Originally Posted by proman
I've been answering in the context of an acute musculoskeletal pain protocol. It's much harder to be concerned about drug seeking behavior when there's a bone sticking out at you. Not impossible, but harder.
My current hospital has a tremendously high rate of IVDA and other drug seekers. When the pain is legit, you still should treat it. Morphine isn't a good drug. Fentanyl is effective but I only recommend it in patients who are at risk of pulmonary complications (like OSA, COPD, etc). Hydromorphone is effective when used appropriately. As another issue, if you stop giving hydromorphone in the ED what are you going to use? Morphine? Fentanyl? Whatever you switch to will get the same abuse down the road, just like meperidine. There's no opioid currently available without side effects and abuse potential.
I just don't see the rabid seeking of morphine to anywhere near the same degree as I see it for Dilaudid. Dilaudid closely mirrors Demerol in that respect. I think using morphine instead of Dilaudid is very viable, it's how I practice.
I certainly believe your position and I do agree that for ortho issues in particular using Dilaudid in EMS settings could be valuable (although I do think the boxes would get jacked a lot). I just have such a high volume of Dilaudid specific seeking in my area I can't advocate for increasing its use.