Alternatives to Narcotics

[macdaddy23]

I think this has come up before but I couldn't find it in a quick search.

When the patient who is allergic to everything comes in with their chronic pain and you question their motive, what do you write for them in place of narcotics?

I know it's horrible but I think a lot of us do it- I seem inclined to write for something to show I attempted to treat their pain, if questioned by administration. (This is only for the case of those I do not believe are truly in pain) However if in doubt I treat their pain with whatever is necessary.

Thanks for any input.

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[GeneralVeers]

Tramadol 50 mg twice daily

Dolobid is also useful as most patients don't know what it is.

 

[spyderdoc]

Tramadol 50 mg twice daily

Dolobid is also useful as most patients don't know what it is.

Percogesic is another great one for the unsuspecting seeker. Tramadol is a good one, but pretty expensive...

 

[deleted77919]

Dolobid is also useful as most patients don't know what it is.

And it starts with the magic letter D!

 

[highdesert]

I use Oxaprozin (daypro) because it *sounds* so good for many folks.

 

[ERMudPhud]

Tramadol is an opiod agonist. Its marketed differently because it also has some SSRI like properties and the clinical trials to get it approved were too short to see any significant dependence or addiction. In overdose it looks like an opiod except for the sertonin syndrome and demerol like seizures. Dependence and withdrawl has been well reported. Its equianalgesic potency is about 10-25% of morphine so that 50 of tramadol is equal to about 4 of oxycodone

 

[kbrown]

no such thing as a true opiate allergy, only adverse effects that the 'allergic' find undesirable (itching, nausea, dizziness, dyspnea, etc..). give some benadryl with it to diminish the effects of histamine release. morphine is a more potent histamine releaser than demerol (though we don't use this drug too often anymore).

 

[macdaddy23]

I like the percogesic. Never used it before but will.

I wonder how many drug seekers have been fooled with this one.

 

[DrQuinn]

In the ED, I give a LOT of haldol for chronic pain. I swear by it, it works GREAT. It gets rid of that supratentorial pain that patient's get. Try it. I've convinced several ED attendings here to use it, and they love it.

That being said, its hard to DC patients on it, so I don't usually do that, I just tell them to f/u with thier doc.

Q

 

[spyderdoc]

In the ED, I give a LOT of haldol for chronic pain. I swear by it, it works GREAT. It gets rid of that supratentorial pain that patient's get. Try it. I've convinced several ED attendings here to use it, and they love it.

That being said, its hard to DC patients on it, so I don't usually do that, I just tell them to f/u with thier doc.

Q

On the same theme, droperidol works very well for the psycho migraine/vomiting and the more psycho cyclic vomiters. Unfortunately, I read somewhere that it may be going bye bye along with Tigan....That will make me a sad panda.....

 

[BADMD]

no such thing as a true opiate allergy, only adverse effects that the 'allergic' find undesirable (itching, nausea, dizziness, dyspnea, etc..). give some benadryl with it to diminish the effects of histamine release. morphine is a more potent histamine releaser than demerol (though we don't use this drug too often anymore).

Keep in mind that the anticholinergic effects of diphenhydramine can potentiate the rush asociated with opioids and many drug seeking patients will ask for both together.

 

[Ephesus]

I've dealt with doctors like you (I have extensive chronic pain and sometimes the Duragesic transdermal patches don't do it) so I go in to the ER with a note from my pain doc for 100mg IV fentanyl q1 if needed (usually not) and I end up getting Toradol once or twice. It's the only drug that is almost as strong as narctoics but the side effect profile is horrible (can't take more than five days), and I prefer the sleep Fentanyl gives me, not to mention, the total pain free body.

 

[GeneralVeers]

I've dealt with doctors like you (I have extensive chronic pain and sometimes the Duragesic transdermal patches don't do it) so I go in to the ER with a note from my pain doc for 100mg IV fentanyl q1 if needed (usually not) and I end up getting Toradol once or twice. It's the only drug that is almost as strong as narctoics but the side effect profile is horrible (can't take more than five days), and I prefer the sleep Fentanyl gives me, not to mention, the total pain free body.

We only accept notes from your pain doctor if they are cosigned by your mom.

 

[ERMudPhud]

pain doc for 100mg IV fentanyl q1 .

I'm not sure we have that much fentanyl in the whole hospital!

If your pain doctor really sent a note saying 100mcg q1 I'd honor it. We keep a file of protocols from pain doctors. Its the patients who refuse to get a protocol from their PCP or refuse to stick to it or try to sneak around it that cause problem.

 

[Ephesus]

I'm not sure we have that much fentanyl in the whole hospital!

If your pain doctor really sent a note saying 100mcg q1 I'd honor it. We keep a file of protocols from pain doctors. Its the patients who refuse to get a protocol from their PCP or refuse to stick to it or try to sneak around it that cause problem.

Sorry, mcg. I take the 100mcg/hr Duragesic patches right now. Sometimes, on good weeks, I get down to 75mcg/hr.

I had this one PA that decided I was a drug addict and needed to check myself into rehab after handing him the note, stating what was wrong. Those were his next words. Then he began to say, "In medicine, we all have different views..." and I replied, "I agree. Now I'd like the view of your supervisor, aka, a doctor."

 

[Ephesus]

I'm not sure we have that much fentanyl in the whole hospital!

If your pain doctor really sent a note saying 100mcg q1 I'd honor it. We keep a file of protocols from pain doctors. Its the patients who refuse to get a protocol from their PCP or refuse to stick to it or try to sneak around it that cause problem.

Addendum: Yeah, I understand that. One time when I was in the ER, there was a drug seeker there, or at least the doctor labeled him as one, and said he had to see a PCP before they would treat him with pain meds again and he'd have to sign a contract with the hospital and the PCP.

Ironically, walking out of the hospital, there was another guy yelling at the nurse saying he didn't get any pain meds and he was in pain (that's a tough case to make when you're screaming at the top of your lungs in anger) and the nurse replied, "You did get Motrin." I laughed and I am sure you could guess the guys response.

 

[docB]

Addendum: Yeah, I understand that. One time when I was in the ER, there was a drug seeker there, or at least the doctor labeled him as one, and said he had to see a PCP before they would treat him with pain meds again and he'd have to sign a contract with the hospital and the PCP.

Ironically, walking out of the hospital, there was another guy yelling at the nurse saying he didn't get any pain meds and he was in pain (that's a tough case to make when you're screaming at the top of your lungs in anger) and the nurse replied, "You did get Motrin." I laughed and I am sure you could guess the guys response.

You are a drug seeker. You have come to the ED with a chronic problem demanding narcotics. Drug seeker. If you have to use (abuse) the ED for your narcotic needs your pain doctor is not doing their job or you are going off your contract. And yes we do deal with exacerbations of chronic conditions in the ED but we are really there to deal with threats to life like breathing, etc. It sounds as if you have been into the ED several times so clearly there is a problem.

 

[Ephesus]

I was always told there are certain times to go to the ER, and when vomitting, dehydration and severe pain are apart of the picture, it's pretty unanimous that one goes to the ER.

But hey, continue your armchair dx'ing; it may make you feel better.

You think my doctor hasn't talked with the ER before? Of course they are worried/curious/concerned, so after I am in the ER, getting IV meds when I can't keep down po meds, I see my doctor. Or I just go see him (if he's at the office), and he admits me to a room.

 

[docB]

I was always told there are certain times to go to the ER, and when vomitting, dehydration and severe pain are apart of the picture, it's pretty unanimous that one goes to the ER.

But hey, continue your armchair dx'ing; it may make you feel better.

You think my doctor hasn't talked with the ER before? Of course they are worried/curious/concerned, so after I am in the ER, getting IV meds when I can't keep down po meds, I see my doctor. Or I just go see him (if he's at the office), and he admits me to a room.

This is a different picture than the one you painted before. You were talking about chronic pain unrelieved by Duragesic.

I've dealt with doctors like you (I have extensive chronic pain and sometimes the Duragesic transdermal patches don't do it) so I go in to the ER with a note from my pain doc for 100mg IV fentanyl q1 if needed (usually not) and I end up getting Toradol once or twice. It's the only drug that is almost as strong as narctoics but the side effect profile is horrible (can't take more than five days), and I prefer the sleep Fentanyl gives me, not to mention, the total pain free body.

I agree that if you can't tolerate po you wind up an inpatient. You don't necessarily need the ED if this is an exacerbation of a chronic condition but most primary docs use us as an overflow and after hours clinic so that's how it goes. I would, and will always, be skeptical of someone who presents with demands for a particular cocktail of narcotics. I have a crew of frequent fliers, most with chronic "gastritis" and gastroparesis, who present like this all the time. Most require central lines and all love Dilaudid ("I need 8 mg IV with that Phenergren - the drug that puts the grin in your narcotics"). By continuing to admit these people for yet another round of narcs I know I'm not doing them any good. I am putting off seeing them again for another week. Ugh. The biggest difference between me and the drug dealer on the corner is that he gets to name his own prices.

 

[The White Coat Investor]

Dolobid is also useful as most patients don't know what it is.

Especially if you pronounce it DolObid (rhymes with dilaudid)

 

[DeLaughterDO]

meditation, creative visualization, self-hypnosis - these are for the lowly practitioner, of course. The patient will demand narcs, usually "something... duh... duh... It starts with a 'D.' It should be in my records - can't you look it up?"



jd

 

[GeneralVeers]

meditation, creative visualization, self-hypnosis - these are for the lowly practitioner, of course. The patient will demand narcs, usually "something... duh... duh... It starts with a 'D.' It should be in my records - can't you look it up?"



jd

This is why I never tell people what medicine I'm giving them (unless they ask me). I usually say "I'm going to give you a shot for pain". This could be Toradol, morphine, dilaudid, or Haldol for that "supratentorial pain".