What conditions do you (generally) refuse to give narcotics for?

[Angry Birds]

I'm getting so sick of drug-seekers. I've started to become more and more stringent about it.

What conditions do you (generally) refuse to give narcotics for?

Here are a few for me:

1) Headaches.

2) Chest pain, r/o ACS.

3) I never give narcotic refills or anything like that. Or, "Vicodin is not working for me, can I get Percocet?" I can't believe some ER docs oblige this sort of thing, "to get them to their next appointment," which is always "just a few days away."

4) I'm tempted to add toothache to the list. I have two siblings that are dentists, and they both say they never give narcotics to their patients for toothache, and they question why I routinely do. I think I may just switch to NSAID's and offering dental blocks, but the problem with this is that it is much more time-consuming. Your thoughts?

What else, and why?

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[dotcb]

I separate - in the ED...
from - prescription to go home...

No opiate Rx for:
abdominal pain
rashes
arthritis

 

[deleted547339]

I write narcs for malignant pain and traumatic injury.....very little else.

 

[goodoldalky]

Because my state requires triplicates for schedule 2s, I write narcotics for CT proven kidney stones and fractures. Occasionally a cancer patient in unusual circumstances, out of town without access to their PCP or a new bony met. That's pretty much it.

 

[Angry Birds]

Holy crap, that's amazing. How do ya all get away without giving narcotics except for these few conditions? Tips?

 

[Rendar5]

If you don't really care about someone's pain, you can do pretty much anything. Narcotic pain relievers do serve an important purpose though in abdominal or flank pain, and they really are needed. If you think someone's drug seeking of course don't give it. But I don't think you really can apply a hard and fast rule for most issues. Undifferentiated BS abdominal pain. Don't give it. Gallstones? Hell yeah give some.

That said I have never prescribed them for headaches or chest pain unless you're counting rib fractures. And I've told people that are out of luck if they are looking for a refill, or just to get to the next appointment. That is against department policy, and I don't feel like getting arrested in Florida for being accused of over prescribing them

 

[deleted245139]

Swear I heard it on here (sorry, don't know who deserves credit), but for dental pain I've adopted the dental block barganing chip... If you don't let me block you, no narc. If I block and the pain is still bad (case by case), I'll add to it. Has worked very well so far

 

[goodoldalky]

Holy crap, that's amazing. How do ya all get away without giving narcotics except for these few conditions? Tips?

It started off statewide as a discussion about how the law had changed and generally I would say something along the lines of my not being allowed to prescribe your percocet from the emergency department because of the new law. This of course is not really the case, I can prescribe narcotics for whatever I want as long as it is triplicate.

After about 3-4 months it became so ubiquitous across the state that no patient ever really questioned nor asked for narcotic scripts to go home with, probably because it has become exceedingly rare. They all get tramadol or tylenol #3. Pharmacies had run out of tylenol #3 for a period of time shortly after the legislation was passed. Our ED walk in traffic did decrease significantly (but not the number of admissions). I think this was probably a direct result and it has been sustained.

Now I will say that I was coming from another state where I don't think I ever once prescribed codeine or ultram for pain, they really aren't that effective, and my practice was to give narcotics for almost any undifferentiated pain complaint that seemed legitimate. And initially I was very much opposed to this legislation trying to make it more difficult for me to practice the way I was accustomed to. However, having been through it and seeing the full impact, I am now in favor and convinced it is a good thing. I never have to have a conversation about how a drug seeker is not getting narcotics to go home with.

Edit: We also have a department chronic pain policy which supports the no-narcotic policy and this is also an important piece.

 

[The White Coat Investor]

If you don't really care about someone's pain, you can do pretty much anything.

Exactly. Some fairly extreme positions in this thread. I don't find deciding who to give drugs to and who not to give drugs to all that hard. If I consider giving pain meds, I look at the state database. If it looks concerning, we have the narcotic talk. If it doesn't, and if the patient says ibuprofen/tylenol/toradol etc isn't working, then I use a narcotic. The only severely painful complaint I rarely treat with narcotics is non-traumatic headaches. # 1 because I usually don't need them, # 2 because those who say the other stuff doesn't work usually got the narcotic talk at the initial encounter. It's very rare that someone who says the other stuff doesn't work or has allergies to ibuprofen, toradol, benadryl, phenergan, and tylenol doesn't have a concerning database record, and it's usually because they didn't check in with ID or have a name change recently.

I guess I'm not all that worried about a patient who has only had 10 Norcos in the last year. And it's easy to deal with the person who has had 8,000 pills this year. I guess it's the "gray" patient that's tough to deal with. You know, the person with 8 scripts from 6 docs in the last year for 150 total pills and a sprain who says ibuprofen isn't cutting it.

 

[GeneralVeers]

I'd add non-traumatic back pain to the list. Evidence shows that narcs and muscle relaxers have no impact on non-traumatic back pain. Back pain is improved with NSAIDS and physical therapy.

 

[deleted109597]

I don't use narcotics for much, not because I don't believe the people don't have pain, but because narcotics don't add much over non-narcotics.
We finally passed the line where more people die from narcotics than from MVCs last year. And while we may not be the ultimate cause, plenty of people become addicted to narcotics because we prescribe them for some non-emergent, non-traumatic cause.
If it helps you sleep at night giving them, by all means do it. I sleep better at night not giving them.

 

[Tenk]

In the ED: I'm ok with pretty much anything except most headaches, pregnant patients, and kids (unless trauma for these).

Scripts: usually only for fractures, stones, post op, cancer, and lastly but most importantly: I messed something up and I want you to like me.

 

[Old_Mil]

pgy1: Narcs to people who appear to be in pain.
pgy2: Narcs for fractures.
pgy3: Narcs for open fractures.

I kid.

Sort of.

 

[The White Coat Investor]

In the ED: I'm ok with pretty much anything except most headaches, pregnant patients, and kids (unless trauma for these).

Scripts: usually only for fractures, stones, post op, cancer, and lastly but most importantly: I messed something up and I want you to like me.

Give me a break. You don't give narcs for any of the following conditions?

Appendicitis
Diverticulitis
Perforated viscous
Aortic dissection
Cholecystitis
Pneumo/hemothorax with chest tube
Liver laceration
Splenic laceration
Renal laceration
ACS
Miscarriage
Ectopic pregnancy
Ovarian torsion
Testicular torsion
PID
Orchitis
Fournier's Gangrene
Compartment syndrome
Necrotizing fasciitis
Severe cellulitis
Large facial abscess
Corneal abrasion
Perforated globe
Meningitis

Should I go on? Get off your high horse people. I use narcotics when they're indicated and I bet you do too. Sure, it's probably not the best thing for fibromyalgia and flakey pelvic pain and low back pain x months with zero findings on imaging or exam, but come on.

 

[southerndoc]

I guess I'm not all that worried about a patient who has only had 10 Norcos in the last year. And it's easy to deal with the person who has had 8,000 pills this year. I guess it's the "gray" patient that's tough to deal with. You know, the person with 8 scripts from 6 docs in the last year for 150 total pills and a sprain who says ibuprofen isn't cutting it.

Unfortunately, many ER physicians don't have the time to search for every patient's controlled substance history before prescribing controlled substances. Usually I try my best, but sometimes time doesn't allow me to do so. This should be interesting when phase II of the state databases gets implemented (if it's implemented): requirement to check the database before any controlled substance prescription.

Back in June I busted a chronic abdominal pain patient. She presented with the "worst abdominal pain she's ever had." I started ordering labs, CT, etc. I happened to look her up in the database to find that she had 677 (yes, that is correct) schedule II's (mainly hydrocodone and oxycodone 5-10 mg, but also some hydromorphone 4 mg tablets) filled in a 74-day period. She was hopping from ER to ER getting multiple prescriptions each day. When I told her I wasn't giving her any controlled substances, she eloped. There's no telling how many CT's this poor lady has had.

 

[winkleweizen]

.

 

[winkleweizen]

Give me a break. You don't give narcs for any of the following conditions?

Appendicitis
Diverticulitis
Perforated viscous
Aortic dissection
Cholecystitis
Pneumo/hemothorax with chest tube
Liver laceration
Splenic laceration
Renal laceration
ACS
Miscarriage
Ectopic pregnancy
Ovarian torsion
Testicular torsion
PID
Orchitis
Fournier's Gangrene
Compartment syndrome
Necrotizing fasciitis
Severe cellulitis
Large facial abscess
Corneal abrasion
Perforated globe
Meningitis

Should I go on? Get off your high horse people. I use narcotics when they're indicated and I bet you do too. Sure, it's probably not the best thing for fibromyalgia and flakey pelvic pain and low back pain x months with zero findings on imaging or exam, but come on.

To be fair, I don't think he's discharging many patients with meningitis or aortic dissections.

 

[deleted109597]

To be fair, I don't think he's discharging many patients with meningitis or aortic dissections.

Agree. I was implying at discharge.


And no, I don't give narcotics for corneal abrasions. Topical anesthetics is all they need anyway. And I absolutely don't give it for ACS.

 

[The White Coat Investor]

I saw those papers on topical anesthetics supposedly now being okay. Then I heard some more horror anecdotes. Have you had any trouble with the practice?

What's the issue with morphine in ACS? At least it used to be standard care- remember MONA- morphine, oxygen, nitro, ASA? Did I miss a major paper somewhere saying we shouldn't be doing this?

 

[WilcoWorld]

In the ED: I'm ok with pretty much anything except most headaches, pregnant patients, and kids (unless trauma for these).

Scripts: usually only for fractures, stones, post op, cancer, and lastly but most importantly: I messed something up and I want you to like me.

Narcotics are actually pretty safe in pregnancy when used responsibly.

 

[WilcoWorld]

I saw those papers on topical anesthetics supposedly now being okay. Then I heard some more horror anecdotes. Have you had any trouble with the practice?

What's the issue with morphine in ACS? At least it used to be standard care- remember MONA- morphine, oxygen, nitro, ASA? Did I miss a major paper somewhere saying we shouldn't be doing this?

Morphine in ACS has been found to correlate with higher mortality.

That being said, I don't think chest pain rule-outs are the patients we really need to be talking about here.

 

[goodoldalky]

Morphine in ACS has been found to correlate with higher mortality.

That being said, I don't think chest pain rule-outs are the patients we really need to be talking about here.

I believe this is correlated with the nausea and vomiting that can accompany IV narcotics that result in aspirin and plavix in an emesis basin. I don't hesitate to use morphine if nitro doesn't cut it but I do give an antiemetic with it.

As far as WCI's post above, like the other poster I give plenty of narcotics to patients with that above list of very legitimate complaints. My opinion is that all physicians (EM is not alone in this and imo a minority of the overall problem) prescribe too many outpatient narcotics for chronic or undifferentiated pain complaints. I understand physicians will also take offense to that comment. This is with full disclosure that I believe I was one of those that was too liberal with outpatient narcotics previously.

 

[GeneralVeers]

Interesting how MONA has fallen out of favor:

M - morphine demonstrates higher mortality (causation or correlation?)
O- Oxygen has shown higher morbidity and mortality in STEMI
N - No mortality benefit demonstrated versus not using
A - aspirin is the only thing left with improvement in outcomes.

 

[The White Coat Investor]

Now you're not supposed to use oxygen either? What the heck is wrong with some oxygen? That makes zero sense.

 

[The White Coat Investor]

Morphine in ACS has been found to correlate with higher mortality.

That being said, I don't think chest pain rule-outs are the patients we really need to be talking about here.

That paper is retrospective. Perhaps the patients with more severe pain (and thus more likely to get morphine) did worse. Correlation is not causation. Maybe that explains the oxygen too. Plus the confidence intervals overlap. I don't think I'm going to change my practice based on that. I think they did come to the most appropriate conclusion though:

This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.

 

[WilcoWorld]

That paper is retrospective. Perhaps the patients with more severe pain (and thus more likely to get morphine) did worse. Correlation is not causation. Maybe that explains the oxygen too. Plus the confidence intervals overlap. I don't think I'm going to change my practice based on that. I think they did come to the most appropriate conclusion though:

This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.

I agree on all counts. I didn't intend to suggest that narcotics should never be used in ACS. I still use them when I can't get the patient's pain under control with nitro. I was simply replying to your question asking if you'd missed a paper addressing this issue - here's one, imperfect though it undoubtedly is.

 

[deleted109597]

Now you're not supposed to use oxygen either? What the heck is wrong with some oxygen? That makes zero sense.

Well, the same reason therapeutic normothermia works after ROSC. Prevents inflammatory mediators. Now, if they're hypoxic, give oxygen, but anything above 92% and you're doing more harm that good. Damn those studies interfering with the homeopathy we do based on history and not science.

I believe this is correlated with the nausea and vomiting that can accompany IV narcotics that result in aspirin and plavix in an emesis basin. I don't hesitate to use morphine if nitro doesn't cut it but I do give an antiemetic with it.

And it doesn't help...
http://www.medscape.com/viewarticle/754372

 

[DocEspana]

Now you're not supposed to use oxygen either? What the heck is wrong with some oxygen? That makes zero sense.

Its a carry over from pretty much every study showing prolonged exposure to high FiO2 without hypoxia (which is a damn good reason to give it) leads to worse outcomes for anyone when you track long term outcomes. Its not MI specific, but I imagine there was some MI-specific literature. Its really a general move against giving hi FiO2 to anyone with good saturations, especially if they may have chronic cariopulmonary issues coming their way and small amounts of additional free radical damage can translate to small but appreciable functional outcome differences down the line.

 

[Tenk]

Give me a break. You don't give narcs for any of the following conditions?

Appendicitis
Diverticulitis
Perforated viscous
Aortic dissection
Cholecystitis
Pneumo/hemothorax with chest tube
Liver laceration
Splenic laceration
Renal laceration
ACS
Miscarriage
Ectopic pregnancy
Ovarian torsion
Testicular torsion
PID
Orchitis
Fournier's Gangrene
Compartment syndrome
Necrotizing fasciitis
Severe cellulitis
Large facial abscess
Corneal abrasion
Perforated globe
Meningitis

Should I go on? Get off your high horse people. I use narcotics when they're indicated and I bet you do too. Sure, it's probably not the best thing for fibromyalgia and flakey pelvic pain and low back pain x months with zero findings on imaging or exam, but come on.

I wrote I was ok with anything in the ED. I would narc all that **** to kingdom come. Their pain would be a -5 when I was done with them. The dilaudid coupon never expires baby.

Of all those things, though, I would only send a corneal abrasion, orchitis, PID home. I guess you are right, I do prescribe narcotics for these things I guess? So those three would be on the script list (sometimes). I missed those, my bad.

If you're saying a pregnant or pediatric patient for all that crap came into the department well yeah I'm going to give narcotics too. I was talking more common things. I'd ask you when the last time you saw a pregnant patient come into your department with a dissection or meningitis but I'm at work right now and that would be the next thing that would walk through my door...

 

[DrDrummer]

Its a carry over from pretty much every study showing prolonged exposure to high FiO2 without hypoxia (which is a damn good reason to give it) leads to worse outcomes for anyone when you track long term outcomes. Its not MI specific, but I imagine there was some MI-specific literature. Its really a general move against giving hi FiO2 to anyone with good saturations, especially if they may have chronic cariopulmonary issues coming their way and small amounts of additional free radical damage can translate to small but appreciable functional outcome differences down the line.

And now the AVOID trial, and soon more data from a Scandinavian study which should be studied to evaluate mortality differences.

I think eventually we'll have data to show transient hypoxemia in the form of remote ischemic conditioning improves outcomes-- it's always interesting to see how counter-intuitive things can be.

 

[Angry Birds]

I had a shift since this thread, and I can safely say that some of the earlier input was, in my mind, clearly unrealistic.

I'm giving narcotics to who I think is actually in pain and doesn't abuse narcotics. I guess my fear is that I am subconsciously profiling patients (socially and, even more concerningly, probably racially?).

 

[The White Coat Investor]

Its a carry over from pretty much every study showing prolonged exposure to high FiO2 without hypoxia (which is a damn good reason to give it) leads to worse outcomes for anyone when you track long term outcomes. Its not MI specific, but I imagine there was some MI-specific literature. Its really a general move against giving hi FiO2 to anyone with good saturations, especially if they may have chronic cariopulmonary issues coming their way and small amounts of additional free radical damage can translate to small but appreciable functional outcome differences down the line.

I guess I have a hard time buying that putting them on 2L by NC and raising their sats from 92% to 96% is actually causing harm. Sure, if you intubate them and leave them on 100% O2 for hours. Might not help (would require a massive study to prove it) but probably wouldn't hurt.

 

[deleted109597]

I guess I have a hard time buying that putting them on 2L by NC and raising their sats from 92% to 96% is actually causing harm. Sure, if you intubate them and leave them on 100% O2 for hours. Might not help (would require a massive study to prove it) but probably wouldn't hurt.

Do you believe that therapeutic normothermia helps? I mean, how different is 36C from 38C?

 

[The White Coat Investor]

Do you believe that therapeutic normothermia helps? I mean, how different is 36C from 38C?

Next you're going to tell me that 99.2 isn't a fever!

 

[deleted547339]

That paper is retrospective. Perhaps the patients with more severe pain (and thus more likely to get morphine) did worse. Correlation is not causation. Maybe that explains the oxygen too. Plus the confidence intervals overlap. I don't think I'm going to change my practice based on that. I think they did come to the most appropriate conclusion though:

This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.

There's literature to suggest that morphine induces platelet aggregation.

 

[GeneralVeers]

If I go in the room, and you are smiling, laughing, texting or talking on your cell phone, or generally displaying no signs of distress then I am not giving you narcotics.

 

[TheBlueBlazer]

I tend to be fairly liberal up front with opiates but generally try to run them as 50cc drips rather than pushes and if you're going to argue, no soup for you. But non-traumatic headaches are a non-starter and if nothing else is working, well then you're getting an LP. Absolutely no Rx for opiates for abdominal pain without a diagnosis. I'll do a short course for back pain in normal community dwellers without red flags only because I've been there, and the pain was worse than when I broke the hell out of my arm. Also, you would be amazed at the wonders a shot of dexamethasone will do for someone with increased cancer pain, so keep that in your toolbox

 

[southerndoc]

I guess I have a hard time buying that putting them on 2L by NC and raising their sats from 92% to 96% is actually causing harm. Sure, if you intubate them and leave them on 100% O2 for hours. Might not help (would require a massive study to prove it) but probably wouldn't hurt.

It increases free oxygen radicals which cause further damage to tissue when blood flow is restored. The same phenomenon is seen with stroke patients who get TPA/endovascular treatment and are on supplemental oxygen.

O2 sats of 92% are normal. I know we all just want to do something, but somethings less is more. If you think it's hard for an ER doc to grasp this, try to give this talk to a paramedic. It's taken me 10 years to get paramedics to stop putting every dyspneic patient on a non-rebreather.

 

[GeneralVeers]

It increases free oxygen radicals which cause further damage to tissue when blood flow is restored. The same phenomenon is seen with stroke patients who get TPA/endovascular treatment and are on supplemental oxygen.

O2 sats of 92% are normal. I know we all just want to do something, but somethings less is more. If you think it's hard for an ER doc to grasp this, try to give this talk to a paramedic. It's taken me 10 years to get paramedics to stop putting every dyspneic patient on a non-rebreather.

Correct. I've been educating my nurses about this with some success. If it's clearly ACS or CVA, then I remove the oxygen from them. All others I just let the nurses put O2 on them, as it's not worth my time fighting the nurses and explaining my reasoning.

 

[Angry Birds]

It increases free oxygen radicals which cause further damage to tissue when blood flow is restored. The same phenomenon is seen with stroke patients who get TPA/endovascular treatment and are on supplemental oxygen.

O2 sats of 92% are normal. I know we all just want to do something, but somethings less is more. If you think it's hard for an ER doc to grasp this, try to give this talk to a paramedic. It's taken me 10 years to get paramedics to stop putting every dyspneic patient on a non-rebreather.

I've been having a bear of a time explaining to RT's that you shouldn't give passive oxygenation with a BVM but with a non-rebreather. But, without fail, they always just put the BVM mask over their face and just let it sit there, without bagging.

 

[deleted109597]

Correct. I've been educating my nurses about this with some success. If it's clearly ACS or CVA, then I remove the oxygen from them. All others I just let the nurses put O2 on them, as it's not worth my time fighting the nurses and explaining my reasoning.

Mine put it on for "anemia" even if the patient is sat'ing 100%. Explaining that we don't use extra oxygen that is in the plasma is met with blank stares. ****ing patient advocates. And all of them are going for their NP to practice ****ty medicine independently in terrible states.