How would you treat an alcoholic in severe pain?

[PreMedAdAG]

this thread is frustrating.. what began as a simple question from one user trying to sort our his/her thoughts turned into an ego-oriented parade. These forums are quite useful at times particularly for people looking ahead in the future, but in terms of discussing topics, why is it that the jerks manage to dominate every conversation. Get off your horse.... and stop being so condescending. I thought medicine was collaborative? I have no interest in picking fights or implying stupidity just because I disagree with someone elses thoughts. Thank god for diversity in physicians otherwise our diversity of treatment would be nonexistent.

Argh... this is sooo irritating and one of the lamest aspects of this career
take your egos and attitude problems elsewhere!

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[Rendar5]

this thread is frustrating.. what began as a simple question from one user trying to sort our his/her thoughts turned into an ego-oriented parade. These forums are quite useful at times particularly for people looking ahead in the future, but in terms of discussing topics, why is it that the jerks manage to dominate every conversation. Get off your horse.... and stop being so condescending. I thought medicine was collaborative? I have no interest in picking fights or implying stupidity just because I disagree with someone elses thoughts. Thank god for diversity in physicians otherwise our diversity of treatment would be nonexistent.

Argh... this is sooo irritating and one of the lamest aspects of this career
take your egos and attitude problems elsewhere!

umm...if u don't want comments like "real S-M-R-T" whenever you make a mistake,. don't have it say "I am so smart. s-m-r-t" under your name.

 

[Law2Doc]

this thread is frustrating.. what began as a simple question from one user trying to sort our his/her thoughts turned into an ego-oriented parade.

I don't think it was a simple question at all. More facts are needed about the nature of the ailment to answer the question, because physicians don't blindly dispense medications. With more facts provided it could be made into a simple question.

 

[PreMedAdAG]

umm...if u don't want comments like "real S-M-R-T" whenever you make a mistake,. don't have it say "I am so smart. s-m-r-t" under your name.

It's from the Simpsons...if you haven't seen the episode then you wouldn't think it's funny when Homer starts singing.. I am so smart... s-m-r-t....

it's just a joke.. lighten up

 

[PreMedAdAG]

I don't think it was a simple question at all. More facts are needed about the nature of the ailment to answer the question, because physicians don't blindly dispense medications. With more facts provided it could be made into a simple question.

fine... but everyone is still taking it wayyyyyy too seriously.

 

[PreMedAdAG]

umm...if u don't want comments like "real S-M-R-T" whenever you make a mistake,. don't have it say "I am so smart. s-m-r-t" under your name.

and what exactly was my mistake?

 

[Rendar5]

It's from the Simpsons...if you haven't seen the episode then you wouldn't think it's funny when Homer starts singing.. I am so smart... s-m-r-t....

it's just a joke.. lighten up

I thought I was being funny. I know it's a joke and I know it's from the simpson's.

 

[Rendar5]

and what exactly was my mistake?

saying tylenol was best option for alcoholics and saying to give the guy methadone (I gave a long-winded explanation of why it's fine to give people morphine w/o worrying about causing an addiction). Not sure there's a high cross-reactivity between alcohol addiction and opiate addiction based on what i've learned so far in school.

quick pubmed look-up. this isn't a definitive study by any chance, but closest so far to the question of linkage between opiate addiction and alcohol addiction:

http://www.ncbi.nlm.nih.gov/entrez/...ed&dopt=Abstract&list_uids=8486082&query_hl=3

"clients of methadone programs reported the lowest rates [of alcohol abuse]" "The frequency of drug use (by specific type) and most social characteristics showed no direct association with drinking patterns or problems."

 

[PreMedAdAG]

saying tylenol was best option for alcoholics and saying to give the guy methadone (I gave a long-winded explanation of why it's fine to give people morphine w/o worrying about causing an addiction). Not sure there's a high cross-reactivity between alcohol addiction and opiate addiction based on what i've learned so far in school.

quick pubmed look-up. this isn't a definitive study by any chance, but closest so far to the question of linkage between opiate addiction and alcohol addiction:

http://www.ncbi.nlm.nih.gov/entrez/...ed&dopt=Abstract&list_uids=8486082&query_hl=3

"clients of methadone programs reported the lowest rates [of alcohol abuse]" "The frequency of drug use (by specific type) and most social characteristics showed no direct association with drinking patterns or problems."

Fair enough.. but here's the deal... we lack vital pieces of information... how long will the patient be on narcotics, history of substance abuse.. blah blah... you know what i'm talking about. I wish it wasn't 12:08am and i wish i didn't have to wake up at 5am to catch a plane, but if i had more time (and maybe i will later), I can show you some very promosing research regarding significant correlation between alcohol and substance misuse. Tie those physiological findings with a nice psychiatric combination of depression (usual for people in chronic pain... blah blah) and addictive personality issues, and bam.. you have yourself a dangerous addict. Anywhoo...i co-authored a paper that looked at this issue and is coming out in the Winter issue of the JMLE... anyway.. i'm sure there are differing opinions... and just my personal opinion.. i've been shadowing docs who work with chronic pain patients in fairly severe pain and the fact that they have any history of abuse makes them very hesitant to give them drugs. I've seen docs give shots, give a handful of vicodin, but for the most part.. it's a no... especially if they've got a history of addiction.. blah.. anyway.. this issue has been talked to death. g'night

 

[UCLA2000]

liver failure isn't the issue. chronic alcohol intake is the issue. I have had it taught that you can have the tylenol-booze interaction even in the absence of booze when u're talking severe alcoholics, and that is what some people have brought up. I'm going to look up studies if i have a chance to see whether this is true.

http://www.ncbi.nlm.nih.gov/entrez/...ed&dopt=Abstract&list_uids=7657281&query_hl=6
that's a case report abstract. still gotta have an RCT in patients w/ alcoholic liver disease to prove anything, though.

My bad! I misunderstood the question.

The issue isn't the presence or abscence of alcohol in the system. If you're splitting hairs its not really a booze-acetaminophen interaction.

The actual mechanism of the pathophys is worth looking up. Here's the big picture view of it.


The problem is that alcohol causes depletion of glutathione stores (NAC helps to restore them as well as binds etoh in the gut etc). Acetaminophen is normally converted to a toxic metabolite NAPQI which is then broken down by Glutathione. Without Glutathione, NAPQI accumulates and causes toxicity.

The question is, can a chronic etoh person have low glutathione levels without having etoh on board. Frankly, if they have no etoh on board you have bigger problems such as DT's to deal with.

That being said, given the mechanism of the acetaminophen toxicity I would think that the answer would be yes. It is possible to have toxicity without etoh on board.

 

[UCLA2000]

Wanted to adress this post.. after doing extensive reserach in pain medication addiction, I can respond with some fair wit:
Addicts in severe pain, unless it's cancer pain or end of life care, are not normally given tons and tons of narcotics. Some docs wont even think about it. However if it acute and severe, then sure an IM would be in order, but the question is of what?
In response to 1. You are correct, absolutely.. however, those who are addicted to other items such as alcohol and nicotine have a propensity for other types of abuse, namely pain medications
In response to 2. Do you really want to go there.. what sane person would say.. wow, let's deal with the minor pain now and then have a horrific life altering addiction to overcome later, that doesn't even make sense (granted I'm playing devils advocate, so i'm going to extremes too)

1. Great fact. 100% correct however we're not talking demographics of narcotics abusers here. We're discussing treatment/management of someone in pain. As the previous poster stated, patients who are acutely treated with narcotics for pain relief do not generally become addicts. Don't even get me started on chronic narcotic treatment though.

2. The whole "treat the addiction later" argument by the prior poster was a little overboard. That being said, there are definately conditions such as terminal cancer that if the patient were in severe pain, I'd be prone to say "the hell with addictive tendencies, comfort is number 1".

 

[EctopicFetus]

This might qualify for the dumbest thread of all time. Uhh whats reall wrong with the guy? Did he happen to fall and crack his head open? How drunk is he?

Anyhow giving this guy tylenol if he is acutely intoxicated would be malpractice. On another note if he is simply an alcoholic and not drunk and in acute pain then MSO4 would be fine. so would any other non-tylenol containing compound. Of course if you used your omniscient skills and knew his LFTs were fine..

Ahh who cares..

 

[UCLA2000]

I've never been one to get on a moral high horse, but this whole thread is a little sketchy. It's completely irresponsible to offer medical advice under the guise that it's a valid opinion when there's no history, examination, or context given at all. And that would be the case even if we were pain management anesthesiologies with specific training in the treatment of alcoholic patients. Not only are we just medical students, many are just 1st years without any pharmacological training at all without even the faintest disclaimer to that effect. The OP might actually intend to use what we say on a patient, God forbid. Again, I don't mean to be a drag on an educational conversation... but consider the weight your words might carry for the OP.

-dope-

Interesting point. Please note the long list of disclaimers used in my original post regarding the type of pain location etc. It all really depends on the case, clinical impression, patient hx, exam etc. It is impossible to formulate a good opinion without having a full case scenario given.

That being said, I completely disagree with your assessment regarding the inappropriate nature of this thread. You'll find that in medical school you learn from doing case studies and discussing management plans. This is how we learn. This is how we improve.

There is a 0% chance that anyone would take an entire management plan from this thread. Why? Because to manage a patient in that manner would require convincing a resident AND attending that the plan is the proper one to follow with the patient.

You should read the responses, think about them, and then do research of you own (uptodate or google searches).

I understand your hesitation to fully participate in this thread. It is apparent from your post that YOU are a first year with 0 pharmacologic experience, however you'll soon discover that this board is frequented by people with varying levels of medical knowledge/experience.

Personally, I'm a 4th year medical student who has fulfilled ALL of my graduation requirements.

Have a nice day.

 

[stoic]

Fair enough.. but here's the deal... we lack vital pieces of information... how long will the patient be on narcotics, history of substance abuse.. blah blah... you know what i'm talking about. I wish it wasn't 12:08am and i wish i didn't have to wake up at 5am to catch a plane, but if i had more time (and maybe i will later), I can show you some very promosing research regarding significant correlation between alcohol and substance misuse. Tie those physiological findings with a nice psychiatric combination of depression (usual for people in chronic pain... blah blah) and addictive personality issues, and bam.. you have yourself a dangerous addict. Anywhoo...i co-authored a paper that looked at this issue and is coming out in the Winter issue of the JMLE... anyway.. i'm sure there are differing opinions... and just my personal opinion.. i've been shadowing docs who work with chronic pain patients in fairly severe pain and the fact that they have any history of abuse makes them very hesitant to give them drugs. I've seen docs give shots, give a handful of vicodin, but for the most part.. it's a no... especially if they've got a history of addiction.. blah.. anyway.. this issue has been talked to death. g'night

are you a premed? are you trying to lecture a bunch of med students? does anybody else find that extremely annoying? significant promising reasearch regarding the relationship between etoh and substance abuse???? don't bother with the stats, i think we all understand that there is a strong coorelation. same with relaitonships between psychiatric comorbidities and substance use/abuse/dependence. geez.

people in acute, severe pain deserve treatment, regardless of their history of addiction. if you break your leg, i'll write you for narcotics. long term therapy with opioids in pts w/significant history of drug abuse/addiction is tricky. and that's what pain management is for. but don't forget that recovered addicts can still hurt and that they deserve treatment, the same as anyone else. there are good options for these patients; some non-narcotic and some narcotic.

and the fact that suggested APAP for a chronic alcoholic is just crazy. congrats, you just killed your first patient!

 

[UCLA2000]

are you a premed? are you trying to lecture a bunch of med students? does anybody else find that extremely annoying? significant promising reasearch regarding the relationship between etoh and substance abuse???? don't bother with the stats, i think we all understand that there is a strong coorelation. same with relaitonships between psychiatric comorbidities and substance use/abuse/dependence. geez.

people in acute, severe pain deserve treatment, regardless of their history of addiction. if you break your leg, i'll write you for narcotics. long term therapy with opioids in pts w/significant history of drug abuse/addiction is tricky. and that's what pain management is for. but don't forget that recovered addicts can still hurt and that they deserve treatment, the same as anyone else. there are good options for these patients; some non-narcotic and some narcotic.

and the fact that suggested APAP for a chronic alcoholic is just crazy. congrats, you just killed your first patient!

1. Although I'm not 100% sure, I believe that AGAG is a med student.
2. In her defense the op was very vague and never stated the duration of tx of the alcoholic for pain, or even the location/severity of the pain for that matter.

I think that most of us were working under the assumption that the alcoholic pt was presenting to the ed and being tx episodically for acute pain.

If that were the case then AGAG's lecture on the predisposition of ppl c etoh abuse to abuse narcotics would be completely irrelevant, as would the paper that she authored. In that situation I would agree with you 100% regarding the use of narcotics to tx the patient's pain. Unless of course the pt had a hx of narcotic abuse!

However, if we were discussing long term treatment then all of the things which AGAG mentioned become very important. However, I don't think that anyone was really trying to dispute that.

 

[dynx]

and what exactly was my mistake?

Here is a hint for third year. If your in the Burn unit at the med center the correct answer to this question is Budwieser.

 

[rtmcad2319]

I would recommend a program where he can SEE hes got problem for Sure, ciao

 

[Purifyer]

WhenＩread the Original post I thought this was a trick question regarding opiates and sphincter of oddi spasm (with the alcoholic keyword suggesting pancreatitis or something as a possible cause).

Meh. Completely off topic but I find it interesting as to whether opiates cause sphincter spasm or not. I think it's one of those 'classic' medical anecdotes that someone wrote in a textbook 50 years ago but which has little basis in reality.

 

[Jamezuva]

WhenＩread the Original post I thought this was a trick question regarding opiates and sphincter of oddi spasm (with the alcoholic keyword suggesting pancreatitis or something as a possible cause).

Meh. Completely off topic but I find it interesting as to whether opiates cause sphincter spasm or not. I think it's one of those 'classic' medical anecdotes that someone wrote in a textbook 50 years ago but which has little basis in reality.

Sphincter of Oddii spasm from morphine in the setting of pancreatitis is old dogma and is considered bogus nowadays. We routinely give MSO4 to our pancreatitis patients and they do fine. Demerol is a horrible narcotic and pretty much should never be used.

 

[PreMedAdAG]

1. Although I'm not 100% sure, I believe that AGAG is a med student.
2. In her defense the op was very vague and never stated the duration of tx of the alcoholic for pain, or even the location/severity of the pain for that matter.

I think that most of us were working under the assumption that the alcoholic pt was presenting to the ed and being tx episodically for acute pain.

If that were the case then AGAG's lecture on the predisposition of ppl c etoh abuse to abuse narcotics would be completely irrelevant, as would the paper that she authored. In that situation I would agree with you 100% regarding the use of narcotics to tx the patient's pain. Unless of course the pt had a hx of narcotic abuse!

However, if we were discussing long term treatment then all of the things which AGAG mentioned become very important. However, I don't think that anyone was really trying to dispute that.

So ya, been away a while, so here's my deal. Yes I am a medical student.. i've just been on SDN for a few years and my original name was from when i was an undergrad 2.5 years ago.... and no i'm not trying to lecture anyone, I am simply sharing my opinion. In all fairness I have learned a great deal (granted taken with a grain of salt) about other drug interactions, other options from some of the older students (which is why I began posting on here in the first place... to rack my brain) Anyway, I'm sure I was straying from the original question because we weren't given that much information. I am not a fan of drugs, probably never will be unless they're necessary, so I'm a little conservative when it comes to pain killers (except for people in severe pain... ie cancer patients, chronic pain patients that comply with their contract, and acute pain due to trauma or sickle cell crisis, etc.). I just wanted to bring up the point that drug distribution of this sort is fairly dangerous in an addicted population. I agree that most people will NOT get addicted... however, I still don't know if this alcoholic patient the OP was talking about will be on chronic management or what exactly the details are. I also agree that UCLA brings up an awesome point. We are just running our brains here, working out "fake" cases online. As sad as it may be, it can be a great way of getting thoughts out. I just thought we would be a little more collaborative at this point vs. ripping each other's heads off for having differing opinions. There's no need to make fun of others or bash what people are saying...we're all trying to work out an issue... so wow.. please chill

 

[UCLA2000]

I just thought we would be a little more collaborative at this point

I'd "collaborate" with you any day cutie

 

[Gyark]

Interesting question.

I recently read on article on using some of the older antidepressants like elavil, trazodone, etc in conjunction with low dose NSAIDs or acetaminophen for chronic pain. I know there is something to this serotonin thing as drugs like tramadol offer pain relief and work by a similar mechanism.

Anyone know or read anything further about this? Obviously we all agree that a drugless option would be best, but there might be some alternatives out there that haven't been considered yet, and might avoid the use of narcotics.

 

[chef_NU]

Shove a banana down his/her mouth and up his/her rectum to quickly absorb K+ from both ends.

I started crying when i read this. LOL!

 

[Obedeli]

It is truly amazing how such intelligent people can bicker over the most petty things. For crying out loud, all this fuss about Tylenol?! I don't know why I hopped on this thread but I can see the limits of medical school pharmacology and pathology being stretched to their limits. All the way to the point of people taking a stand against Tylenol. Crazy. Having cared for many liver patients (as an M.D. not an MS) let me share some thoughts.
Where is the pain, how long, etc, etc. All the good history questions. Before you can recommend a treatment, you must have a differential dx. You can only get this by knowing more about it. If we are talking about abdominal pain (original poster did not even specify where the pain is...nice), then obviously pancreatitis is a concern, in which case IV morphine with a PCA (no basal, minimal demand) can be titrated for relief. Psueodocyst rupture, acute hepatitis, budd chiari syndrome, gastritis, GERD, MI, pancreatic cancer, hepatocellular carcinoma, cholecystitis can all also be considered.
Tylenol can be given to liver patients in minimal doses. But that is not the point of this thread.