I would love to know how you know this, because you are absolutely right.
Fentanyl is, IMO, almost the perfect analgesic for EMS. It acts fast which is great in an emergency, but it also doesn't last that long (20-40 mins or so), which is good for a philosophical reason.
When I started, they said, "Don't give pain meds to abdominal pain people. When the doctor pushes on and palpates their stomach in the ED in order to asses pain, the drug will mask the true pain and throw the doctor off the scent of what's really going on inside. And of course it is implied that he would then come to the wrong diagnosis and give the wrong treatment.
But that philosophy assumed morphine was the analgesic. Which comes on slow and stays around a while. It doesn't account for the fact that chemists have since moved on from that starting point.
So, I have been taught that Fentanyl changes the game. That it is a drug we can give in the field and not even have to bother worrying about the 'masked pain' dilemma.
To hear that it works the way that you describe, to the street abuser, is actually really interesting. It kinda makes sense to me that it would be that way.
Same with the dilaudid you describe.
A thing I have noticed, 10 years now on the ambulance, is that people are really fond of being allergic to everything but dilaudid.
I spent a few years addicted to opiates (back pain, OTC codeine pills, tolerance, started extracting higher doses then went onto stronger pills, blah blah blah the usual story) a while back. Even before that I was really into the harm reduction thing because of the time I spent in the club/rave scene in my late teens/early 20's, combined with a natural curiosity/obsessiveness about all these chemicals which made me feel so great (and more generally in neurobiology, and altered states of consciousness - which I mostly achieve with meditation these days), and I ended up doing a lot of reading and research, spent a ton of time on forums like bluelight, etc. Throw in the 8 years or so of personal experience and that's it. I'm just a drug geek.
But yeah, Fentanyl is the go-to for EMT's this side of the Pacific as well - there was a big media fuss a few years back about ambulance operators who'd experiment with the leftovers, start stealing it and allegedly replacing it with water, etc, although I don't think it was actually that wide-spread a problem, just the media looking for something to scare people with. I certainly never met anyone who'd been involved in any of that, all the fentanyl I ever saw was patches, imported powder and once some taken from a hospital drip.
I lolled at the "allergic to anything but Dilaudid" thing because you're 100% right, it's total BS. Hydromorphone is rare enough here in Aus that most addicts don't even know what it is unless they've seen Drugstore Cowboy, although it's become a bit more common since they released the high dose XR pills I mentioned - in my 5 years of active opiate use, I only came across a source once, and that was obviously from someone who had knocked over a pharmacy or supply truck or somesuch (it was a huge stash of the 32/64mg Jurnista XR pills and vials I don't remember the dose of - given the vials, probably a supply truck, since I think any major hospital robberies would have hit the media). But yeah, online on the less reputable drug sites I see a lot of US addicts talk about the best way to get the best opiates, and most of the discussion is focused around getting hydromorphone.
As someone who's extremely oversensitive to the histaminergic side effects of opiates (to the point where I had to take an antihistamine every time I got high or I'd spend the next few hours throwing up and, in the case of morphine/codeine, breaking out in painful hives), I can tell you that in my personal experience, neither is more histaminergic than the other by a noticeable degree. In fact aforementioned morphine/codeine are the only opiates which stand out as producing allergic side effects stronger than the rest of the opiates - again, just in my personal experience (although I never did try oxymorphone or tramadol).
That said, and maybe this is just the junky in me, but anyone who specifically requests dilaudid is almost certainly an active user/probable addict anyway, and if they're in a situation where they're being dosed by EMT's then I'd think they're in very obvious pain and probably in a generally shitty situation, so I don't see the harm in just cutting them some slack and giving them the drug that makes them feel nicer for the ride to the hospital. But that's just me.
