The Dilaudid Poll

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Should Dilaudid be restricted to slow infusion only?

  • Total voters
    128
Apollyon said:
I voted "no" because I'm in my third disparate area of the US (NYC, US south, now Pacific island), and I didn't/don't see it as a really severe problem - at most, I saw it in the south, but not enough to affect me.
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Yes. Just saw a "nurse" today who is "disabled" on Worker's Comp who has a Mediport for IV antibiotics. She also has chronic pain for which she gives herself 8mg of Diludid IV push several times daily.

But she states she's not a druggie.....
 
southerndoc said:
I hate it when they come in saying "only the stuff that starts with a D helps my pain" or they request "Dilauda"
Click to expand...

I always figured those folks were going for Demerol. Dilaudid is my IV narcotic of choice for treating severe pain, but I flat out tell patients that I do not give Demerol.
 
I've heard good things about "diacetyl morphine" in the UK, maybe y'all should have dilaudid as a schedule I and bring in this foreign opioid.
 
I'm amazed at the overwhelming majority that say "No." I have heard of several hospitals that have enacted policies like this because of the idea that it's the IV push and the resultant euphoria that keeps the seekers coming back. If it's given in 50cc of IVF and goes in over 10 to 15 minutes it has the same analgesic effect without the euphoria and without some of the histamine release. Since it's still Dilaudid you have sidestepped the whole morphine "allergy" thing.
 
docB said:
I'm amazed at the overwhelming majority that say "No." I have heard of several hospitals that have enacted policies like this because of the idea that it's the IV push and the resultant euphoria that keeps the seekers coming back.
Click to expand...

I hear you, but that is what I tried to address in my post. Where you (the "royal" you) practice is a big part of it.

I simply didn't and don't get that. It's a minor to nonexistent practice issue where I am and where I've been.
 
It's such a huge problem in my town (and DocB's) that my group enacted a policy whereby chronic painers get Diluadid (if they appear to be in actual discomfort) but only mixed in 250 ml to 1 L of NS and run in slowly over 30 minutes to an hour. It really does work, and you can tell the ones who like the euphoria because they will complain and whine at this new method.

I will not do IV push Dilaudid unless you have a kidney stone, gallstone, appendicitis or long-bone fracture.
 
We have enacted a pain policy whereby we only give those patients with chronic pain oral dilaudid (no IV medications) in the ER, and no prescriptions for opioids. I only actually use the policy every couple of days. Similar to your slow IV infusion, there should really be equivalent analgesic efficacy without the addicting euphoria (especially considering that by the time a peripheral IV is started, the oral medication could have been already administered). I've had a couple of immediate AMAs immediately after the patient was told that they would not recieve IV narcotics.
 
Percogesic is a good one as well.....Kinda the passive aggressive way to let the pt know he ain't getting narcs since he will realize it well after he leaves the ER and is in the pharmacy trying to get it filled.....
 
I have Sickle Cell so I've been the recipient of hundreds of doses of I.V. pain meds up to this point, and about 90% of them, even on floors were given by I.V. push(not counting PCA drips/doses). It's not that I requested it this way; I.V. push just seems to be standard procedure at most places I've been. I think it would be good to see a change though, from my experience the i.v. push isn't really necessary for anything but acute pain. A patient deliberately requesting i.v. push just for managing chronic pain would be kinda suspicious to me.
 
WhizoMD said:
I have Sickle Cell so I've been the recipient of hundreds of doses of I.V. pain meds up to this point, and about 90% of them, even on floors were given by I.V. push(not counting PCA drips/doses). It's not that I requested it this way; I.V. push just seems to be standard procedure at most places I've been. I think it would be good to see a change though, from my experience the i.v. push isn't really necessary for anything but acute pain. A patient deliberately requesting i.v. push just for managing chronic pain would be kinda suspicious to me.
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As with a lot of nursing-related issues nurses like IV push because it's quick, and easy for them. The fact that it leads to drug euphoria and addiction doesn't seem to matter to many of them.

I will now only give IV narcotics for acute pain (and not the "my stomach hurts again just like it does every week" patients).
 
The euphoria associated with giving meds IV push is a behavioral issue. I'm not aware of any evidence that narcotics given IV push in a population causes more addiction than slow infused meds.

GeneralVeers said:
The fact that it leads to drug euphoria and addiction doesn't seem to matter to many of them.
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If you don't think that somebody warrants narcs or is seeking, they shouldn't receive narcs period. If you don't want to deal with the issues associated with IV administration, IM and PO narcotics work just fine.
 
Subjectively, I think there are pro's and cons to using dilaudid as a first line med for "severe" pain. Working in an ED we see a significant amount of drug seeking behavior and generally do our best to weed it out with non narcotics but conversely being bothered for permission to give every 2mg dose of morphine can eat up even more of your time if the patient is having "severe" pain. I agree that nurses like push meds over drips if no fluids are ordered since the set up of an IV pump requires more time, but if fluids are already ordered adding the dialudid to prevent an opiod type rush is a valid idea and no more labor intensive.
I just think in some ways we can end up rationing narcotic prescriptions in an almost passive agressive way. We end up denying narcs as a non verbal f*** you to an irritating pt as opposed to an impartial clinical decision. I know I've never had maor pain issues to deal with, and while I can be just as jaded as the next guy, I think that we can become so biased to the "I want the drug with a d" crowd we would rather see them suffer than feel we've been fooled.
 
bartleby said:
The euphoria associated with giving meds IV push is a behavioral issue. I'm not aware of any evidence that narcotics given IV push in a population causes more addiction than slow infused meds...
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Yep, it was my understanding the two main issues/components associated and/or contributing to addiction is delay in adequate treatment of real pain and medications with shorter half lifes. I've not heard of any evidence that rate of IV administration is a causative factor.
 
JackADeli said:
Yep, it was my understanding the two main issues/components associated and/or contributing to addiction is delay in adequate treatment of real pain and medications with shorter half lifes. I've not heard of any evidence that rate of IV administration is a causative factor.
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Now wait a minute. This discussion is changing from the initial topic of the Dilaudid euphoria that causes additional ED visits to the question of real opiate addiction. I don't know about the IV push causing actual addiction (although I do see a population of pts who come in like clockwork every 48 to 72 hours for a bump) but I do see a ton of pts who come to the ER just to get the Big D.

I think that actual physiologic addiction and drug seeking behavior are separate entities.
 
I don't have any references to support this, but I do have reasoning...

Diacetyl morphine, aka heroin, is able to cross the blood brain barrier much more quickly than morphine, and it is this characteristic that leads to a more euphorogenic response. It is this same characteristic that is blamed for it's exceptional addictive potential. It would stand to reason that the same would hold true for meds given via IV push (rapid increase in serum, and, assuming it can cross the BBB, intrathecal concentration) vs slow infusion (with a more gradual rise in concentrations).

Just the other day I had a patient with the frustrating combination of drug seeking behavior and real disease. I ordered dilaudid as a slow infusion. The patient said she said she wanted it IV push, I declined, and soon after the nurse caught her manipulating the IV pump to try to get the med to run in more quickly. That was proof enough for me.
 
how much trouble do you all see with respiratory depression and Dilaudid?

My new hospital apparently can't handle it and has seen some enormous increase in rapid response situations with increased Dilaudid usage. And now you have attendings who put it as an "allergy" any time a patient becomes sleepy on it.

Poor nursing? Poor prescribing practices? (Today I saw an order changing dilaudid 1 mg IV Q2H prn to dilaudid 4 mg Q4H around the clock - would that be an excessive increase? I honestly didn't call on it.)
 
WilcoWorld said:
Just the other day I had a patient with the frustrating combination of drug seeking behavior and real disease. I ordered dilaudid as a slow infusion. The patient said she said she wanted it IV push, I declined, and soon after the nurse caught her manipulating the IV pump to try to get the med to run in more quickly. That was proof enough for me.
Click to expand...

When I use dilaudid now for any condition that's not obviously acutely painful, I give it by slow infusion over 15 to 60 minutes (depending on dose). The nice thing about it is that patients who have real pain will feel much better. The druggies will complain and whine about it not being IV push. I find it's an excellent method to promote self-assortment of real pain versus drug-seeking patients.
 
I don't think I've ever had dilaudid administered to me.

I had demerol when I was giving birth, which did absolutely nothing for me because I was at the point where the baby was coming out imminently, and I was just tired and ready to be done.

I had morphine the last time I visited an emergency room. The ER doctor decided to give me IV push morphine for a migraine. I hated it. I didn't like feeling like my skin was on fire, or breaking out in hives. Yeah, it sucks to find out the hard way that you're actually allergic to morphine. I also didn't feel any euphoria, I just felt like crap, like I was unpleasantly drunk and underwater at the same time.

To be honest, I usually refuse most painkillers. Most of the time, give me a couple of ibuprofen, and I'll suck it up and tough it out. But, that being said? I have a good friend who is in the ER continually, and says she's allergic to this painkiller and that painkiller, and has a doctor who has prescribed her fentanyl suckers (are there such things?) for her fibro (don't get me started), and so on.

The woman is on more pills than I can count. She decided to compare with me one afternoon, and was shocked that counting allergy meds, a multivitamin, and a calcium supplement, I was taking five pills a day (one bc pill, one 20mg Prozac for generalized anxiety disorder). I asked her how many. She lost count. She LOST COUNT.

I love my friend....but I think she has issues.
 
Katydid said:
I had morphine the last time I visited an emergency room. The ER doctor decided to give me IV push morphine for a migraine. I hated it. I didn't like feeling like my skin was on fire, or breaking out in hives. Yeah, it sucks to find out the hard way that you're actually allergic to morphine.
Click to expand...

Just a thought here, but there's a pretty good likelihood that you're not allergic to morphine. Morphine causes a histamine release which relatively frequently causes these symptoms. Histamine is also part of the pathway involved in an allergic reaction, this is the reason it seems similar.

Take care,
Jeff
 
Jeff698 said:
Just a thought here, but there's a pretty good likelihood that you're not allergic to morphine. Morphine causes a histamine release which relatively frequently causes these symptoms. Histamine is also part of the pathway involved in an allergic reaction, this is the reason it seems similar.

Take care,
Jeff
Click to expand...

Classically it's a "histamine release" phenomenon, so just regular itching isn't an allergy. If she broke out in actual hives wouldn't that be an allergy?
 
Jeff698 said:
Just a thought here, but there's a pretty good likelihood that you're not allergic to morphine. Morphine causes a histamine release which relatively frequently causes these symptoms. Histamine is also part of the pathway involved in an allergic reaction, this is the reason it seems similar.

Take care,
Jeff
Click to expand...

All I know is that the ER doc who administered morphine and saw the hives told me I was allergic.

I know that when I had demerol, I remember the skin-on-fire feeling, but it went away fairly quickly. When I had morphine, my skin felt like it was on fire until the hives went away. It totally sucked. Sucked hard. Sucked like a Hoover sucks.

And I just don't want to have that experience EVER again. And honestly, if I'm in enough pain that someone says the solution is morphine? Please, just shoot me.
 
Well, histamine release gives the itch and the "whelps" (!), so...

I put an ellipsis there, because I still - to this day - don't understand the difference between an allergic reaction, and a histamine reaction to opiates or vancomycin. I guess it's like fever vs. hyperpyrexia. Or maybe not.
 
Apollyon said:
Well, histamine release gives the itch and the "whelps" (!), so...

I put an ellipsis there, because I still - to this day - don't understand the difference between an allergic reaction, and a histamine reaction to opiates or vancomycin. I guess it's like fever vs. hyperpyrexia. Or maybe not.
Click to expand...
Vancomycin can cause two types of reaction: anaphylactoid (red man syndrome) and anaphylactic. The red man syndrome causes a direct degranulation of mast cells and basophils to release histamine without forming any IgE antibodies. Initially this was thought to be from contaminants/impurities in the manufacturing process. Now it's thought that the drug itself can cause mast cell reaction in susceptible people. Those that are allergic and get a true anaphylactic reaction develop IgE antibodies.
 
So, clinically, truly, you couldn't factually tell the difference, due to not knowing if there were IgE antibodies at that moment. Otherwise, since IgE causes the mast cell degranulation, it's apples and apples, but you can't tell the difference between Granny Smith (anaphylactoid) and golden delicious (anaphylactic).
 
Apollyon said:
So, clinically, truly, you couldn't factually tell the difference, due to not knowing if there were IgE antibodies at that moment. Otherwise, since IgE causes the mast cell degranulation, it's apples and apples, but you can't tell the difference between Granny Smith (anaphylactoid) and golden delicious (anaphylactic).
Click to expand...
You can't tell the difference unless you draw IgE levels. You can guess though. If the patient has never been exposed to that medicine before, and they had an allergic reaction, it's most likely an anaphylactoid and not an anaphylactic reaction. Of course you can't be 100% sure though because they may have IgE antibodies that are cross-reacting.
 
southerndoc said:
You can't tell the difference unless you draw IgE levels. You can guess though. If the patient has never been exposed to that medicine before, and they had an allergic reaction, it's most likely an anaphylactoid and not an anaphylactic reaction. Of course you can't be 100% sure though because they may have IgE antibodies that are cross-reacting.
Click to expand...

The end result is the same. You should try to avoid the repeat exposure as it could be much more significant whether anaphylactoid or anaphylactic.
 
docB said:
I'm amazed at the overwhelming majority that say "No." I have heard of several hospitals that have enacted policies like this because of the idea that it's the IV push and the resultant euphoria that keeps the seekers coming back. If it's given in 50cc of IVF and goes in over 10 to 15 minutes it has the same analgesic effect without the euphoria and without some of the histamine release. Since it's still Dilaudid you have sidestepped the whole morphine "allergy" thing.
Click to expand...

Sorry to bring back an old topic, but do you have the citation to the study showing this? I vaguely remember reading it awhile back but wanted to go back over it and can't find it now. Thanks.
 
Katydid said:
I have a good friend who is in the ER continually, and says she's allergic to this painkiller and that painkiller, and has a doctor who has prescribed her fentanyl suckers (are there such things?) for her fibro (don't get me started), and so on.

The woman is on more pills than I can count. She decided to compare with me one afternoon, and was shocked that counting allergy meds, a multivitamin, and a calcium supplement, I was taking five pills a day (one bc pill, one 20mg Prozac for generalized anxiety disorder). I asked her how many. She lost count. She LOST COUNT.

I love my friend....but I think she has issues.
Click to expand...

Your friend is addicted to narcotics. Unfortunately, while there are no studies whatsoever that show improvement in function or quality of life with long-term narcotic therapy for fibromyalgia (or other similar chronic pain syndromes without definitive pathology), some physicians prescribe narcotics because the euphoric side-effects tend to placate otherwise-difficult patients.

Also, Actiq (fentanyl suckers) and Fentora (fentanyl dissolving tabs) were only approved to treat breakthrough pain in cancer patients.

In response to the poll -- I said yes, they should. Not sure how effective that would be re: discouraging drug seeking, but I'd be in favor of anything that could potentially reduce seeking behavior. I'm not sure what the necessity of having it available IVP is -- at least in EMS, for true severe pain where we needed a quick fix, we used fentanyl, so I assume that would still be an option in the ED for rapid relief.
 
sanityonleave said:
Your friend is addicted to narcotics. Unfortunately, while there are no studies whatsoever that show improvement in function or quality of life with long-term narcotic therapy for fibromyalgia (or other similar chronic pain syndromes without definitive pathology), some physicians prescribe narcotics because the euphoric side-effects tend to placate otherwise-difficult patients.

Also, Actiq (fentanyl suckers) and Fentora (fentanyl dissolving tabs) were only approved to treat breakthrough pain in cancer patients.

In response to the poll -- I said yes, they should. Not sure how effective that would be re: discouraging drug seeking, but I'd be in favor of anything that could potentially reduce seeking behavior. I'm not sure what the necessity of having it available IVP is -- at least in EMS, for true severe pain where we needed a quick fix, we used fentanyl, so I assume that would still be an option in the ED for rapid relief.
Click to expand...

Dilaudid was just recently added prehospital out here with positive result. The ED also doesn't have a problem with seekers. Now where I was previously(south-heavy drug seeking population) there was a mix of hardline docs and some who just didn't care. Hardline docs wouldnt give dilaudid, only for confirmed kidney stones-breaks-few other acute things. The docs who didn't care seemed to give it if you came in c/o stubbed toe, and narcs to take home. Seekers would routinley call ahead to see who was working if it was someone they knew wouldn't cave they would go to another hospital. Finally the ED got it's act together so the seekers began calling EMS knowing they could possibly get their IV fix in the ambulance.

So in short I think depending on your location(not pt population) slow infusion would definitely be the go to option, and acute things IV push.
 
Katydid said:
All I know is that the ER doc who administered morphine and saw the hives told me I was allergic.

I know that when I had demerol, I remember the skin-on-fire feeling, but it went away fairly quickly. When I had morphine, my skin felt like it was on fire until the hives went away. It totally sucked. Sucked hard. Sucked like a Hoover sucks.

And I just don't want to have that experience EVER again. And honestly, if I'm in enough pain that someone says the solution is morphine? Please, just shoot me.
Click to expand...
Morphine coadministered with a low dose narcan drip might be an option should you ever need it.
 
Peds2ER said:
Morphine coadministered with a low dose narcan drip might be an option should you ever need it.
Click to expand...

that doesn't really make sense to me...
dilaudid, morphine + benadryl, or morphine + cromolyn all seem to make more sense
 
Katydid said:
I don't think I've ever had dilaudid administered to me.

I had demerol when I was giving birth, which did absolutely nothing for me because I was at the point where the baby was coming out imminently, and I was just tired and ready to be done.

I had morphine the last time I visited an emergency room. The ER doctor decided to give me IV push morphine for a migraine. I hated it. I didn't like feeling like my skin was on fire, or breaking out in hives. Yeah, it sucks to find out the hard way that you're actually allergic to morphine. I also didn't feel any euphoria, I just felt like crap, like I was unpleasantly drunk and underwater at the same time.

To be honest, I usually refuse most painkillers. Most of the time, give me a couple of ibuprofen, and I'll suck it up and tough it out. But, that being said? I have a good friend who is in the ER continually, and says she's allergic to this painkiller and that painkiller, and has a doctor who has prescribed her fentanyl suckers (are there such things?) for her fibro (don't get me started), and so on.

The woman is on more pills than I can count. She decided to compare with me one afternoon, and was shocked that counting allergy meds, a multivitamin, and a calcium supplement, I was taking five pills a day (one bc pill, one 20mg Prozac for generalized anxiety disorder). I asked her how many. She lost count. She LOST COUNT.

I love my friend....but I think she has issues.
Click to expand...

IV DHE + Maxeran = Tx of choice for ultra severe migraine + no whining for "allergy to morphine" + added benefit of zero abuse potential.

That's how it's done son.
 
ghost dog said:
IV DHE + Maxeran = Tx of choice for ultra severe migraine + no whining for "allergy to morphine" + added benefit of zero abuse potential.

That's how it's done son.
Click to expand...

compazine is preferred at my place. seen 1g depakote/1g solumedrol work too. not sure which was the ingredient that actually had the desired effect.

The only times i've ever needed opiates for headaches were in traumatic headaches and IIH headaches.
 
not only would i VOTE to have it given over a slow infusion, but i would go as
far as to have a preset list of viable indications to give it: (significant fracture, peritonitis, intractable renal colic [for example]).

i'm convinced dialaudid is so highly addictive that given it to a patient in the ED who's never received it can have them return to the E.R. drug-seeking. i've seen it, i've seen it in young patients, old patients, those with underlying psych issues and those without diagnosed psych illness.

i give morphine for the vast majority of my patients. it works well. i like to titrate it. if the patient claims they are still in pain, then I'll give them more.

i've never had a patient come in begging for morphine, but i have patient's coming in daily with their mouth water asking for that medicine that starts with the "D".
 
We started a "no Dilaudid" policy in our community suburban ED in Texas on August 1st. We've even placed signs around the department and in every room. Only patients with active cancer get Dilaudid.

Allergic to everything else? So sorry - you can see a pain management doctor. We're curing Morphine allergies left and right out here.

I tried the Dilaudid slow infusion thing; our pharmacy nixed it because the narcotics have to be locked up (ie😛CA).
 
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