Dilaudid

You mean the ones with allergies to tylenol and ibuprofen but want to scoop up that Vicodin (with tylenol!) like its candy?  Or, the only thing that worked was something with a D... Dil...? 

Honestly I usually blame the physician.  I'm sorry, he didn't order that for you, he gave xyz as options instead, would you like one of those?  Sometimes I try education--Your ankle is sprained and swollen, ibuprofen/toradol helps the swelling which helps the pain.  The "insert opiate here" won't actually help the healing process or the source of your pain.

It can become very frustrating for sure.  Don't take anything they say personally. Document what they said in quotes, what you offered, etc.  Educate if you think it will help (there is a new migraine protcol out-that is what our hospital uses. or your injury doesn't require a narcotic, but getting the swelling down will help your pain alot.) 

But honestly, a drug seeker doesn't care the reasoning. And they will leave AMA if they don't get that quick fix.  Write on the AMA document "wanted opiate for sprain, physician did not find pt needed opiate, ibuprofen/ice/brace offered and rejected"

28 minutes ago, RuralMOSchoolRN said:

[...]

... Write on the AMA document "wanted opiate for sprain, physician did not find pt needed opiate, ibuprofen/ice/brace offered and rejected"

Why?  What, aside from antagonizing the patient, is this going to accomplish?  Review their after visit summary or other discharge paperwork, document any  education you provided, and let them go.

CHARE- I meant the AMA paperwork that stays at the ER/UC.  Not the patient's.  We have a spot on our flow sheet for AMA reasons and that is where I would put it.

I don't encounter the dilaudid demander all that often. I do, however, encounter the Norco Needers quite a bit. Mostly I get the "I usually get the Norco 10s" when they're offered pain medication, which sometimes is a Norco 5, but often it's a Tylenol or Ibuprofen that gets offered. I usually let them know that's what the provider ordered and has available for the patient. If the patient refuses and demands the Norco (or Percocet or whatever) then I'll simply state "I'll ask the provider but the provider doesn't have to, and may not, order it." Then I actually will go ask the provider. If the order is put in, I happily give it, if not, I say so and the previous pain meds are still available. Regardless, I document the episode and move on. If the patient wants to AMA because of it, they're free to go... and I'll still document the episode and let the provider know so their documentation can reflect the drug - seeking. 

There are a few patients (every ED has them) that are well known for this and they're usually told upfront that no opiates will be provided and for those particular patients, I know they've been told this upfront, so for those, I won't approach a provider, I just reiterate that the pain med orders are what they are and I'm happy to go get them. Ultimately they either begrudgingly take what's offered or they leave and the episode gets documented anyway...

ha ha, this makes me giggle.. 

Give them the dilaudid, shoot, it's ordered.. and have a good rest of your shift. 

As a new cross-covering hospitalist, I've already encountered this and I can see where it will be a struggle. Just the other night I had a patient demanding dilaudid for what she described as gas pains. I went to the room and offered the PRN simethicone first, she refused. I recommended ambulating to help the discomfort and she said she was in too much pain to get up. I told her that she had a CT scan that indicated she may have some constipation and giving her another dose of a narcotic would potentially exacerbate that problem. She refused tramadol, couldn't get toradol because of kidney function. I was in there about 30 minutes trying to come up with an appropriate strategy but in the end I did order another one time of 0.2mg, which she had received a few times already on this admission. If she hadn't already gotten it I feel like I would have had more confidence in sticking to my plan, but in all honesty I knew the patient was going to make the shift hell for her nurse until she got that dilaudid. I hate that we give narcotics out like candy, and I definitely have concerns about the long term effects of the opiate prescribing, but I went with the path of least resistance. 

My biggest issue wasn't with the dilaudid pt's but the pt's who set alarms on their phones to let them know when they were due pain meds next. That really burned my biscuits. Glad I don't have to deal with that nonsense anymore. Thanks JCAHO for making pain the 5th VS.

1 hour ago, OUxPhys said:

My biggest issue wasn't with the dilaudid pt's but the pt's who set alarms on their phones to let them know when they were due pain meds next. That really burned my biscuits. Glad I don't have to deal with that nonsense anymore. Thanks JCAHO for making pain the 5th VS.

LOL This!!!

JBMmom said:

As a new cross-covering hospitalist, I've already encountered this and I can see where it will be a struggle. Just the other night I had a patient demanding dilaudid for what she described as gas pains. I went to the room and offered the PRN simethicone first, she refused. I recommended ambulating to help the discomfort and she said she was in too much pain to get up. I told her that she had a CT scan that indicated she may have some constipation and giving her another dose of a narcotic would potentially exacerbate that problem. She refused tramadol, couldn't get toradol because of kidney function. I was in there about 30 minutes trying to come up with an appropriate strategy but in the end I did order another one time of 0.2mg, which she had received a few times already on this admission. If she hadn't already gotten it I feel like I would have had more confidence in sticking to my plan, but in all honesty I knew the patient was going to make the shift hell for her nurse until she got that dilaudid. I hate that we give narcotics out like candy, and I definitely have concerns about the long term effects of the opiate prescribing, but I went with the path of least resistance. 

well if we have excluded organic pathology and all the ct has is constipation I doubt I would give anything more than simethicone and some laxatives. They can leave if they want.