Personal Bests

[ampaphb]

Had a local neurologist retire the other day, and got a number of his patients referred to me for meds.

First one was on Norco 10 2-3 tabs q3h (#500). Next was on Methadone 10mg 5 tabs q3h (#560 q2wks)

---

Members don't see this ad.

 

[Ducttape]

pretty impressive, esp the methadone... the best referrals i have had:

dilaudid 8 mg, 4 pills q 2 hour prn, #1440.

fentanyl 200 mcg/hr, Oxy IR 30 mg q4 hr prn breakthrough (#180), and morphine SQ pump at 30 mg/hr.

 

[Apollyon]

I had a guy in the ED last week who was 9 days off heroin. He had a pretibial abscess that put out more pus than I've ever seen from a cutaneous abscess - about 15mL. I did not suspect that AT ALL from the exam, and even Xray prior didn't show lucency.

Anyways, he was so hyperalgesic that he literally cried. I can't even imagine the opioid hyperalgesia on these people.

 

[lobelsteve]

oxy 30 12 per day for peripheral neuropathy with normal EMG. Care from PCP.

Nothing close what is above.

 

[Yo GabbaPentin]

My first place: in fellowship, had a guy come in who was homeless VA patient. He was wearing 8 100 mcg patches and 3 50 mcg patches for his undiagnosed abdominal pain.

My second place: 40 y/o patient on oxycodone 30 mg four tablets every 3 hours for his post op leg pain from 4 years prior. He said he could really use 6 tabs every 2 or 3 hours as that would really give him his life back. Hadn't worked for 8 years, yet somehow he could afford a brand new 70k vehicle... weird huh?

 

[powermd]

In fellowship I had a guy being treated by heme-onc as an outpatient with a dilaudid PCA hooked up to a PICC delivering 30K MED when combined with some fent patches and liquid roxi. He had a weird abdominal tumor wrapped around the aorta not expected to be lethal any time soon.

We had him admitted and started oral ketamine, tapering him to 3K MED/day over 2 weeks. a slight bump in his roxi at that point led to much better pain control.

 

[deleted185747]

My first place: in fellowship, had a guy come in who was homeless VA patient. He was wearing 8 100 mcg patches and 3 50 mcg patches for his undiagnosed abdominal pain.

My second place: 40 y/o patient on oxycodone 30 mg four tablets every 3 hours for his post op leg pain from 4 years prior. He said he could really use 6 tabs every 2 or 3 hours as that would really give him his life back. Hadn't worked for 8 years, yet somehow he could afford a brand new 70k vehicle... weird huh?

The good old fentanyl vest....

 

[Ducttape]

hes not homeless... that 70K truck is his mobile home...

 

[jonnylingo]

On a different note... saw a 20 something year old guy who was seeing NP, getting Q2 week TPIs into scap stabilizers, 40mg of Depo each, had > 1000 mg in past year alone, and this was going on for 1.5 years.

Had a fat face, buffalo hump, and looked like a zebra throughout thorax. Sent to endocrine to rescue what remained of his adrenals.

 

[lord_jeebus]

When I was an intern I had to admit a patient with FBSS who was on most available opioids. I don't remember the doses anymore but the total was around 10000 MED. It was difficult to determine exactly because he was chugging Roxanol from the bottle without measuring it. Methadone, MS Contin, Oxycontin, Dilaudid, Fentanyl patches, Roxycodone, MSIR, all at ridiculous doses. He also had a PICC line for IV Demerol, which he self-administered 8 times daily. On several muscle relaxants and anticonvulsants and at least 3 different NSAIDs.

He was on a total of 57 medications, which caused the EMR to crash on medication reconciliation.

His PCP yelled at me when I questioned this regimen. The wise pain consultant recommended "discharge ASAP." He was OK with this plan because we took away his jug of liquid morphine.

 

[geauxg8rs]

Fentanyl vest.

I almost fell out of
My chair that was
So funny

 

[geauxg8rs]

Saw a
Patient in the past on 100mg of methadone four times a day. She had the 100mg pills compounded so that she would only have
To take 4 pills
Per day
Rather than 40. She didn't want to
Be
Just chugging pills all day as that would
Cramp her
Style

 

[emd123]

Fentanyl vest.

I almost fell out of
My chair that was
So funny

That's nothing. I can better it:

Fentanyl t u x e d o

Patches from head to toe...

 

[Jcm800]

When I was an intern I had to admit a patient with FBSS who was on most available opioids. I don't remember the doses anymore but the total was around 10000 MED. It was difficult to determine exactly because he was chugging Roxanol from the bottle without measuring it. Methadone, MS Contin, Oxycontin, Dilaudid, Fentanyl patches, Roxycodone, MSIR, all at ridiculous doses. He also had a PICC line for IV Demerol, which he self-administered 8 times daily. On several muscle relaxants and anticonvulsants and at least 3 different NSAIDs.

He was on a total of 57 medications, which caused the EMR to crash on medication reconciliation.

His PCP yelled at me when I questioned this regimen. The wise pain consultant recommended "discharge ASAP." He was OK with this plan because we took away his jug of liquid morphine.

that is amazing,

 

[emd123]

When I was an intern I had to admit a patient with FBSS who was on most available opioids. I don't remember the doses anymore but the total was around 10000 MED. It was difficult to determine exactly because he was chugging Roxanol from the bottle without measuring it. Methadone, MS Contin, Oxycontin, Dilaudid, Fentanyl patches, Roxycodone, MSIR, all at ridiculous doses. He also had a PICC line for IV Demerol, which he self-administered 8 times daily. On several muscle relaxants and anticonvulsants and at least 3 different NSAIDs.

He was on a total of 57 medications, which caused the EMR to crash on medication reconciliation.

His PCP yelled at me when I questioned this regimen. The wise pain consultant recommended "discharge ASAP." He was OK with this plan because we took away his jug of liquid morphine.

That's pharcking unbelievable.

Let me guess, his pain score was still at least 8-10/10 on every visit?

 

[lord_jeebus]

That's pharcking unbelievable.

Let me guess, his pain score was still at least 8-10/10 on every visit?

I only had to deal with him during his hospital stay, but it was always 10/10. The sad thing was that he really looked like someone who was having the worst imaginable pain: diaphoretic, screaming, crying, tachycardic and tachypneic, etc. Not like the "10/10" sickle-cell patients who would be calmly watching TV while enjoying their Dilaudid PCA, which was the more common pain admission from my medicine internship.

 

[emd123]

I only had to deal with him during his hospital stay, but it was always 10/10. The sad thing was that he really looked like someone who was having the worst imaginable pain: diaphoretic, screaming, crying, tachycardic and tachypneic, etc. Not like the "10/10" sickle-cell patients who would be calmly watching TV while enjoying their Dilaudid PCA, which was the more common pain admission from my medicine internship.

At some point that patient was started on opiates, probably on 30-40mg daily morphine equivalent (likely Percocet 5/325 q6hr or hydrocodone 5-10mg q 6 hr) with pain 10/10. Now his dose is 300 times greater and the pain is 10/10. I can see no better example of an opiate trial failure and/or opiate induced hyperalgesia. Yet, "Let's increase the dose a 301st time and see if we get a different result!"

Why have a patient on 10,000 mg of morphine per day at 10/10 pain with the dose risk and side effects when you can have him on zero mg and 10/10 (or less) with no dose risk and no side effects?

 

[lord_jeebus]

At some point that patient was started on opiates, probably on 30-40mg daily morphine equivalent (likely Percocet 5/325 q6hr or hydrocodone 5-10mg q 6 hr) with pain 10/10. Now his dose is 300 times greater and the pain is 10/10. I can see no better example of an opiate trial failure and/or opiate induced hyperalgesia. Yet, "Let's increase the dose a 301st time and see if we get a different result!"

Why have a patient on 10,000 mg of morphine per day at 10/10 pain with the dose risk and side effects when you can have him on zero mg and 10/10 (or less) with no dose risk and no side effects?

Yeah, that's basically what I told his PCP. He told me that I don't understand the nuances of opioid therapy like he does.

I also forgot to mention that he started having seizures after starting the high dose IV Demerol via PICC, but his PCP didn't see a connection there either.

His progression through the medical system was telling. Back pain -> Fusion -> Back and leg pain -> Intrathecal pump -> Infection -> Pump removal and high dose opioids -> Whole body pain

 

[lobelsteve]

Yeah, that's basically what I told his PCP. He told me that I don't understand the nuances of opioid therapy like he does.

I also forgot to mention that he started having seizures after starting the high dose IV Demerol via PICC, but his PCP didn't see a connection there either.

His progression through the medical system was telling. Back pain -> Fusion -> Back and leg pain -> Intrathecal pump -> Infection -> Pump removal and high dose opioids -> Whole body pain

If it were acceptable to society, we could kill the PCP to save the patient.