Inflection point between dilaudid and methadone dangers

[deleted185747]

---

Members don't see this ad.

I am seeing more patients on crazy doses of dilaudid when doing inpatient consults. When I say crazy I mean dilaudid 20mg po q3 plus dilaudid 8mg iv q2 for years. There was even a guy giving himself dilaudid 10mg i.m. q4 at home also using this for years, who came in because he needed more (he also had newly diagnosed spine osteomyelitis).

My question is specifically for these pts on chronically high doses of dilaudid who are admitted:

What dose of dilaudid would you consider too dangerous to give and use methadone instead which is relatively more dangerous? Sending the patient home on methadone 10 q8 seems safer than dilaudid 8mg q4..... or dilaudid 16mg po q4...... or dilaudid 20.....

 

[Aether2000]

Methadone takes weeks to titrate up to the proper amount...probably not a viable option for hospitalized patients. It is also 10 times more deadly than any other opioid.

 

[lobelsteve]

None of this makes sense.

Turf to detox.

 

[deleted185747]

None of this makes sense.

Turf to detox.

Steve: what would you do in the following scenario:

Consulted for 25 y/o admitted with sickle cell crisis (seen on microscope) and chest/limb pain. Patient is on dilaudid 16mg po q6 at home and has never been tapered as outpatient in-between crisis. Level of pain between crisis is 7/10 due to AVN of hip. Pain is now 10/10. Primary team has already increased her to 20mg po and added 8mg iv with a benadryl chaser.

Recs?

 

[101N]

Steve: what would you do in the following scenario:

Consulted for 25 y/o admitted with sickle cell crisis (seen on microscope) and chest/limb pain. Patient is on dilaudid 16mg po q6 at home and has never been tapered as outpatient in-between crisis. Level of pain between crisis is 7/10 due to AVN of hip. Pain is now 10/10. Primary team has already increased her to 20mg po and added 8mg iv with a benadryl chaser.

Recs?

Time to change your moniker from SpineBound to SickleCellCrisisBound. You must be in Oakland, Richmond, or LA.

 

[lobelsteve]

Steve: what would you do in the following scenario:

Consulted for 25 y/o admitted with sickle cell crisis (seen on microscope) and chest/limb pain. Patient is on dilaudid 16mg po q6 at home and has never been tapered as outpatient in-between crisis. Level of pain between crisis is 7/10 due to AVN of hip. Pain is now 10/10. Primary team has already increased her to 20mg po and added 8mg iv with a benadryl chaser.

Recs?

Turf to addiction at discharge.
Stop consulting to hospital.

But for this patient: Get UDS before seeing inpatient. Note the cocaine and THC. Turf to addiction as inpatient.

If UDS appropriate: turf to acute pain service.

I do not have the "luxury" of seeing folks like this and can only scoff from afar. If they were tachy, sweaty, and in crisis, IV PCA fentanyl, use Neurontin to get them drowsy with added Zanaflex. Ignore pain levels and titrate to VSS, then wean by 20% per day and turf to addiction as outpatient.

I do not treat SC patients. They go to the university pain clinic.

 

[deleted185747]

I am in a university hospital near LA. My recs are usually tapers and adjuvants. The sicklers raise the most questions for me although I don't see many of them and certainly don't enjoy it. Still in fellowship. Asking for advice outside my hospital. Thank you steve. Sicklecellcrisisbound lol JustShootMeNow

 

[emd123]

I am seeing more patients on crazy doses of dilaudid when doing inpatient consults. When I say crazy I mean dilaudid 20mg po q3 plus dilaudid 8mg iv q2 for years. There was even a guy giving himself dilaudid 10mg i.m. q4 at home also using this for years, who came in because he needed more (he also had newly diagnosed spine osteomyelitis).

My question is specifically for these pts on chronically high doses of dilaudid who are admitted:

What dose of dilaudid would you consider too dangerous to give and use methadone instead which is relatively more dangerous? Sending the patient home on methadone 10 q8 seems safer than dilaudid 8mg q4..... or dilaudid 16mg po q4...... or dilaudid 20.....

Whe I was in fellowship, I saw way worse than this. Agree with the others. Solution? Don't see inpatient consults when you're done with fellowship. During fellowship? Do what you're attending recommends and signs each chart, "Pt seen, examined with Dr. -----, plan discussed at length with Dr. ------."

It all depends if you think opiates are like any other drug, and that there is no reason not to keep titrating the dose up infinitely, as long as there are no side effects, aberrancy, etc. Then you'll end up with doses much higher than these easily, and they'll be your patients. If you don't believe that then at some point you draw the line on maximal dose and say, "We maximized the benefit we are going to get out of opiates."

Going up with no limit will get you into some crazy dose territory, and I can guarantee you the patient will still complain of severe pain (8+/10)

Patient comes to you on no opiates, pain - 8/10.

Another patient comes to you on dilaudid 20mg po q3 plus dilaudid 8mg iv q2. Pain = 8/10


What's the problem here?