Friday, Feb. 19th 2016

IV Hydromorphone

In 1979 during my psychiatry rotation in medical school I was sent to the Methadone clinic in Kansas City. I still remember talking about drug addiction with the clients.   One comment stuck with me.  A guy trying to stay clean told me “If God made anything better than IV Dilaudid, he’s keeping it for himself!” That was the first time I had ever heard of the drug Dilaudid.

Dilaudid is the trade name for hydromorphone, an opioid in the morphine family. It has a rapid onset and a short duration. Because it’s effects are rapid it has benefits to quickly bring pain under control. It can be given by mouth or IV. It is a VERY good pain reliever and if given as an IV bolus (quickly through the the IV) pain will drop rapidly and dramatically.  There is often a sense of warmth, well being and calm, for first time users euphoria is often described. These IV effects are a lot like the effects of another opioid, heroin. One more thing, it wears off quickly and the pains comes back often with a vengeance leaving the suffer begging for another shot.
IV hydromorphone  Has now become the choice  IV medication for severe 10/10 reported pain in many ERs and in hospital patients. Patients like it and learn its benefit. Many ask for it by name. A poor fellow we saw this week had been getting it for 4 days every three hours on the clock for an amputated toe.  He was angry with the nurses if it wasn’t given right on time. It was the ONLY thing that worked for his terrible amputation pain. When I was consulted I told him that this was learned behavior, his brain now trained to only get relief from an IV bolus of a strong narcotic. In laymen terms I explained why this was a bad thing and he got angry with me also. I spent a lot of time trying to educate him on the longer term consequences of this brain training. He wasn’t interested. Although I addressed the phenomenon as addictive behavior I was careful not to directly label an angry guy as an addict. He only sees himself as a miserable pain patient. I have tried telling new patients on a first visit that they’re an addict. I usually get tossed out of the room.  Since I was asked to help with the case,   I stopped the IV bolus as a first step and put him on an oral medication similar with slower onset, less rapid effects and also added a non-narcotic coanalgesic to help with nerve pain. This would prevent withdrawal but would begin to change his need for the IV effect. He requested that I be taken off his case (I was fired) and the next day he was back on IV Dilaudid again.
This is addiction and clear addictive behavior albeit in a miserable guy with  pain.  He has had experience with chronic pain.   Reversing this learned behavior is not easy, and we are not helping patients when we use these excellent pain killers for too long. In acute settings like the hospital it may be useful to apply these powerful tools, but managing them to prevent addiction is important. Not all patients recieving IV opioids become addicted, but this is one example of how we have created drug addicts in our efforts to be compassionate about pain.  If we truly care about our patients we will also need to spend time explaining why we are not giving them what they want. Most who have received this discussion understand and are agreeable to changes that will prevent further harm and the risk of addiction. Unfortunately there are many who reject the information and are angry. This denial is also a sign of addiction. We have to be smarter about using our best pain relievers and that sometimes means being the bad guy to help our patients.

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