16 February 2007

An Ambitious Request

I saw a pleasant young lady this afternoon. She was requesting a refill on her pain medications. She reported that she was in a bad car accident about 5 months ago in Another City of a Far Away State. She spent four months in a rehab "nursing home," and upon release had come to Our Fair State to visit family. She, unfortunately, reported that all her pain medications and other possessions had been stolen. She asked for enough pain medicine to get her through the next two to three weeks until she got back to the Far Away State.

Her regimen was 20 mg Dilaudid four times daily. (note to non-medicos: that is an insanely high dose; a typical dose is 2-4 mg) That works out to about 1.7 GRAMS of Dilaudid.

I doubt I have ever written for that much Dilaudid in my career, let alone at one time.

I examined the patient and she did indeed have scars on both legs consistent with multiple surgical procedures and external fixators, and they looked like they were a few months old. So she wasn't lying. But that amount of pain meds, to be polite, stretches credulity. So I said that I would like to call her doctor back home and verify the meds and dose.

"I don't know the name of the doctor," she said.

Was it a surgeon or a rehab doc or primary care doc or a pain specialist?

"I don't know."

What hospital were you treated at?

"I don't know."

Which rehab facility were you at?

"I don't know."

Can I call your family -- husband, parents and find out from them where you were cared for so I can get supporting documents regarding this prescription?

"I don't know where they are."

Do they have cell phones?

"I don't know."

Um, you're not helping me out here.

Tough situation. My instinct is to believe her, and the evidence is on her side. And people hospitalized for months do get disoriented. But the sheer incredible amount of drugs was such that I just could not bring myself to write the prescription. Ultimately we negotiated that I would give her three day's worth and she would do the research to find out where she was treated and by whom, and then we could work better with her to control the pain. Just amazing.

12 comments:

  1. sounds fishy.... just been burned too many times. unfortunatly sometimes innocent people get caught in the crossfire.

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  2. that is a freaking lot of dilaudid. and yeah, it sounds fishy to me too, and i'm not a doctor yet so i should have at least a small amount of faith left in humanity. if you hear, let us know if she shows up with the proper documentation!

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  3. I'm on the "its crap" side, too, because she is in your "Fair State" visiting family from her "Far Away State." She doesn't know how to get in touch with her family though? Yeah.

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  4. so I just looked up dilaudid on micromedex... it makes no mention of any dosing remotely near that much. for opioid-tolerant individuals, they list an extended-release formulation which is dosed at 12-36mg once daily...

    isn't her regimen enough to cause fatal respiratory depression, anyway?

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  5. If you gave her 3 days worth at her requested dose that still would be about as much dilaudid as I've written in 10 years. And I'm one of the few docs in these parts that actually brings my triplicate pad to work.

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  6. wow, that is a lot of dilaudid. we used to use dilaudid for breakthrough pain for some of our oncology pts, but never that much. we did like the dilaudid as there wasn't a max dose to exceed, but if you really needed that much drug we'd switch to increasing their long acting opiate.

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  7. I can sympathize with the desire to believe a patient's story and help them out. But on the other hand, as an ex-ER nurse, I've heard the old "out of town" story a zillion times. And once on a cruise ship, the ship's nurse told me that the ship doctor gets the "my drugs were stolen" story a lot, where the passenger blames it on the cabin-cleaning service. But I will give the all-time Academy Award Oscar nomination to a patient who tried to convince me, in triage, that she was allergic to NSAIDS and every single other narcotic painkiller in existence---except for dilaudid, heh!

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  8. I know very little about anything and reading that dose of Dilaudid made my jaw drop. o.o Good lord. I thought _I_ had a high opiate tolerance.

    I carry contact info for all my doctors, names and dosages of all my meds, and an abbreviated version of my medical history when I travel anywhere. My first instinct would be to think, thanks to stories like this, that doing that is helpful to ER doctors - I really hope I'm not actually just a big pain in the ass. ^^;

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  9. Did she call back, or is she busy making the rounds at every other ER and clinic in Fair City? People I've encountered with this kind of chronic pain are usually on more than just one med: oxy, Fentanyl patches, etc.

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  10. I agree with the others- i think you just got taken for a ride.
    Canadian ERP

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  11. I agree.I can understand not knowing medical history after a long illness, but not knowing if family are reachable by cell phone??

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