You Might Be A ...

[group_theory]

You Might Be A Drug Seeker

1. If you've ever asked when Dr. Feelgood works next then you might be a drug seeker

2. If you've walked into the ER limping on your left leg, and leave the ER limping on your right leg then you might be a drug seeker.

3. If you've ever paused the show Trauma: Life in the ER at the exact moment that a doctor is writing a prescription for vicodin to see if you can decipher his DEA number, then you might be a drug seeker.

4. If your urine drug screen lab report came back as positive for Rush Limbaugh, then you might be a drug seeker.

5. If you've ever thrown up right after taking two vicodin and then proceed to pick out of your own vomit said undigested vicodin, then you might be a drug seeker.

6. If your doctor immediately sells his stock in the company that makes vicodin after you declare that you have a problem with vicodin and want treatment, then you probably were a drug seeker.

7. If the nurse over hears you whispering to your 11 year old daughter behind a closed curtain "remember to ask the doctor for some vicodin", then you probably are a drug seeker.

8. If you've ever traded sexual favors with a stranger for 10 vicodin, not only did you get a a bad deal, but you also might be a drug seeker.

9. If your allergy list is over 10 medications long, of which one is toradol, then you might be a drug seeker.

10. If you've ever changed the number 1 on a doctor's prescription to look like a 6, so that you get 60 vicodin instead of 10, then you might be a drug seeker. (This is why you should always write out the number.)

11. If the DEA has your number on speed dial, then you might be a drug seeker.

12. If you've ever stolen your own mom's pain medication for her terminal cancer, then not only are you a low life scum, but you might be a drug seeker.

13. If you are give a prescription for 10 vicodin and then ask "how is this suppose to get me through the day?", then you might be a drug seeker.

14. If you're given 4 mg of dilaudid IV in the ER and are told that you can't drive home, and then you say, "are you kidding me? I don't feel anything", then you might be a drug seeker.

15. If you are asked to rate your pain on a scale of 1 to 10 and you answer 23, then not only are you incapable of following simple directions, but you also may be a drug seeker.

16. If you begin our encounter with "Doc, usually I have a high pain tolerance, but...........", then you are probably a drug seeker.


Stolen from this website: http://www.thedocaroundtheclock.com/dribear/2006/12/you_might_be_a_.html

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[deleted6669]

1.if you are allergic to 2 of dilaudid but not 4 then you might be a drug seeker
2. if you have had 10 complete neg evals for abd pain at 10 different er's in ten days then you might be a drug seeker( I saw this pt last night)
3. if the dilaudid pca pump is maxed out for your chronic, intractable nonmalignant pain secondary to "end stage fibromyalgia" then you have an idiot doctor for admitting you and you are a drug seeker
4. if you are allergic to toradol and all nsaids, all phenothiazines, tylenol, and ultram you are a drug seeker
5. if you have ever used a fentanyl patch as a tea bag you might just be a drug seeker
6. if your dog has ever eaten a months worth of your narcotic you just might be a drug seeker
7. if your narcotics(but not your bp meds) were stolen by some dude on the bus then you and the dude are drug seekers
8. if you drop a months supply of percocet in the toilet 2 months in a row you are a drug seeker
9. if I give you narcan and you wake up and say you don't use drugs then I point out your track marks whereupon you ask me for methadone you just might be a drug seeker
10. if you say you can have percocet but not vicodin because tylenol is bad for your hep c you are a stupid drug seeker

 

[DropkickMurphy]

15. If you are asked to rate your pain on a scale of 1 to 10 and you answer 23, then not only are you incapable of following simple directions, but you also may be a drug seeker.

I guess I might be a drug seeker then....the first time I had kidney stones the doc (a friend of mine) asked me that question to which I replied "100.....just give me ****ing pain meds!"

 

[deleted6669]

if your only answer to the pain scale querstion is always 10/10 regardless of complaint(wart, ankle sprain, sinus pain, splinter in finger, dental pain) you have no clue what real pain is and you are a drug seeker

 

[lucky_deadman]

if you ask that your IV catheter be left in.

if you request a PICC line be inserted and left in for a single dose of pain meds.

 

[CueDoc]

someone told me once they were having pain from their chronic stomach condition... when asked about the condition they stated they were diagnosed with "idiopathic abdominal pain".

 

[beanbean]

I had a r/o seizure pt tell me she had a history of "pseudoseizures" Makes my job easy.

Always nice when people try to leave AMA with their PICC/central line, etc still in....nice access for your next fix.

Had a patient who liked to pour brandy and ice cream into his PEG. I get the brandy, but why the ice cream?

 

[Chronic Student]

1. If you got 240 norco one day and then go back to the same pharmacy the next day to have a scrip filled for 50 lortab and explain to the pharmacist that its for a different kind of pain...

2. If you say that you have 10/10 pain when I wake you up from your nap and you know to ask for fentanyl by name...

3. If you are attacked by two different dogs in the same month and threw out your back... (same guy also broke his foot, fell down the stairs, lost a few scrips and did I mention when I got to the office one day at 6 AM he was waiting outside with another wild story)

4. If you think you need percocet after a carpal tunnel release for post-surgical pain...

5. If you always pay cash for your scrips and use three or more pharmacies...

6. If the pharmacist knows you by name and you are under fifty years old ...

7. If the pharmacist calls me about you...

8. If they always ask for your license at the pharmacy...

9. If you know more pharmacology than your doc...

-Mike

 

[lucky_deadman]

If you know the EPs schedule better than the ED staff does.

If you call ahead to see what doc is working.

If you leave unhappy and immediately check in with a different complaint in hopes of seeing a different doc in another part of the ED.

 

[The White Coat Investor]

16. If you begin our encounter with "Doc, usually I have a high pain tolerance,

This phrase always bothers me. Why do patients think this will affect their evaluation in any way? Even those who aren't seeking like to point out their high pain tolerance. Most of these people are wussies too. It kills me. The high pain tolerance guys are the ones who turn down the pain meds for their kidney stone until you talk them into it because it makes you uncomfortable to watch them writhe.

 

[deleted109597]

If you answer the allergies question with "lots of pain meds, doc."
Also, when asked what has helped in the past, you say "I can't remember, but it starts with a D"

 

[DropkickMurphy]

If you ride your bike up to the EMS station and then do a bad fake limp while holding your back to the door......

 

[vtucci]

I hope I never have anything again that requires pain meds because most docs (myself included with someone else's history) would assume I was drug seeking. My history is like a walking punch-line.

I had gastric bypass surgery this past summer and learned that I am allergic to multiple pain killers (including vicodin and percocet) to the point where I have a bad systemic rash and low grade fever. I am also allergic to a number of other drugs (PCN, ceclor etc) and am somewhat atopic with foods and environmental allergies- lucky me.

Morphine does absolutely nothing for me (or my father and my father's side of the family- pharmacogenetic issue, maybe?), which is why they probably never tried Diluadid either. I really did say I would rather have nothing than morphine (which I actually did for ninety minutes when they ran out of demerol). The only thing that works for intense pain for me or my dad is demerol.

Imagine being in the ER and asking for demerol for intractable pain. I can picture the attendings face now. LOL.

 

[ERMudPhud]

I had a patient the other day ask the nurse to flush the line one more time before removing it to get the last traces of Dilaudid from the line

 

[spyderdoc]

I hope I never have anything again that requires pain meds because most docs (myself included with someone else's history) would assume I was drug seeking. My history is like a walking punch-line.

I had gastric bypass surgery this past summer and learned that I am allergic to multiple pain killers (including vicodin and percocet) to the point where I have a bad systemic rash and low grade fever. I am also allergic to a number of other drugs (PCN, ceclor etc) and am somewhat atopic with foods and environmental allergies- lucky me.

Morphine does absolutely nothing for me (or my father and my father's side of the family- pharmacogenetic issue, maybe?), which is why they probably never tried Diluadid either. I really did say I would rather have nothing than morphine (which I actually did for ninety minutes when they ran out of demerol). The only thing that works for intense pain for me or my dad is demerol.

Imagine being in the ER and asking for demerol for intractable pain. I can picture the attendings face now. LOL.

C'mon man. Demerol, morphine, and all the others work on exactly the same Mu receptor....Must be the ephoric buzz you like...

 

[spyderdoc]

The high pain tolerance guys are the ones who turn down the pain meds for their kidney stone until you talk them into it because it makes you uncomfortable to watch them writhe.

This would be me. I had my first stone last year. My wife was post-call, so I went through about 2 hours of pain before I couldn't take it anymore. I finally woke her up, and she thought I was having a MI since I was pale and had sweat through my clothes. I thought she was gonna have a MI when she saw me....She took me to the ER and my buddy wanted to give me MS and ketorlac. I took the ketorolac, but did not take the MS. My wife veto'ed this and pretty much drugged me up anyhow....I now have a new respect for pts with ureteral colic, that's for sure....At any rate, he gave me 24 Vicodins to go home with, I took 2 on the first day, then only needed ibuprofen to control the pain. I still have 22 Vicodin left. I just don't like taking that stuff. I guess I see what it does to people....

 

[vtucci]

C'mon man. Demerol, morphine, and all the others work on exactly the same Mu receptor....Must be the ephoric buzz you like...

Not according to my pharm professors....there is apparently some variation.

In any event, morphine is supposed to be a strong agonist and demerol is supposed to be a strong agonist. It is not as if it is a comparison between a weaker or intermediate agonist and a strong agonist.

 

[tonem]

Why does everyone with chronic intractable pain always take their last percocet on saturday night when their PCP is on vacation???

Recent exchange:

"Doc I have bad cellulosis and some lady called me and told me my percocet was ready and I should come to the ED to pick it up"

Me: Didn't you tell me when I saw you yesterday (at a different hospital) that you couldnt call your PCP because you didnt have a phone?

 

[deleted6669]

I've had this happen as well. same pt, 2 different facilities in 2 different cities( I work all over), 2 days in a row. same complaint and "it just happened" both days.....

 

[tonem]

I agree with spyderdoc...I think the biggest problem with morphine is that people don't get big enough doses.

 

[The White Coat Investor]

I agree with spyderdoc...I think the biggest problem with morphine is that people don't get big enough doses.

Yea man, if you ain't baggin', they ain't had enough!

 

[The White Coat Investor]

most docs....would assume I was drug seeking.

Yup.

Don't blame us though; blame the 200 drug-seekers with the same story who we've seen before. Let's see...how's that story go again?

gastric bypass surgery

I am allergic to multiple pain killers (including vicodin and percocet)

I am also allergic to a number of other drugs

Morphine does absolutely nothing for me

I would rather have nothing than morphine

The only thing that works for intense pain for me or my dad is demerol.

Yup, that's the one.

Although I suppose it is possible for morphine not to work for you. I had an interesting patient the other day where multiple injections of lidocaine didn't seem to work on them, but a touch of marcaine did.

 

[tonem]

Yea man, if you ain't baggin', they ain't had enough!

Thats what narcan is for....morphine until they stop breathing...touch of narcan...problem solved. They wont be pestering me for demerol.



another quote..."I dont know what its called but it rhymes with Demi Moore."

 

[DropkickMurphy]

Yea man, if you ain't baggin', they ain't had enough!

 

[vtucci]

Yup.

Don't blame us though; blame the 200 drug-seekers with the same story who we've seen before. Let's see...how's that story go again?



Yup, that's the one.

Although I suppose it is possible for morphine not to work for you. I had an interesting patient the other day where multiple injections of lidocaine didn't seem to work on them, but a touch of marcaine did.

I don't blame anyone. I have seen the drug-seeking first hand as an EMT and when I shadowed in the ED.

I just think it is hilarious and hope never to need pain meds for the obvious reason. I find the family trend (on my dad's side) interesting from a scientific perspective. My mom is perfectly fine w/hydrocodone.

Most people think morphine is the strongest pain-killer available and for some, it might be. But for me, aspirin works as well/badly (i.e., not at all-- if the pain is that bad). Maybe it's crazy but I don't see the point in taking something that doesn't work. I just wouldn't relish the conversion.

 

[ERMudPhud]

Morphine does absolutely nothing for me (or my father and my father's side of the family- pharmacogenetic issue, maybe?).

Pharmacogenomics and Opiates a few choice papers

1: Sindrup SH, Brosen K. Related Articles, Links
The pharmacogenetics of codeine hypoalgesia.
Pharmacogenetics. 1995 Dec;5(6):335-46. Review.
PMID: 8845855 [PubMed - indexed for MEDLINE]

This is a review of the well known observation that about 7-10% of the white population fails to respond to codeine because they can't metabolize it to morphine. Why I never prescribe codeine for pain or cough


2: Mogil JS, Ritchie J, Smith SB, Strasburg K, Kaplan L, Wallace MR, Romberg RR, Bijl H, Sarton EY, Fillingim RB, Dahan A. Related Articles, Links
Melanocortin-1 receptor gene variants affect pain and mu-opioid analgesia in mice and humans.
J Med Genet. 2005 Jul;42(7):583-7.
PMID: 15994880 [PubMed - indexed for MEDLINE]

Red heads are about 2-4 times more sensitive to morphine than non-redheads


3: Rakvag TT, Klepstad P, Baar C, Kvam TM, Dale O, Kaasa S, Krokan HE, Skorpen F. Related Articles, Links
The Val158Met polymorphism of the human catechol-O-methyltransferase (COMT) gene may influence morphine requirements in cancer pain patients.
Pain. 2005 Jul;116(1-2):73-8.
PMID: 15927391 [PubMed - indexed for MEDLINE]

2-4 fold decreased sensitivity to morphine in patients with mutant COMT gene probably related to enhanced metabolism so not an issue when given acutely by IV push

4: Lotsch J, Skarke C, Grosch S, Darimont J, Schmidt H, Geisslinger G. Related Articles, Links
The polymorphism A118G of the human mu-opioid receptor gene decreases the pupil constrictory effect of morphine-6-glucuronide but not that of morphine.
Pharmacogenetics. 2002 Jan;12(1):3-9.
PMID: 11773859 [PubMed - indexed for MEDLINE]

2-4 fold decreased sensitivity of mutant receptors for M6G, an active metabolite of morphine. Again probably an issue in the chronic setting but not when morphine given IV push.

Couldn't find any hard evidence for decreased sensitivity to morphine in the acute setting but that doesn't mean it isn't true. In any case if demerol works its just a case of finding an equianalgesis dose of morphine or diluadid. I'm amazed sometime at how people dose opiates they often don't seem to have a clue on relative potency and make pretty significant underdosing or overdosing errors when switching to an opiate they are less familiar with. Just for fun everyone should calculate the equianalgesic doses for IV morphine, dilaudid, and demerol of the 100mcg of fentanyl we are so quick to give people. You might be surprised by the result

 

[DropkickMurphy]

Pharmacogenomics and Opiates a few choice papers

1: Sindrup SH, Brosen K. Related Articles, Links
The pharmacogenetics of codeine hypoalgesia.
Pharmacogenetics. 1995 Dec;5(6):335-46. Review.
PMID: 8845855 [PubMed - indexed for MEDLINE]

This is a review of the well known observation that about 7-10% of the white population fails to respond to codeine because they can't metabolize it to morphine. Why I never prescribe codeine for pain or cough


2: Mogil JS, Ritchie J, Smith SB, Strasburg K, Kaplan L, Wallace MR, Romberg RR, Bijl H, Sarton EY, Fillingim RB, Dahan A. Related Articles, Links
Melanocortin-1 receptor gene variants affect pain and mu-opioid analgesia in mice and humans.
J Med Genet. 2005 Jul;42(7):583-7.
PMID: 15994880 [PubMed - indexed for MEDLINE]

Red heads are about 2-4 times more sensitive to morphine than non-redheads


3: Rakvag TT, Klepstad P, Baar C, Kvam TM, Dale O, Kaasa S, Krokan HE, Skorpen F. Related Articles, Links
The Val158Met polymorphism of the human catechol-O-methyltransferase (COMT) gene may influence morphine requirements in cancer pain patients.
Pain. 2005 Jul;116(1-2):73-8.
PMID: 15927391 [PubMed - indexed for MEDLINE]

2-4 fold decreased sensitivity to morphine in patients with mutant COMT gene probably related to enhanced metabolism so not an issue when given acutely by IV push

4: Lotsch J, Skarke C, Grosch S, Darimont J, Schmidt H, Geisslinger G. Related Articles, Links
The polymorphism A118G of the human mu-opioid receptor gene decreases the pupil constrictory effect of morphine-6-glucuronide but not that of morphine.
Pharmacogenetics. 2002 Jan;12(1):3-9.
PMID: 11773859 [PubMed - indexed for MEDLINE]

2-4 fold decreased sensitivity of mutant receptors for M6G, an active metabolite of morphine. Again probably an issue in the chronic setting but not when morphine given IV push.

Couldn't find any hard evidence for decreased sensitivity to morphine in the acute setting but that doesn't mean it isn't true. In any case if demerol works its just a case of finding an equianalgesis dose of morphine or diluadid. I'm amazed sometime at how people dose opiates they often don't seem to have a clue on relative potency and make pretty significant underdosing or overdosing errors when switching to an opiate they are less familiar with. Just for fun everyone should calculate the equianalgesic doses for IV morphine, dilaudid, and demerol of the 100mcg of fentanyl we are so quick to give people. You might be surprised by the result

Leave it to everyone's favorite MD/PhD to be the one to provide the citations. Thanks!

 

[Wackie]

I was with a doctor the other day who works at several different hospitals. One of his patients from approx a week ago was in this hospital for abdominal pain.

Pt: "Started yesterday and it's gotten worse. I just couldn't stand it anymore." [dramatically puts arm across forehead to shield eyes]
Doc: "Have you ever had this before?"
Pt: "No, never. I hardly ever go to doctors."
Doc: "Really." [waits a beat] "I saw you about a week ago over at ____ for the same thing and you've been at this hospital for abdominal pain six times." [patient had been there often enough to get flagged by our system]
Pt: [peeks out from under arm totally speechless]

 

[Febrifuge]

if your only answer to the pain scale querstion is always 10/10 regardless of complaint(wart, ankle sprain, sinus pain, splinter in finger, dental pain) you have no clue what real pain is and you are a drug seeker

Fair enough, but the pain scale is pretty lame. I think we reward people who say "6" just because they're trying to be helpful.

As to the "high tolerance" thing, the next time I'm a patient and need to have that conversation I hope to impress and/or confuse the crap out of my provider by saying I have a low pain threshhold, but a high tolerance.

 

[Sweet Tea]

I'm in not quite the same boat as vtucci but I've often wondered what would happen if I went into an ED w/pain. I'm allergic to ibuprofen...my lips swell, my eyelids swell, my hands and feet swell, and most disturbingly my tongue swells. Since I am a fan of breathing on my own, no ibuprofen for me. Other pain meds are just fine for me, but I think that my ibuprofen allergy might raise a few eyebrows.

 

[mikecwru]

I'm in not quite the same boat as vtucci but I've often wondered what would happen if I went into an ED w/pain. I'm allergic to ibuprofen...my lips swell, my eyelids swell, my hands and feet swell, and most disturbingly my tongue swells. Since I am a fan of breathing on my own, no ibuprofen for me. Other pain meds are just fine for me, but I think that my ibuprofen allergy might raise a few eyebrows.

All you have to do is explain that, but say that tylenol is perfectly fine. That would seem like a reasonable explanation to me. Are you allergic to the actual drug or a dye in some preparation you had? Have you ever had toradol? Can you tolerate other nsaids from different families?

mike

 

[The White Coat Investor]

All you have to do is explain that, but say that tylenol is perfectly fine. That would seem like a reasonable explanation to me. Are you allergic to the actual drug or a dye in some preparation you had? Have you ever had toradol? Can you tolerate other nsaids from different families?

mike

Are you suggesting she go get some naprosyn to find out? I think after the whole tongue swelling incident I'd just avoid NSAIDs for a while.

 

[The White Coat Investor]

I hope I never have anything again that requires pain meds because most docs (myself included .....I had gastric bypass surgery this past summer.... .

I've been thinking about this quite a bit lately. Even asking this question will reveal my biases and I'm sure I'm about to get jumped all over by a lot of people. It seems to me that people get gastric bypass surgery as a "last resort" (given its risks, this seems appropriate to me). Gastric bypass patients, for some reason, have been unable to lose weight using the standard methods of eating less and exercising more. For some crazy reason, I always assumed a large component of this was lack of will power. Med students/physicians, as a general rule, have no shortage of will power, and in fact, are some of the most hard-working, diligent, high-achieving, ambitious, full-of-will-power people I know. You may very well be the first med student/physician I've ever met/heard of who has had gastric bypass surgery. Why did you choose that instead of getting a membership at the local Bally's and subsisting on carrot sticks and celery for a few months? Was there an additional medical problem I'm not aware of that prevented dietary changes/increased exercise? Were you not able to control how much you ate without physically shrinking the size of your stomach despite the fact that you could study for weeks straight for the MCAT and USMLE? What gives? I'm not trying to offend here, I'm really curious.

 

[caroladybelle]

I had a patient the other day ask the nurse to flush the line one more time before removing it to get the last traces of Dilaudid from the line

My favorite request is, "Nurse, you have to push it really fast, or it won't work at all for me."

(I'm anaphylactically allergic to acetaminophen - try telling that one to the ER)

 

[methadonian]

Pharmacogenomics and Opiates a few choice papers

1: Sindrup SH, Brosen K. Related Articles, Links
The pharmacogenetics of codeine hypoalgesia.
Pharmacogenetics. 1995 Dec;5(6):335-46. Review.
PMID: 8845855 [PubMed - indexed for MEDLINE]

This is a review of the well known observation that about 7-10% of the white population fails to respond to codeine because they can't metabolize it to morphine. Why I never prescribe codeine for pain or cough


2: Mogil JS, Ritchie J, Smith SB, Strasburg K, Kaplan L, Wallace MR, Romberg RR, Bijl H, Sarton EY, Fillingim RB, Dahan A. Related Articles, Links
Melanocortin-1 receptor gene variants affect pain and mu-opioid analgesia in mice and humans.
J Med Genet. 2005 Jul;42(7):583-7.
PMID: 15994880 [PubMed - indexed for MEDLINE]

Red heads are about 2-4 times more sensitive to morphine than non-redheads


3: Rakvag TT, Klepstad P, Baar C, Kvam TM, Dale O, Kaasa S, Krokan HE, Skorpen F. Related Articles, Links
The Val158Met polymorphism of the human catechol-O-methyltransferase (COMT) gene may influence morphine requirements in cancer pain patients.
Pain. 2005 Jul;116(1-2):73-8.
PMID: 15927391 [PubMed - indexed for MEDLINE]

2-4 fold decreased sensitivity to morphine in patients with mutant COMT gene probably related to enhanced metabolism so not an issue when given acutely by IV push

4: Lotsch J, Skarke C, Grosch S, Darimont J, Schmidt H, Geisslinger G. Related Articles, Links
The polymorphism A118G of the human mu-opioid receptor gene decreases the pupil constrictory effect of morphine-6-glucuronide but not that of morphine.
Pharmacogenetics. 2002 Jan;12(1):3-9.
PMID: 11773859 [PubMed - indexed for MEDLINE]

2-4 fold decreased sensitivity of mutant receptors for M6G, an active metabolite of morphine. Again probably an issue in the chronic setting but not when morphine given IV push.

Couldn't find any hard evidence for decreased sensitivity to morphine in the acute setting but that doesn't mean it isn't true. In any case if demerol works its just a case of finding an equianalgesis dose of morphine or diluadid. I'm amazed sometime at how people dose opiates they often don't seem to have a clue on relative potency and make pretty significant underdosing or overdosing errors when switching to an opiate they are less familiar with. Just for fun everyone should calculate the equianalgesic doses for IV morphine, dilaudid, and demerol of the 100mcg of fentanyl we are so quick to give people. You might be surprised by the result

Dont have the time or energy right now to research it, but I had always thought the reason you underdose morphine so much compared to the equivalent dose of other opioids is because of the hemodynamic effects morphine has. So you can give alot higher doses of demerol, and thus a stronger high for the patient. Please correct me if I'm wrong.

 

[vtucci]

I've been thinking about this quite a bit lately. Even asking this question will reveal my biases and I'm sure I'm about to get jumped all over by a lot of people. It seems to me that people get gastric bypass surgery as a "last resort" (given its risks, this seems appropriate to me). Gastric bypass patients, for some reason, have been unable to lose weight using the standard methods of eating less and exercising more. For some crazy reason, I always assumed a large component of this was lack of will power. Med students/physicians, as a general rule, have no shortage of will power, and in fact, are some of the most hard-working, diligent, high-achieving, ambitious, full-of-will-power people I know. You may very well be the first med student/physician I've ever met/heard of who has had gastric bypass surgery. Why did you choose that instead of getting a membership at the local Bally's and subsisting on carrot sticks and celery for a few months? Was there an additional medical problem I'm not aware of that prevented dietary changes/increased exercise? Were you not able to control how much you ate without physically shrinking the size of your stomach despite the fact that you could study for weeks straight for the MCAT and USMLE? What gives? I'm not trying to offend here, I'm really curious.

Hey Desperado. You are not offending me at all. I take this as an opportunity to educate because too many students and physicians assume that obesity is always related to calories in v. calories out. While it is true that most obese people are that way because they overeat, the equation is not that simple. People have different metabolic rates and set points and our knowledge of obesity and its multifactoral causes and how to measure them is still somewhat limited. You would not believe some of the misconceptions and out-and-out prejudices that I have heard both as a patient and med student. I was even called a liar once by a physician-- that I could not possibly be telling the truth about my food intake.

In my case, I had been obese since the age of 10 once I hit puberty. Before that time, I had been underweight to the extent that my parents had to staple my pants on. ;-) When I entered puberty and started menarche, I literally gained 100 pounds in a year (without any change in dietary or exercise habits). I also exercised 7 days a week for hours on end in a karate dojo (I am a blackbelt) for most of my early adolescence. When I was old enough to work, I was a waitress every night. I had no shortage of physical activity. With respect to my diet, it was not uncommon for me to eat only 500-1000 a day and I was still 200+ pounds. My mother was a full-time waitress and consumed an average of 500 calories a day for 20 years and was still over 200 pounds. My great-grandmother was 300 pounds until the day she died at age 96. It is true that activity levels had made a difference with me but that difference when I was pushing every day was me at 250 pounds and when I was a lawyer or first year med student tied to a desk 8+ hours a day (and closer to 16 as a lawyer), it was more like 315. No amount of diet and exercise could help me break out of the obesity range BMI though. Will power has nothing to do with it.

With respect to diet, I have followed the guidelines of nutritionists. I have been on Atkins, jenny craig, weight watchers etc. The only thing that ever worked for me was Redux (a phen-phen like compound that was pulled from the market in 1996). On Redux, I lost 90 pounds in 6 months. My doctor wanted me to keep the same diet and exercise pattern so we could establish the baseline of the drug. Unfortunately, the FDA pulled it when I hit the 6 month point. I ended up gaining the 90 pounds back in 6 weeks. He told me then that he had no doubt that my issue was metabolic. The problem was none of the normal metabolic tests were low enough to warrant medication (i.e., low TSH, T3 and T4 but in the normal range). I always ate far less than anyone I knew (other than my mom).

I had looked into the surgery back in 2001 and had been told that I did not eat enough to make it worth my while. I had dropped the idea until first year biochem when the course director was an endocrinologist. He had a number of lectures on weight. After speaking with him, he told me that the field has learned so much in the past 6 years and now realize exactly how much of a hormonal component is involved with the surgery. Our profession for the longest time had only thought of fat as a place to store extra calories and had not considered that those cells could interact at the cellular level with our hormonal baseline. With the new research, there now are a lot of medical professionals who have had the surgery. From nurses to doctors to techs, a huge number of professionals now turning to the surgery.

I am sure that my weight loss is only minimally related to the restrictive portion of the surgery. The main force behind my weight loss is the hormonal component.

 

[vtucci]

Dont have the time or energy right now to research it, but I had always thought the reason you underdose morphine so much compared to the equivalent dose of other opioids is because of the hemodynamic effects morphine has. So you can give alot higher doses of demerol, and thus a stronger high for the patient. Please correct me if I'm wrong.

It may have simply been that post-surgery they were concerned about the possibility for respiratory depression or other respiratory complications if they upped the dose to what would be comparable to demerol. It is not that unheard of to have those complications after bariatric surgery and you are up and walking around the wards to prevent a number of post-op complications the same day as surgery (whether you had it open or laproscopic).

Also, none of the pain meds, demerol included ever gave me a "high". Maybe that is because I take Adderall for ADD-- that has never given me a high either. I realize Adderall is an amphetamine and not an opoid but am just speculating as to the way my body processes these compounds.

I have had other times when morphine was given to me but it was always post-surgery (appendectomy etc). I am serious when I say that the doses of morphine that I had vs. no pain meds had the same impact on me. It felt exactly the same so I will opt for the no pain meds rather than get the morphine.

I had never been given any other pain meds besides morphine or the OTCs before this experience when I learned that I am apparently allergic (in the true systemic sense and not the nausea/vomiting sense) to just about everything (oxycodone, hydrocodone) they tried. Classic. I just add it along with everything else-- quite a list now. For those of you who are curious, current allergies: PCN, ceclor, oxycodone, hydrocodone, fish (but not shellfish- don't ask me why), tomatoes (and I am part Italian), mayo, virtually all outdoor and indoor allergens (worst-mold and my parents had to retire to Florida ). LOL.

 

[Ryan]

Pharmacogenomics and Opiates a few choice papers

1: Sindrup SH, Brosen K. Related Articles, Links
The pharmacogenetics of codeine hypoalgesia.
Pharmacogenetics. 1995 Dec;5(6):335-46. Review.
PMID: 8845855 [PubMed - indexed for MEDLINE]

This is a review of the well known observation that about 7-10% of the white population fails to respond to codeine because they can't metabolize it to morphine. Why I never prescribe codeine for pain or cough


2: Mogil JS, Ritchie J, Smith SB, Strasburg K, Kaplan L, Wallace MR, Romberg RR, Bijl H, Sarton EY, Fillingim RB, Dahan A. Related Articles, Links
Melanocortin-1 receptor gene variants affect pain and mu-opioid analgesia in mice and humans.
J Med Genet. 2005 Jul;42(7):583-7.
PMID: 15994880 [PubMed - indexed for MEDLINE]

Red heads are about 2-4 times more sensitive to morphine than non-redheads


3: Rakvag TT, Klepstad P, Baar C, Kvam TM, Dale O, Kaasa S, Krokan HE, Skorpen F. Related Articles, Links
The Val158Met polymorphism of the human catechol-O-methyltransferase (COMT) gene may influence morphine requirements in cancer pain patients.
Pain. 2005 Jul;116(1-2):73-8.
PMID: 15927391 [PubMed - indexed for MEDLINE]

2-4 fold decreased sensitivity to morphine in patients with mutant COMT gene probably related to enhanced metabolism so not an issue when given acutely by IV push

4: Lotsch J, Skarke C, Grosch S, Darimont J, Schmidt H, Geisslinger G. Related Articles, Links
The polymorphism A118G of the human mu-opioid receptor gene decreases the pupil constrictory effect of morphine-6-glucuronide but not that of morphine.
Pharmacogenetics. 2002 Jan;12(1):3-9.
PMID: 11773859 [PubMed - indexed for MEDLINE]

2-4 fold decreased sensitivity of mutant receptors for M6G, an active metabolite of morphine. Again probably an issue in the chronic setting but not when morphine given IV push.

Couldn't find any hard evidence for decreased sensitivity to morphine in the acute setting but that doesn't mean it isn't true. In any case if demerol works its just a case of finding an equianalgesis dose of morphine or diluadid. I'm amazed sometime at how people dose opiates they often don't seem to have a clue on relative potency and make pretty significant underdosing or overdosing errors when switching to an opiate they are less familiar with. Just for fun everyone should calculate the equianalgesic doses for IV morphine, dilaudid, and demerol of the 100mcg of fentanyl we are so quick to give people. You might be surprised by the result

Hey,
Where do you find how to calculate the equianalgesic doses? What about the other effects of Morphine (vasodilation) vs. dilaudid, demerol, fentanyl. Sorry, my books are out of reach right now and I'm just a stupid 3rd year dreaming of going into ER.

Thanks

 

[DropkickMurphy]

From nurses to doctors to techs, a huge number of professionals now turning to the surgery.

One of the RT's I worked with, two nurses I know and a local FP doc have all had it done. Good luck VTucci!

 

[vtucci]

Thanks Dropkick. It is working really well so far-- 130 pounds and counting.

 

[Sweet Tea]

All you have to do is explain that, but say that tylenol is perfectly fine. That would seem like a reasonable explanation to me. Are you allergic to the actual drug or a dye in some preparation you had? Have you ever had toradol? Can you tolerate other nsaids from different families?

mike

Advil made me turn into a little ball of angioedema, and so did the ibuprofen script I got when I broke my fingers (note: do not play waterpolo w/a soccer ball). Can't say I've ever had toradol, but aleve is my best friend.

 

[Sweet Tea]

Are you suggesting she go get some naprosyn to find out? I think after the whole tongue swelling incident I'd just avoid NSAIDs for a while.

LOL naprosyn is fine. For some reason, it's just ibuprofen that makes me all puffy.

 

[jlw2004]

This would be me. I had my first stone last year. My wife was post-call, so I went through about 2 hours of pain before I couldn't take it anymore. I finally woke her up, and she thought I was having a MI since I was pale and had sweat through my clothes. I thought she was gonna have a MI when she saw me....She took me to the ER and my buddy wanted to give me MS and ketorlac. I took the ketorolac, but did not take the MS. My wife veto'ed this and pretty much drugged me up anyhow....I now have a new respect for pts with ureteral colic, that's for sure....At any rate, he gave me 24 Vicodins to go home with, I took 2 on the first day, then only needed ibuprofen to control the pain. I still have 22 Vicodin left. I just don't like taking that stuff. I guess I see what it does to people....

I started to pass a 5+mm kidney stone at the stadium during halftime of an NFL game and suffered quietly through the end of the game so my husband and his buddy could see the end of the game. But finally spoke up about the stone when hubby wanted to watch the players until they all went into the locker room. He thought I was just bored and a bit cranky during the second half! Threw up on the walk back to the car and was taken to my ED against my will. Toradol was AWESOME! I only needed narcs for a few days when I had to get a stent. I did get dilaudid while I was an inpatient (stent complications). It converted me to prescribing dilaudid for my patients instead of morphine. It took away the pain and didn't give you too much of the dizzy rush if the nurse pushed it vveeerrrrrrrryyy slowly which I always ask the nurses to do for my patients (hell, and me). I remember one patient who told me the pain meds didn't work unless you pushed them real quick!

That's one -- you might be a drug seeker if you tell the nurse the pain meds only work if you push them really, really quickly!

 

[Orthonut]

Thanks Dropkick. It is working really well so far-- 130 pounds and counting.

Cool! I've got some non-medical/veterinary related friends (n=3) that went down your path-it worked for them. Keep up the good work.!