomiting but I was one of the lucky ones that had an adverse reaction. I wanted to peel off my skin and jump off a building, I literally cracked a tooth because my jaw was involuntarily clenching so hard. I couldn't effectively communicate what was happening to me either.
It took forever to wear off, even after I got home the next day I was having panic attacks and I was suicidal.
Droperidol works great for most people I guess, but not for me, never again.
This may be prevented by giving it in a minibag over a few minutes. Can also be easily treated with Benadryl. I typically ask the nurses to give all of the agents that cause akathisia in a mini bag or by very slow IV push. Since I started doing that probably 12 years ago, I've had no patients who reported akathisia.
Have you heard about the astoundingly popular look-alike sound-alike [Dilaumed?](https://gomerblog.com/2013/11/look-alike-sound-alike-medication-praised-er-physicians-everywhere/)
Let me tell you, I almost never see addicts, and those I see are usually with a clinic I can contact and all well-medicated with suboxone or heroine or methadone. I cannot even remember the last obvious drug-seeker. The addiction we 'struggle' most here is alcohol. People who drink hand sanitizer. But even that happens rarely.
Same in Finland. When you tell them enough times that they will not get narcotics when they come to the ER for unknown back or stomach pain they'll stop coming back pretty soon. Obviously not having a huge scale opioid epidemic and providing a proper substance abuse treatment plays a huge role too.
Daily occurrence for me (US based). Our newish interns become highly adept quickly at saying no to people over and over. We had some EM trainees from another country visit our hospital recently and one of the most striking things to them was how often we end up in an adversarial relationship with some patients. I generally think we are a compassionate bunch that wants to work with patients, but we are seen as deceitful, greedy, and gatekeepers to pain relief, even before we enter a patient's room. I also chemically restrain patients that are verbally and physically aggressive to staff regularly - can't tell you how many people I have seen patients attempt or successfully assault, and have even intubated patients with supreme violence and agitation in the setting of polysubstance use, which I considered not "weird" and I'm pretty sure blew their minds.
The topic of tramadol being more common in your community interests me. Certainly don't love our opiate epidemic, but dear god do I hate tramadol as a drug. I am much more likely (let's say a 2-3 day Rx to one patient once every few weeks) to prescribe oxycodone than I would tramadol (never and I publicly debate anyone who suggests I do); I think it should be banned as a drug.
Obligatory Juurlink article: [https://toxandhound.com/toxhound/tramadont/](https://toxandhound.com/toxhound/tramadont/)
That was a fascinating read. I was prescribed tramadol once and it gave me essentially no pain relief but it did contribute to an impressive (though not ER-level) bout of constipation. My vet later told me about someone abusing their dog's prescription for it and I was utterly perplexed as to why anyone would do such a thing!
Tramadol made me feel awful when it was prescribed to me once like 10 years ago. It made me super sweaty and I couldn't stop grinding my jaws like I was on stimulants or something, it just felt really weird.
Some people must just respond differently to it.
Tramadol is metabolized into an SNRI-like compound and an opioid. How much is each metabolite you make friends in your own genetics and it's not very predictable what you'll get.
I prescribe it when either I've tried everything else, or when someone else has already started the patient on it and they're doing well but still have a need for it.
We like to joke that if your doctor prescribes you tramadol, they either don't believe you have pain or they hate you. The other joke (which is basically just truth) is that tramadol is the irony drug: it's horrible at the one thing it's supposed to do (decrease pain) and really great at doing tons of things it isn't supposed to do (side effects).
As someone who was in a US pain clinic back in like 2004, doctors back then absolutely loooooved prescribing Tramadol to absolutely everyone and were always telling me how it's not addictive like other pain meds... Of course that was discovered to be inaccurate because there were a lot of people who got addicted to it.
As a paramedic I am quite regularly called by people who were recently discharged with a tramadol prescription and it isn't working. Very rarely is it any other drug. Considering the current evidence (and it isn't even *that* current anymore), I don't see why anyone continues to prescribe it.
i just love how he experienced the meme
the person that is "bed bound and cant move" suddenly ripping the IV and walking out without impairment once denied dilauidid (despite no indication for it at the time)
This almost sounds like a parody with how stereotypical it is...this is standard fare in US Emergency Departments. Drug seekers will start by pretending not to know what the medicine is called, so they'll ask for "the medicine that starts with 'd'". Seems you got them to say the quiet part out loud, that they really did know what it was. Often, many will push their luck and ask for IV promethazine and diphenhydramine as well, but push it fast!
The patient feigning ignorance and asking for “the drug that starts with D” is such a common drug seeking behavior in the US that even med students could see it a mile away.
It is also not available in Spain as a parenteral med. Only orally on its XR form. It is rarely prescribed and people do not ask for it. I have only prescribed it for old, annoying people who had not tolerated any other kind of pain relief. They also didn't tolerate XR hydromorphone and went back to their usual tramadol, which is by far the most prescribed opiate in Spain.
I also had an interaction with a weird American tourist/permanent resident who repeatedly requested i.v midazolam over the course of a few weeks. He became famous locally over a few towns, hospitals and EMS units. He always requested a 15mg push dose while screaming and overall doing weird things. Most providers usually just conceded it to him just to shut him up and transported him to our reference hospital (which has 24h psychiatrists on call). He would be discharged at sight. Then he would walk to the nearest clinic and so, when I finally had the chance to meet him on mine, he was also requesting Concerta and making up a mess. As I was the only English spealing person, I came up to the front desk to see what was going on. The worst is that he already had a prescription from another provider who gave it to him to shut him up, but he was complaining he had no money to buy it and was literally asking us for 40 euros to get it. I told him to fuck off and offered a 10mg i.m Diazepam dose, basically because our midazolam is seldomly used and stored in the locked up crash cart. He accepted and then I told our staff to call up his girlfriend, who in turn offered to pay him a taxi back to his lodging. Crazy guy.
We became a dilaudid free ED free years ago and this has been a game changer (you can still use it in cases you determine it is necessary). It is a very easy conversation with patients, ‘Per hospital policy we do not have that drug available in our ED, but we can treat you with another alternative.’
Interesting that you don’t have hydromorphone in NZ. I work in Aus and while it’s rarely prescribed here, it‘s still available as a last resort if other meds are ineffective (mainly in severe cancer pain or palliative care) or contraindicated.
I'm in NZ and have seen it prescribed for just one patient (palliative) in the last decade of working in hospitals - so quite uncommon but not completely absent.
ED nurse here. I had a patient (no joke) clap when I told her the doctor ordered dilaudid the other night. She came in with ankle pain and carried on until it was ordered.
I have never felt more like I was contributing to the problem.
I assumed this was a joke when I started reading it but I think you are serious. It’s very common in the US for chronic pain patients and addicts to come in asking for dilaudid.
Obviously, 200mg or more of oxycodone per day for osteoarthritis is ridiculous but that’s what happens when you mix unchecked corporate greed with medicine. Look up the history of Perdue Pharmaceuticals and OxyContin in the US and you’ll see how we got into this mess.
It’s even more fun when you start seeing all the elderly patients who are on chronic benzodiazepines. There’s a reason we have over 100,000 deaths per year from drug overdose.
Since you brought up paracetamol, I’ll leave you with my favorite case from this week. Pt with LE ischemia that had a foot amp last week and returned for fem-pop bypass. He told us he had been taking up to 27 500mg acetaminophen (our version of paracetamol) pills per day for the last 5 days because he was sent home after surgery with 10mg oxycodone q4hrs for pain but only given 6 pills. Instead of showing up in the ED for his uncontrolled pain he nearly killed his liver trying to treat it at home.
So I took a friend to an ED in Italy once for a broken foot. The ED had no wheelchairs or crutches and told her to hop down the hall to the waiting room and then hop down to x-ray. (She was gray and nauseous but hopped down that corridor like a champ!) They confirmed it was broken and then told her that the doctor was out for the night and to come back in the morning. ?? No paracetemol, no crutches, nothing. Is this a normal Italian ED experience? It has puzzled me ever since!
Well it depends. We haven't got crutches but we've plenty of wheelchairs!
And in Tuscany (where I live and work) a pain evaluation and control is mandatory in triage...
But, you know, especially in southern Italy things can be rough in certain places 😅
(where did it happen btw?)
If I had a dollar for every time I’ve heard the scam “starts with a D” or “ I’m allergic to pain medication, except for one that starts with a D”. I just love playing dumb and seeing how long I can draw it out.
RN here based in Tauranga, NZ.
I’ve had a similar recent experience. Overseas patients expecting to be given their preferred drugs as if they were ordering takeout. Super bizarre.
Here in NZ, most doctors/nurses will look at you sideways if you even request narcotics and know them by name.
Reading this I couldn’t tell if this was satire or not… but then it just made me sad because it made me long to work in an environment where I didn’t have to deal with this every damn shift.
Yup, my mother is a drug seeker, hospital shops, and everything. She says she's allergic to ibuprofen and tordol, so they don't suggest giving her that.
She also would prick her finger and squeeze blood into her urine cup to get more attention.
lolololol everyday, every shift, in every US ED.
thats an amateur US patient. the pro-move is you list every other analgesic (and ironically every other narcotic) as an allergy except dilauded naturally.
best part is due to the profitization/corporatization of US healthcare the customer err "patient" will file a complaint against you, that you will have to answer to when admin sends you the complaint 2 weeks later, then tells you it goes in "your record".
And I always get the sense that the underlying (*but never overtly stated)* message from admin in these emails is "like why couldnt you just write her like 4 percocets/norcos/oxys/hydros etc so she would give us a good review"....
I mean it happens. It’s not as huge a deal as everyone makes it out to be. People demand narcotics, you tell them no, unless they have a good reason to need it, and they leave. Far easier for most addicts to spend 10 dollars for a bag of heroin than wait 11 hours for a ct and some iv Tylenol.
The people that typically do this are doctor created addicts or have psych issues.
To be fair, as bad as our prescription drug seeking is I don't think I've ever seen that daily oxy dose even considering terminal cancer and the "drug with a d" people are not really as common as we all make it out to seem. I still think my/our ed practice can reduce opiate use but I like less than 5 "must have hydromorphone" type in the past year and just one "it only works if you slam iv diphenhydramine first" upstanding citizen.
I’ve definitely seen some insane oxy regimens both for cancer and for chronic pain. At least once a month I see someone who is getting triple digit mg/day.
Took care of someone in the ICU who faked an injury and came in with spinal cord compression symptoms. She was “allergic” to contrast. Basically she got IV Benadryl, dilaudid, and even got intubated for her MRI. Completely clean MRI and she got up and walked out after she was told no more IV meds
Not only is it a common drug for American addicts, it’s the drug of chose for most cases of factitious disorder, so it’s a problem in healthcare specifically. I don’t miss the rabbit hole I learned that down. I can’t imagine getting a bump on the head and asking for narcs lol
I cover a couple of rough hospitals in the ghetto, in addition to my usual place, and I can tell you that the drug seekers are like 10-20% of my patients. It's quite frustrating, because you take on some liability when you diagnose their acute severe pain as drug-seeking. I personally do not order Dilaudid as policy, and will at most give them a single shot of morphine. If they ask for Benadryl, I'll offer it PO. Most of the drug seekers are dissatisfied by this and will leave AMA prior to workup.
Welcome to America.
Profit is the driving force our medical system. As it turns out, patients love heroin and all its more respectable, white collar siblings, and they’ll give us higher ratings if we give them heroin. This makes the shareholders that own my physician company happy. So they expect us to be goddamn smack dealers. And many of us are.
I'm in the US. It's literally all shift, every shift, that people demand their preferred fix. Dilaudid, IV Benadryl, and sometimes Fentanyl but usually Dilaudid. Let's not forget phenergan for "nausea" aka random spitting into an emesis bag.
No nothing wrong with it. IV Phenergan tends to make people more "out of it" but not "high." You won't withdraw or anything if you don't take it. Maybe sleepy is the better word? Zofran doesn't have the same effect, it just helps the nausea. Zofran doesn't work for everyone with legitimate N/V so phenergan is a nice alternative, don't get me wrong. But...
From my anecdotal experience, a lot of people with substance use issues NEED to feel something (sleepy/high/euphoric) or NOT feel something (sad, depressed, pain, withdrawal symptoms, anxiety). So they seek that feeling/comfort/lack of feeling any way they can. Example: IV Benadryl isn't a controlled substance but if you push it fast it gives a "high" feeling which is why you see all the IV Benadryl quips when oral works just fine. It's also not always the med itself but the route it's given and how it's given. Oral Benadryl? Congratulations you itch less and will maybe take a nap in an hour. IVP Benadryl slammed in? Woohoo I'm floating and feel high as a kite.
Same with cough syrup now. People cook it up to make meth and now we all need to show ID for some fucking NyQuil.
TL;DR Don't worry about phenergan plus yours isn't the IV variety. We can't give medical advice here and I'm also a nurse not a doctor but I work in the ER and see this a lot. I gave a little breakdown about WHY people seek non-controlled substances. Do as you wish and talk to your doctor with concerns.
Oh, my god, phenergan was horrible for me….years ago, I broke my leg, so they gave me morphine and phenergan , apparently that was a routine thing, to prevent nausea.
That damn medicine along with the morphine made me so loopy I couldn’t answer the basic questions they needed from me. I think I told them my birthday was in January, and the wrong date….🤣 that shit was horrible. Why people ASK for it is beyond me…
This is the way in the US. I moved from working in South Africa (probably similar attitude to pain control as NZ), to the US. The first time I saw a patient in ER asking for pain meds for back pain I was honestly confused. "You've had it for a long time?" Yes. "And you know what the cause is?" Yes. "And you have a specialist who treats it?" Yes.
I believe the pharma industry got their agenda into the med schools here and taught the medical students that these drugs are safe and effective. I had such fights with attendings when I first arrived because I didn't want to write them. It's all improving now after almost a million prescription opiate deaths, kind of, except for the daily fights with patients like yours.
I'm starting to think most of us in the US are more prone to addictions. You can go back in my post history and though I live in a constant state of pain due to my injuries, I absolutely hate painkillers. I'll take an opiate painkiller and it helps as it was for about 2 hours. The entire 4 hours before I can take another, I feel dehydrated and nauseous.
I also know a guy who got addicted to them. Unless I'm in excruciating pain, I'd prefer not to take any.
Funny enough, the Venn diagram between American patients who inappropriately utilize the ER and Americans who go on cruises is almost a complete circle.
Welcome to the American nursing experience :)
Most of our docs are basically refusing to give dilaudid for almost any reason (because of the severe addictive properties) but we do still get this reaction if I tell people that no, they are not getting strong pain medicine for no reason.
I’ve literally had people wind up to hit me or start trying to jump over the rails to hurt me when they are med seeking. Do they ever behave like this with the doctor? Nope.
The amount of opioids some of these patients are on is insane. I just saw a lady prescribed 45 mg of Morphine XR PO. For migraines!!! No cancer. Just migraines.
But yes, this is a pretty large portion of the patient population we have to work with :))
NZ’s dedication to paracetamol is simply unmatched
The Netherlands would like a word.
We're pulling our weight in Australia too.
We give only small take home packs of the strong one… PanaMAX.
If that doesn't work for you, try some acetaminophen!
Italy would like a word too
Try being in the NHS. You get sent home with advice to go buy your own lol
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Oh but the dose is tiny OTC I think.
My best friend is aussie and she loads up on Canadian cold meds every time she visits because apparently ours are better 😂 (she also brings me a butt ton of salbutamol so I can have a little stash just in case I can't get to the pharmacy for whatever reason)
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Only paracetamol and ibuprofen after c-section here in Germany.
That sounds barbaric in the modern age
You’ve had a taste of a usual shift in a US emergency department; don’t be surprised if the patient files a complaint about the rude doctor that didn’t treat her pain.
Little wonder there’s an opioid crisis if that level of prescribing is for everyday, ambulant OA of the knee. I’d only expect that sort of regime only if the orthopod had attempted a TKR with a claymore mine or there was some sort of comorbidity leading to hyperalgesia.
Man, when I had my kidney stone, I went into the clinic. Got IM toradol and zofran, felt like a million bucks (with that stone still sitting there for the time being). Then they gave me 30 Percocet for my 4mm stone that I passed easily (on Percocet) the next day. I had ~~have~~ 26 of the pills left. It’s a little absurd, and this wasn’t all that long ago, maybe 6 years?
My husband severed 2 tendons in his hand years ago. Went to ER. Wound was cleaned and dressed, sent home with surgery scheduled the next day. My husband was in the 9th realm of hell that night. No pain meds. But! After surgery... dear god. They gave him like 60 percs. In one bottle!! Not refills. He needed them for the first few days or so, and then he would take one before his OT appointments. But even then, after all that, we had over 30 something narcotic pills just chilling in our cabinet. Probably a year after that incident, I had my wisdom teeth cut out. My surgeon was top of the line when it came to "fuck opiods" mentality. He gave me 4, yep you read that right, FOUR hydrocodones. That was my script. And a whole bottle of 800mg ibuprofen. He was stern and serious when he told me I would not be getting a refill unless I got a dry socket. He was not gonna have a 25 yo patient become an addict on his watch. Mad respect for him, as I've lost 3 friends and a brother to those drugs... this is America.
Not condoning the first guy, but I’ve seen a lot of surgeons do that (higher number of pills) so they don’t get a call back from patients asking for more meds—In their eyes it avoids the hassle of dealing with a phone call in another prescription. Again, not saying it’s correct but I think sometimes that’s their thought process
I had two dry sockets and got nothing. 2007 and 2011.
Not even toradol? There’s no opiate in it! I mean it will destroy your kidneys after several weeks, but it is a good short term!
At the moment, my shop will do a take home pack of Oxycodone IR 5mg x4, and that’s it - if you need more, you need either a full script or a GP review and I don’t think many of our docs write up more than about a ten-pack of 5mg tabs unless there’s a comorbidity and always with a GP review for tapering or management. We can also do a 20-pack of paracetamol forte (500mg/30mg paracetamol/codeine IR) but this has become significantly less popular over the last few years due to both changes in scheduling (removed from OTC formulary due to the risk of paracetamol OD) and non-superiority to other agents that lack codeine’s variable metabolism or else just provide more effective pain relief. But it’s always 5mg right from the get-go unless they’re a million years old (and even then, if they’re on normal opioid therapy it often reverts back up to 5mg) even though 2.5mg would often be sufficient (and certainly if one had been considering using paracetamol forte…). And say nothing of the “magic little pill” approach people seem to take with oxycodone, throwing it at everything from headaches (for which opioids are last line therapy and generally ineffective), to renal colic (your toradol is our standard management alongside paracetamol) to neuropathic pain (variable demonstration of effect and certainly not first line treatment…)
I literally donated a kidney - had an entire organ removed from my body - in September, and received no opiates. None. They warned me before the surgery they were using a “no narcotic protocol”. Giving someone a standing prescription oxy for OA is bonkers
I'm getting an adrenal gland removed in 6 weeks. Because it's robotic surgery, I was told my pain should be minimal at best. Basically, you ain't getting 600 oxy as a lovely parting gift.
They gave me 5 pills of Tylenol 3, and wrapped that SOB up like it was gold. I thought it was hysterical. I didn’t need them, I was ok with Tylenol alone. I donated last year. Edit: I think it’s called Tylenol 3? It has an opiate and Tylenol. I hope you are doing ok? It’s an awesome thing you did❤️
Ah yes. Tylenol 3 - it’s Tylenol and codeine.
I think the point is that it has escalated to that point and that the oxy isn't actually required for her pain in OA.
Well yes, unless they're surprisingly annoying and the GP was trying to off them by jumping straight to 220mg Oxycodone per day.
Insane to me! I have a fractured spine in 3 spots and take less drugs....
My daughter had brain surgery a few weeks ago. In the hospital for 4 days and discharged with 8 pills oxycodone 5mg and 9 pills of diazepam and told to alternate tylenol and ibuprofen. Just 8 pills and that seemed like it wouldn't be enough but she ended up not using them all.
Its a complicated history here in the US. The opioid manufacturers bought our academic “thought leaders” and regulatory apparatus. Pain became “the fifth vital sign”. There have been countless lives ruined, but now a strong pushback. However this is on the background of decades of overprescribing, so this type of patient while less common is not rare.
Jeez. I've been in the ER and admitted a few times this year (I'm also working with my primary and cardiologist to get things stable) and it's honestly wild how it's gotten to the point where patients expect SO much. Like it's a hotel. The satisfaction survey after discharge was literally like a hotel. In the ER it's like people's expectations are super high as well. I've overheard complaints about alllll kinds of things. They expect to feel ZERO pain and obviously I understand that they're having a hard time, maybe even the worst day of their life... but feeling some pain is inevitable if you're sick or injured. Idk. I appreciate ya'll and I really try to be as low maintenance as possible.
It's wild how emergency medicine/EMS has turned into a service industry. The whole "customer is always right" mentality has seriously overreached in medicine. Patients should absolutely know their rights, be informed on their treatment, and be part of the decision making process but I've seen so many people walk in with a laundry list of what they expect done. My previous EMS agency has a contract with a local hospital system where we were required to ask patients if they'd like to be contacted with a survey about the care they received that day. They tracked how many entries we did and if we didn't do enough they'd call us into the office. Like bro the patient was suicidal and had slit their wrists, I'm not bothering them with this right now.
It’s a shame. On the one hand I get that some hospitals and doctors weren’t treating patients well. On the other hand, medicine isn’t a customer service industry. The goal is to heal the patient, not make them happy.
A hospital that I used to work at was going to have a hotel come in and teach us about customer service. To a bunch of ER staff. Left before that happened.
I think this is partially due to people now villainizing healthcare workers and feel they can demand their whole work up, what meds they get, when they are going to be discharged, etc. Then they have the nerve to ask why it’s taking so long to get them back to a room 🙄 the amount of people I have who act like I’m an idiot but know absolutely nothing about healthcare is surprisingly large.
I tell patients that zero pain is a celestial discharge.
this is adorable
Happens all the time in the US. “I’m allergic to fentanyl, morphine, tramadol, and Hydrocodone. Do you have dilaudid?”
Can i get iv benadryl on the side?
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.
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
And slam it or it doesn’t work
One time about 10 years ago a patient threatened me that they’ll report me to the board if I didn’t mix Benadryl and dilaudid in the same syringe and slam it real fast. I’ll never forget this persons face or sheer audacity.
I’m so itchy. Oral Benadryl doesn’t work for me.
What about my IV push of phenergan so I don’t get nauseous?
One of our local hospital's pain services has adopted the practice that no one gets IV Benadryl to counteract itching from opioids, only PO. My hospital does not have a pain service, so I have borrowed this approach.
Why the fentanyl? Too short acting
It ain’t Dilaudid and no one has Demerol anymore.
Ohhhh Demerol. The migraine cocktail of Demerol 75, Phenergan 25, Toradol 60. All IM. Fixed all Migraines.😂
Yeah cuz you were too busy *drooling* from the sedation. Your head can't hurt if you're passed tf out.
Pretty sure that falls firmly in the "can't have a headache if you don't know where you are" category.
LOL!! Back in the day, 2002, my husband herniated L5-S1 while turning to lift a box at his job. I had to leave my ICU job to pick him up while they used a forklift to remove him from the trailer of an 18 wheeler. The ER doc gave him that combo AND 5 of Valium PO! He didn’t move for 24 hours. I had to keep checking on him to make sure he was breathing!😂 ETA the best part of this is I went back to work. (Same hospital). He woke up when one of his work buddies came to check on him. This was near Christmastime and he started singing loudly “I’m the happiest Christmas tree, hahaha, heeheehee.” There were other parts to the song which I can’t remember. I was asked to please come get him he was ready for discharge. I helped load him into his buddy’s car and the buddy took him home for me. He had no recollection of the event.
I can offer you a fiorecet in this trying time
Oh man, this sounds like what they gave me for my migraine. Now I couldn't see, couldn't walk, was literally not functioning. Like 2 mins after they have me 3 pills to take (no idea what they were but they were all different) I was out, completely, woke up an hour or 2 later and was fine... So, yeah definitely works, and got a great nap but holy shit.
I used to cure so many migraines as a rural ED locum. I'd take a history, do a neurological exam and by the time I wrote the orders for 1L N/S Billy's, 10mg metoclopranide iv, ketorolac iv, 1g tylenol po...they'd have left the department as they hadn't yet had their usual IM Demerol/Gravol. I assume they felt better.
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.
I think pethidine was thought to be safer than other opioids, which was shown to be incorrect. Some people clearly *really* like it - you still occasionally see alerts, or people caught for using forged prescriptions for it. Despite the fact that presenting a prescription for pethidine to a pharmacy is like holding up a big neon sign saying 'this is a forged/stolen prescription'. Somehow I still see pharmacies handing it out though...
It is less safe than other opioids. One example: Demerol only works for a few hours, but it breaks down into other compounds that take days to leave the body. It was found that with repeated dosing, those breakdown products accumulate, and can cause severe problems like seizures. Also, it doesn't work any better than other drugs of its class. It used to be thought that Demerol worked better for pain in the gallbladder or the pancreas. That turns out not to be true. You can get exactly the same pain relief from an appropriate dose of some other drug, with fewer side effects. It hasn't been a first-line medication i the US for something like 20 years. I have never given it in my entire career. My current hospital doesn't even keep it in stock.
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Suppose more hemodynamically neutral. As I resident I worked for month in Wellington, loved NZ.
Got one right now, chronic pancreatitis with a million allergies including zofran, droperidol and morphine. She’s getting haldol and phenergan. Sometimes I give one dose bc I’m not gonna fix this persons problem but I’m feeling spicy today.
Update she left AMA
Bullet dodged. Hope the rest of your day goes easier.
And you know what? Those are the people who come to the floor and immediately ordered q2hr prn morphine and dilaudid. For which they sit around on their phones waiting for, just living it up watching tv. 10 mins till it’s “due”? Walk within 10ft of their door, now 5ft and rustle your papers “Whimper, moan whimper.” Oh the 10/10 pain is back. Time for their “pain shot”. Literally, so fuckin sick and tired of these people. And the docs who prescribe this shit all day every day, q2-q4 and thats in-between their scheduled PO oxys. These people are fuckin drain and it takes away from the actual patients, you know the ones who need actual medical attention. And god forbid pain relief for actual problems like, oh fresh fractures, acute spinal injuries and post-surgical pain. And here these assholes are, on the call light, like clockwork, for their “pain shot”… because it’s not oxy time yet and why the hell else are they here? This is a fuckin problem on the floors, it’s rampantly commonplace and I know I speak for us all when I say, we are utterly sick of these people. But they sit there, in 0/10 pain, ordered IVP narcs around the clock, to placate their asses. Why do we have to put up with shit? People in far worse pain, far more urgently acute of our time and licensed attention, and we walk back and forth to the Pyxis all fuckin, shooting drug addicts up for funnies, because they have a stomach ache. Yeah, it hurts somethin fierce. Rant over.
Our internal medicine service now has a chronic pain policy. If you have chronic pain, you are not placed on IV opioids for it when you are admitted. It's a fantastic policy. You remain on PO opioids. And when you are discharged, your prescriber of chronic opioids is informed IN WRITING that you were hospitalized and supplied with your PO opioids for X number of days, so this can be considered when refilling your script.
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?
It also causes euphoria.
I thought that fentanyl, morphine and hydrocodone also cause euphoria? Does Dilaudid just cause more? Or for longer?
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.
I have heard it associated with dilaudid more, but not sure if it is more or longer.
1mg dilaudid=7mg of morphine is the simplest explanation
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.
That is exactly how dilaudid should be taken lol.
I honestly hate Dilaudid. It gives me a weird foggy headache on top of whatever was hurting. No thanks lol.
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?
Sock puppets!!! Thanks for the laugh
It causes euphoria in a way the other drugs don’t and lasts much longer. Things like fentanyl only last about an hour
It’s a nice, warm high
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.
Also allergic to Tylenol, all NSAIDs and Benadryl
But not if the Benadryl is given by IV doc, I'm only allergic if it's by mouth.
Where I trained in the US there was a guy who presented to the ED more than 365 times per year (so on average more than once per day). He dressed like a TGIF manager with a flashy reflective light purple button up, large striped tie and pin stripe slacks. He came in with abdominal pain, pouring tears out of his eyes like faucets screaming "dilaudid, dilaudid DILAUDID!" It was honestly insanity.
Well I guess administration was on top of this dire situation without hesitation, contacted his GP and social services, made a treatment plan with a walk-in clinic, informed local law enforcement who would show up if requested and drive the patient home without escalating.
Wow it's like you were there. 99/100 I discharged him by security. One day I gave him dilaudid. He then wanted more and was discharged by security.
"One day I gave him dilaudid" If you want the daily entertainment, you need to pay the price of admission from time to time, I guess
How many pieces of flair did he have?
🤣🤣🤣
I work in a veteran’s hospital. We have our regulars. Sadly, they are sick enough to be admitted, and some of the veterans are just awesome, they are just horribly sick and not very compliant. Others….they drive the poor nurses bonkers.
and this is why I now practice in NZ. Thank you, this post has reminded me once again why I will never go back.
As Childish Gambino once said - "This is America..." Yep, this is a common theme - "the only thing that works for me is duh-duh-dilaudid"
I work with a hand surgeon from Spain and he says they don’t give opiates unless it’s severe trauma. They manage the pain with a acetaminophen drip after surgeries and it does the trick. Granted a acetaminophen drip is outrageously expensive but they don’t have anywhere near the opioid problem like here. They just don’t expect to get it there.
>Granted a acetaminophen drip is outrageously expensive Most European governments price fix their drugs by law, so they're probably getting a significant discount.
They do the same at the SICU where I work, they really try not to use opiates. (I work at a USA veterans hospital as a respiratory therapist).
You just witnessed a daily occurrence of what we see every day in the States. Addicts will come in demanding narcs for minor injuries like ankle sprains and lacerations. They'll say the only thing that works for them is, "da, di, did, the did... You know what it is!" I wonder what it's like to work in culture where there's not some angle for many ED visits.
My favorite interaction: "only the Bin Laden one works for me." I was dying under my mask
I love doing, oh, diclofenac? Sure thing!
100mg PR
It’s actually not available PR in the US. I had that argument with a British orthopedic surgeon who was demanding it for his daughter with a 2mm stone. Thing was so small that it fell out of her in the OR when they were moving her 🙄
Are you serious it's not available there? Ireland here and pr difene is very common here and works like magic for many things, it's standard for renal stones.
Kidney stone? Or debris embedded in a wound?
Kidney stone. Demanded surgery even though it wasn’t obstructing.
I like when explaining to the demanders that the surgery isn't to make them feel better, it's to protect their kidneys. The stent won't feel good at all.
I'm convinced that small stones hurt more. It's always the 1-3 mm stones that have people screaming and sweating IME.
this guy ERs
D...D...Droperidol it is!
Vitamin D!!!
Noooooooo! lmao I get flashbacks just seeing the word. I had Droperidol back in August when I had a really bad gallbladder attack with vomiting, and it did stop the vomiting but I was one of the lucky ones that had an adverse reaction. I wanted to peel off my skin and jump off a building, I literally cracked a tooth because my jaw was involuntarily clenching so hard. I couldn't effectively communicate what was happening to me either. It took forever to wear off, even after I got home the next day I was having panic attacks and I was suicidal. Droperidol works great for most people I guess, but not for me, never again.
Did you get/try Benadryl when you started feeling those symptoms? Definitely akathisia
This may be prevented by giving it in a minibag over a few minutes. Can also be easily treated with Benadryl. I typically ask the nurses to give all of the agents that cause akathisia in a mini bag or by very slow IV push. Since I started doing that probably 12 years ago, I've had no patients who reported akathisia.
"Begins with a Di..." "Oh, discharge? You got it! Byeeeee"
Have you heard about the astoundingly popular look-alike sound-alike [Dilaumed?](https://gomerblog.com/2013/11/look-alike-sound-alike-medication-praised-er-physicians-everywhere/)
"Di... duh... duhlulu?" They know what it's called lol.
Let me tell you, I almost never see addicts, and those I see are usually with a clinic I can contact and all well-medicated with suboxone or heroine or methadone. I cannot even remember the last obvious drug-seeker. The addiction we 'struggle' most here is alcohol. People who drink hand sanitizer. But even that happens rarely.
Where?
Denmark
Same in Finland. When you tell them enough times that they will not get narcotics when they come to the ER for unknown back or stomach pain they'll stop coming back pretty soon. Obviously not having a huge scale opioid epidemic and providing a proper substance abuse treatment plays a huge role too.
This is fairly prevalent.
That prescription regimen isn’t. Maybe back in 2008
Theres some old FM docs out there still prescribing PRN oxy and ativan to their geriatrics. I see it at least once a shift
I had a patient with a PMH of gastritis prescribed fentanyl patches lmao wild.
Daily occurrence for me (US based). Our newish interns become highly adept quickly at saying no to people over and over. We had some EM trainees from another country visit our hospital recently and one of the most striking things to them was how often we end up in an adversarial relationship with some patients. I generally think we are a compassionate bunch that wants to work with patients, but we are seen as deceitful, greedy, and gatekeepers to pain relief, even before we enter a patient's room. I also chemically restrain patients that are verbally and physically aggressive to staff regularly - can't tell you how many people I have seen patients attempt or successfully assault, and have even intubated patients with supreme violence and agitation in the setting of polysubstance use, which I considered not "weird" and I'm pretty sure blew their minds. The topic of tramadol being more common in your community interests me. Certainly don't love our opiate epidemic, but dear god do I hate tramadol as a drug. I am much more likely (let's say a 2-3 day Rx to one patient once every few weeks) to prescribe oxycodone than I would tramadol (never and I publicly debate anyone who suggests I do); I think it should be banned as a drug. Obligatory Juurlink article: [https://toxandhound.com/toxhound/tramadont/](https://toxandhound.com/toxhound/tramadont/)
That was a fascinating read. I was prescribed tramadol once and it gave me essentially no pain relief but it did contribute to an impressive (though not ER-level) bout of constipation. My vet later told me about someone abusing their dog's prescription for it and I was utterly perplexed as to why anyone would do such a thing!
Tramadol made me feel awful when it was prescribed to me once like 10 years ago. It made me super sweaty and I couldn't stop grinding my jaws like I was on stimulants or something, it just felt really weird. Some people must just respond differently to it.
Tramadol is metabolized into an SNRI-like compound and an opioid. How much is each metabolite you make friends in your own genetics and it's not very predictable what you'll get. I prescribe it when either I've tried everything else, or when someone else has already started the patient on it and they're doing well but still have a need for it.
Same I don’t get any pain relief with tramadol
We like to joke that if your doctor prescribes you tramadol, they either don't believe you have pain or they hate you. The other joke (which is basically just truth) is that tramadol is the irony drug: it's horrible at the one thing it's supposed to do (decrease pain) and really great at doing tons of things it isn't supposed to do (side effects).
As someone who was in a US pain clinic back in like 2004, doctors back then absolutely loooooved prescribing Tramadol to absolutely everyone and were always telling me how it's not addictive like other pain meds... Of course that was discovered to be inaccurate because there were a lot of people who got addicted to it.
It wasn't discovered... It was always known it's an opiate. It was a marketing ploy- "I tell them it's not an opiate so it's nice".
Yea our toxicologists have thoroughly beaten tramadol or codeine out of me.
As a paramedic I am quite regularly called by people who were recently discharged with a tramadol prescription and it isn't working. Very rarely is it any other drug. Considering the current evidence (and it isn't even *that* current anymore), I don't see why anyone continues to prescribe it.
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i just love how he experienced the meme the person that is "bed bound and cant move" suddenly ripping the IV and walking out without impairment once denied dilauidid (despite no indication for it at the time)
Do you at least have Tuna Sandwiches on the cruise ship????
Just turkey
This almost sounds like a parody with how stereotypical it is...this is standard fare in US Emergency Departments. Drug seekers will start by pretending not to know what the medicine is called, so they'll ask for "the medicine that starts with 'd'". Seems you got them to say the quiet part out loud, that they really did know what it was. Often, many will push their luck and ask for IV promethazine and diphenhydramine as well, but push it fast!
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End stage fibro.
1992 surgery on their back.
Acute fibro storm, hate to see it.
The patient feigning ignorance and asking for “the drug that starts with D” is such a common drug seeking behavior in the US that even med students could see it a mile away.
It is also not available in Spain as a parenteral med. Only orally on its XR form. It is rarely prescribed and people do not ask for it. I have only prescribed it for old, annoying people who had not tolerated any other kind of pain relief. They also didn't tolerate XR hydromorphone and went back to their usual tramadol, which is by far the most prescribed opiate in Spain. I also had an interaction with a weird American tourist/permanent resident who repeatedly requested i.v midazolam over the course of a few weeks. He became famous locally over a few towns, hospitals and EMS units. He always requested a 15mg push dose while screaming and overall doing weird things. Most providers usually just conceded it to him just to shut him up and transported him to our reference hospital (which has 24h psychiatrists on call). He would be discharged at sight. Then he would walk to the nearest clinic and so, when I finally had the chance to meet him on mine, he was also requesting Concerta and making up a mess. As I was the only English spealing person, I came up to the front desk to see what was going on. The worst is that he already had a prescription from another provider who gave it to him to shut him up, but he was complaining he had no money to buy it and was literally asking us for 40 euros to get it. I told him to fuck off and offered a 10mg i.m Diazepam dose, basically because our midazolam is seldomly used and stored in the locked up crash cart. He accepted and then I told our staff to call up his girlfriend, who in turn offered to pay him a taxi back to his lodging. Crazy guy.
We became a dilaudid free ED free years ago and this has been a game changer (you can still use it in cases you determine it is necessary). It is a very easy conversation with patients, ‘Per hospital policy we do not have that drug available in our ED, but we can treat you with another alternative.’
Every. Fucking. Shift.
In Australia, I’ve only ever seen Hydromorphone used in Palliative Care. Oxycodone is handed out like candy though.
Interesting that you don’t have hydromorphone in NZ. I work in Aus and while it’s rarely prescribed here, it‘s still available as a last resort if other meds are ineffective (mainly in severe cancer pain or palliative care) or contraindicated.
I'm in NZ and have seen it prescribed for just one patient (palliative) in the last decade of working in hospitals - so quite uncommon but not completely absent.
Welcome to the American experience™️ doc.
ED nurse here. I had a patient (no joke) clap when I told her the doctor ordered dilaudid the other night. She came in with ankle pain and carried on until it was ordered. I have never felt more like I was contributing to the problem.
I assumed this was a joke when I started reading it but I think you are serious. It’s very common in the US for chronic pain patients and addicts to come in asking for dilaudid. Obviously, 200mg or more of oxycodone per day for osteoarthritis is ridiculous but that’s what happens when you mix unchecked corporate greed with medicine. Look up the history of Perdue Pharmaceuticals and OxyContin in the US and you’ll see how we got into this mess. It’s even more fun when you start seeing all the elderly patients who are on chronic benzodiazepines. There’s a reason we have over 100,000 deaths per year from drug overdose. Since you brought up paracetamol, I’ll leave you with my favorite case from this week. Pt with LE ischemia that had a foot amp last week and returned for fem-pop bypass. He told us he had been taking up to 27 500mg acetaminophen (our version of paracetamol) pills per day for the last 5 days because he was sent home after surgery with 10mg oxycodone q4hrs for pain but only given 6 pills. Instead of showing up in the ED for his uncontrolled pain he nearly killed his liver trying to treat it at home.
What you experienced is a bread and butter American drug seeker. Basically a walking meme
Woa 😅 In Italy we feel heroic when we prescribe oxycodon 5mg/paracetamol 325 mg TID for bad fractures 🤣
Americans have no clue how the rest of the world rolls with stimulates ans narcotics.
So I took a friend to an ED in Italy once for a broken foot. The ED had no wheelchairs or crutches and told her to hop down the hall to the waiting room and then hop down to x-ray. (She was gray and nauseous but hopped down that corridor like a champ!) They confirmed it was broken and then told her that the doctor was out for the night and to come back in the morning. ?? No paracetemol, no crutches, nothing. Is this a normal Italian ED experience? It has puzzled me ever since!
Well it depends. We haven't got crutches but we've plenty of wheelchairs! And in Tuscany (where I live and work) a pain evaluation and control is mandatory in triage... But, you know, especially in southern Italy things can be rough in certain places 😅 (where did it happen btw?)
If I had a dollar for every time I’ve heard the scam “starts with a D” or “ I’m allergic to pain medication, except for one that starts with a D”. I just love playing dumb and seeing how long I can draw it out.
RN here based in Tauranga, NZ. I’ve had a similar recent experience. Overseas patients expecting to be given their preferred drugs as if they were ordering takeout. Super bizarre. Here in NZ, most doctors/nurses will look at you sideways if you even request narcotics and know them by name.
"The one that starts with D...you mean droperidol, sure thing..." Is about how that would go in my antipodean shop 😂
Hahahaha your utter astonishment is so fucking hilarious. Yes it happens *truly* daily here.
People want to flit through life, feeling nothing. It's wild.
Reading this I couldn’t tell if this was satire or not… but then it just made me sad because it made me long to work in an environment where I didn’t have to deal with this every damn shift.
It happens in the US all. The. Time. “The one that starts with a D … I can’t remember the name …”
They all know the name lol.
Ah yes, I hope my patient I had once who is prescribed fentanyl patches for gastritis pays you a visit too
Extremely prevalent in the US. She is an opioid addict and was drug seeking. You did a great job!!
IV dilaudid.... this is a regular request. Some will even say they are allergic to acetaminophen and ibuprofen
Yup, my mother is a drug seeker, hospital shops, and everything. She says she's allergic to ibuprofen and tordol, so they don't suggest giving her that. She also would prick her finger and squeeze blood into her urine cup to get more attention.
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lolololol everyday, every shift, in every US ED. thats an amateur US patient. the pro-move is you list every other analgesic (and ironically every other narcotic) as an allergy except dilauded naturally. best part is due to the profitization/corporatization of US healthcare the customer err "patient" will file a complaint against you, that you will have to answer to when admin sends you the complaint 2 weeks later, then tells you it goes in "your record". And I always get the sense that the underlying (*but never overtly stated)* message from admin in these emails is "like why couldnt you just write her like 4 percocets/norcos/oxys/hydros etc so she would give us a good review"....
As an American doc, it’s weird that this is weird for you lol
I mean it happens. It’s not as huge a deal as everyone makes it out to be. People demand narcotics, you tell them no, unless they have a good reason to need it, and they leave. Far easier for most addicts to spend 10 dollars for a bag of heroin than wait 11 hours for a ct and some iv Tylenol. The people that typically do this are doctor created addicts or have psych issues.
To be fair, as bad as our prescription drug seeking is I don't think I've ever seen that daily oxy dose even considering terminal cancer and the "drug with a d" people are not really as common as we all make it out to seem. I still think my/our ed practice can reduce opiate use but I like less than 5 "must have hydromorphone" type in the past year and just one "it only works if you slam iv diphenhydramine first" upstanding citizen.
I’ve definitely seen some insane oxy regimens both for cancer and for chronic pain. At least once a month I see someone who is getting triple digit mg/day.
I’m cracking up at you guys Googling “the one that starts with D”. That’s one of the first things I learned in residency.
Took care of someone in the ICU who faked an injury and came in with spinal cord compression symptoms. She was “allergic” to contrast. Basically she got IV Benadryl, dilaudid, and even got intubated for her MRI. Completely clean MRI and she got up and walked out after she was told no more IV meds
Not only is it a common drug for American addicts, it’s the drug of chose for most cases of factitious disorder, so it’s a problem in healthcare specifically. I don’t miss the rabbit hole I learned that down. I can’t imagine getting a bump on the head and asking for narcs lol
Common
NZ drug seekers asking for tramadol and codeine? That’s wild.
Sounds like Tuesday...
I cover a couple of rough hospitals in the ghetto, in addition to my usual place, and I can tell you that the drug seekers are like 10-20% of my patients. It's quite frustrating, because you take on some liability when you diagnose their acute severe pain as drug-seeking. I personally do not order Dilaudid as policy, and will at most give them a single shot of morphine. If they ask for Benadryl, I'll offer it PO. Most of the drug seekers are dissatisfied by this and will leave AMA prior to workup.
I love to give dilaudid. To my Hospice patients.
This
Welcome to America. Profit is the driving force our medical system. As it turns out, patients love heroin and all its more respectable, white collar siblings, and they’ll give us higher ratings if we give them heroin. This makes the shareholders that own my physician company happy. So they expect us to be goddamn smack dealers. And many of us are.
I'm in the US. It's literally all shift, every shift, that people demand their preferred fix. Dilaudid, IV Benadryl, and sometimes Fentanyl but usually Dilaudid. Let's not forget phenergan for "nausea" aka random spitting into an emesis bag.
Wait, what’s the issue with phenergan? I was recently prescribed it for chronic nausea, and I don’t want to start it if it’s addictive or anything.
No nothing wrong with it. IV Phenergan tends to make people more "out of it" but not "high." You won't withdraw or anything if you don't take it. Maybe sleepy is the better word? Zofran doesn't have the same effect, it just helps the nausea. Zofran doesn't work for everyone with legitimate N/V so phenergan is a nice alternative, don't get me wrong. But... From my anecdotal experience, a lot of people with substance use issues NEED to feel something (sleepy/high/euphoric) or NOT feel something (sad, depressed, pain, withdrawal symptoms, anxiety). So they seek that feeling/comfort/lack of feeling any way they can. Example: IV Benadryl isn't a controlled substance but if you push it fast it gives a "high" feeling which is why you see all the IV Benadryl quips when oral works just fine. It's also not always the med itself but the route it's given and how it's given. Oral Benadryl? Congratulations you itch less and will maybe take a nap in an hour. IVP Benadryl slammed in? Woohoo I'm floating and feel high as a kite. Same with cough syrup now. People cook it up to make meth and now we all need to show ID for some fucking NyQuil. TL;DR Don't worry about phenergan plus yours isn't the IV variety. We can't give medical advice here and I'm also a nurse not a doctor but I work in the ER and see this a lot. I gave a little breakdown about WHY people seek non-controlled substances. Do as you wish and talk to your doctor with concerns.
Oh, my god, phenergan was horrible for me….years ago, I broke my leg, so they gave me morphine and phenergan , apparently that was a routine thing, to prevent nausea. That damn medicine along with the morphine made me so loopy I couldn’t answer the basic questions they needed from me. I think I told them my birthday was in January, and the wrong date….🤣 that shit was horrible. Why people ASK for it is beyond me…
America makes up 5% of the world's population but uses 90% of the world's opiates.
This is the way in the US. I moved from working in South Africa (probably similar attitude to pain control as NZ), to the US. The first time I saw a patient in ER asking for pain meds for back pain I was honestly confused. "You've had it for a long time?" Yes. "And you know what the cause is?" Yes. "And you have a specialist who treats it?" Yes. I believe the pharma industry got their agenda into the med schools here and taught the medical students that these drugs are safe and effective. I had such fights with attendings when I first arrived because I didn't want to write them. It's all improving now after almost a million prescription opiate deaths, kind of, except for the daily fights with patients like yours.
I'm starting to think most of us in the US are more prone to addictions. You can go back in my post history and though I live in a constant state of pain due to my injuries, I absolutely hate painkillers. I'll take an opiate painkiller and it helps as it was for about 2 hours. The entire 4 hours before I can take another, I feel dehydrated and nauseous. I also know a guy who got addicted to them. Unless I'm in excruciating pain, I'd prefer not to take any.
Funny enough, the Venn diagram between American patients who inappropriately utilize the ER and Americans who go on cruises is almost a complete circle.
In the movie Drugstore Cowboy, Dilaudid is the holy grail drug they are after in all their drugstore break ins.
Welcome to the American nursing experience :) Most of our docs are basically refusing to give dilaudid for almost any reason (because of the severe addictive properties) but we do still get this reaction if I tell people that no, they are not getting strong pain medicine for no reason. I’ve literally had people wind up to hit me or start trying to jump over the rails to hurt me when they are med seeking. Do they ever behave like this with the doctor? Nope. The amount of opioids some of these patients are on is insane. I just saw a lady prescribed 45 mg of Morphine XR PO. For migraines!!! No cancer. Just migraines. But yes, this is a pretty large portion of the patient population we have to work with :))
Brooklyn ED PA working overnights here. Weekly if not daily. Sometimes multiple in a shift. And people get violent about it.
This is America
Look what I’m scrippin now
First time?
Meanwhile I just got my gallbladder removed and got 20 Percocets 😆
I SCREAMED AT THIS - American ED