New Record for Narcotic Dosage

[The White Coat Investor]

I had a new record for me today, documented on the state controlled substance database and all coming from one clinic. It was only 9000 something pills, which isn't my record, but the fact that almost all of them are oxycodone 30s was.

His daily dose of oxycodone? 1920 mg. That's right, 60 grams a month, all from one provider. Insanity. Not too bad for a young guy that's never been in an IED explosion or some similar event. Where's your pain? Mostly my neck and abdomen, but all over really. Insanity.

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[shoal]

holy crap.... hows his gut even working

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[WilcoWorld]

Did you report this clinic to your state medical board?

I didn't used to be one for pointing fingers, but this crisis is pushing me in that direction.

 

[WilcoWorld]

holy crap.... hows his gut even working

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He's probably selling most of them.

 

[Perrin]

Saw a pt a year ago who was prescribed;
Hydromorphone 8mg 3-4 tabs q4-6 hrs, dispo 960 tabs.

That's 196 mg a day!

She also had bottles of oxycodone and something else that I can't remember, each with similar dosings.

She flew across the country every 3 months to a doc in California that was the "only doc who can control my chronic headaches." Her mom brought her to the ED for her typical headache that night. I told her that there wasn't anything I could short of sedating and intubating her. Surprisingly, they didn't seem upset when I just discharged her.

 

[DarkHorse22]

holy crap.... hows his gut even working

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Sounds like a job for Relistor! The latest ridiculous medication to put ads on tv.

 

[Tenk]

His pain spans all known time and dimensions like Doctor Sam Beckett from Quantum Leap.

 

[PlutoBoy]

I had a patient walk in the clinic with a pump that was giving her around 200 mg of morphine plus prn boluses for her chronic pain (TM)

 

[Psai]

Saw a pt a year ago who was prescribed;
Hydromorphone 8mg 3-4 tabs q4-6 hrs, dispo 960 tabs.

That's 196 mg a day!

She also had bottles of oxycodone and something else that I can't remember, each with similar dosings.

She flew across the country every 3 months to a doc in California that was the "only doc who can control my chronic headaches." Her mom brought her to the ED for her typical headache that night. I told her that there wasn't anything I could short of sedating and intubating her. Surprisingly, they didn't seem upset when I just discharged her.

Sickler?

 

[Perrin]

Sickler?

Nope. Just a 30 something female with chronic headaches.

 

[deleted547339]

Nope. Just a 30 something female with chronic headaches.

Please tell me you reported that to the medical board...

 

[alpinism]

He's probably selling most of them.

Bingo. We have a winner.

 

[Old Grunt]

"You are not in pain. You are just depressed and self medicating that with pill form opium."

<Press Ganey Scores Plummet>

 

[canigetawhatwhat]

I had a patient with an intrathecal dilaudid pump.

For fibro.

Came in with decreased level of consciousness.

Got narcan.


Man that patient was FURIOUS

 

[GeneralVeers]

I had a patient with an intrathecal dilaudid pump.

This is not a thing that has any reason to exist.

 

[deleted547339]

This is not a thing that has any reason to exist.

Did you not hear him say the patient had FIBROMYALGIA!?!? Of course there's a reason!

 

[Psai]

Did you not hear him say the patient had FIBROMYALGIA!?!? Of course there's a reason!

It's stage 4!

 

[deleted547339]

This is not a thing that has any reason to exist.

@Birdstrike - Thoughts?

 

[MSmentor018]

It's stage 4!

actually end-stage with frequent episodes of fibrostorms

 

[Perrin]

Please tell me you reported that to the medical board...

It didn't really occur to me to do that. I looked up his bio and he did seem to be some sort of headache specialist. I was more shocked at the 40k street value of drugs she was carrying around.

 

[txpharmguy]

Had a lady come the pharmacy many years ago. She was taking 1320 methadone 10mg per month and 360 oxycodone 30mg.per per month

 

[deleted547339]

Had a lady come the pharmacy many years ago. She was taking 1320 methadone 10mg per month and 360 oxycodone 30mg.per per month

That methadone dosing doesn't even make sense. Methadone is long acting and comes in higher than 10mg tabs. The only explanation for that is selling it on the street. 40+ pills a day? Come on...

 

[GeneralVeers]

I don't even know methadone dosing. I won't prescribe it. My eyes glaze over and I start thinking about vacation when patients start rambling about their chronic pain, and narcotic dosing schedules.

 

[txpharmguy]

That methadone dosing doesn't even make sense. Methadone is long acting and comes in higher than 10mg tabs. The only explanation for that is selling it on the street. 40+ pills a day? Come on...

That's what I said. 40 mg tabs are for detox only and can't be dispensed in Texas "for pain"

 

[goodoldalky]

I had some guy with chronic pain nonsense on intranasal ketamine q 2 prn. In addition to more dilaudid and oxycodone than I cared to add up. That's thriller killer territory... Still not sure if that's legal

 

[Arcan57]

This is not a thing that has any reason to exist.

The problem with them is when they malfunction or run dry you're mostly hosed. I had a patient that had just moved and didn't want to travel the 30miles to see their original pain doc. Their pump was about to run out and they wanted a refill. The ED was slow so I actually called one of our pain guys who came and saw him with a plan to write a taper to get him through. That got scrapped when the equivalent PO dose was in the 500mg hydrocodone q6 range.

 

[canigetawhatwhat]

I had some guy with chronic pain nonsense on intranasal ketamine q 2 prn. In addition to more dilaudid and oxycodone than I cared to add up. That's thriller killer territory... Still not sure if that's legal

The problem with them is when they malfunction or run dry you're mostly hosed. I had a patient that had just moved and didn't want to travel the 30miles to see their original pain doc. Their pump was about to run out and they wanted a refill. The ED was slow so I actually called one of our pain guys who came and saw him with a plan to write a taper to get him through. That got scrapped when the equivalent PO dose was in the 500mg hydrocodone q6 range.

This is a great time for the "narcotic withdrawal is not life threatening" talk lolololol

 

[BoardingDoc]

The problem with them is when they malfunction or run dry you're mostly hosed. I had a patient that had just moved and didn't want to travel the 30miles to see their original pain doc.

I still can't believe that these things exist. That said, in your case I'd explain very quickly that you don't have the ability to refill the meds or provide an alternative and so the best thing you could do was discharge him quickly and have him drive the 30-45 minutes to his pain clinic.

 

[RustedFox]

I don't even know methadone dosing. I won't prescribe it. My eyes glaze over and I start thinking about vacation when patients start rambling about their chronic pain, and narcotic dosing schedules.

+1. Grand Teton, here I come.

 

[Birdstrike]

@Birdstrike - Thoughts?

Intrathecal opiate pumps for end of life/cancer pain: Very legit

Intrathecal pump using baclofen for spasticity/stroke/MS/neuromuscular disease: very legit

Intrathecal opiate pumps for chronic non-cancer pain: More harm than good, in my opinion.

 

[MSmentor018]

+1. Grand Teton, here I come.

totally worth going.....as they're babbling think of a nice long week vacation

 

[deleted547339]

Intrathecal opiate pumps for end of life/cancer pain: Very legit

Intrathecal pump using baclofen for spasticity/stroke/MS/neuromuscular disease: very legit

Intrathecal opiate pumps for chronic non-cancer pain: More harm than good, in my opinion.

Figured. Thanks for the input.

 

[Birdstrike]

Figured. Thanks for the input.

Personally, I don't put IT pumps in anyone, though I had plenty experience in fellowship. Reason (the short version): They're a nightmare.

 

[deleted547339]

Personally, I don't put IT pumps in anyone, though I had plenty experience in fellowship. Reason (the short version): They're a nightmare.

So if you have a patient you think would be a good candidate, do you refer them to one of your colleagues, or manage their pain through other modalities? Is an intrathecal pump ever the best or only option?

 

[Birdstrike]

So if you have a patient you think would be a good candidate, do you refer them to one of your colleagues, or manage their pain through other modalities? Is an intrathecal pump ever the best or only option?

I rarely if ever, refer anyone for an intrathecal pump. I tend to see mostly chronic non-cancer pain patients who aren't good candidates for IT pump, in my opinion. If I did have someone who's a good candidate (end of life pain or spasticity patient needing IT baclofen) then, yes, I'd refer them out to someone to place it.

Pumps are just an expensive, and hi-tech way, to get ultra-high doses of opiates in patients. My philosophy (in general, there are exceptions) is that the lower the opiate dose, the better, in chronic non-cancer pain, with the preferred dose being ZERO. There are exceptions, of course, and there is a legacy generation of people on opiates, that have to be dealt with, however, in general, "less is more," when it comes to opiates. How anyone could spend 10 years in EDs, like I have, and feel otherwise would be hard to understand. Unfortunately, often reality intervenes and so many patients are already on opiates, not abusing them and doing reasonable well, so sometimes I continue them, but with a very, very, high bar to get over to be on them and stay on them. In 4 years as a Pain physician (post EM career) I've started, maybe, 5 total patients on opiates, with most of those being cancer patients or over age 75. On the other hard, I've discontinued, or refused to prescribe to hundreds, maybe thousands who I felt were on them inappropriately by someone else or had some other reason to conclude they carried more harm than benefit.

Another side note on pumps, is that I set up my practice to be outpatient-only, night/weekend/holiday free with no call. Intrathecal pumps mean lots of hospital work, late night calls, and surgeon related headaches. Sorry, but that's just not for me. I have a great work life and I don't want to give it up: Mon through half-Friday, no nights, weekends, holidays or call. Ever. It's amazing. I'm very blessed.