Demerol - have it? Use it?

My medical school hospital pulled it from the formulary.
My residency hospital I believe only used it in anesthesia shivering. (Not in ED)
My real job, well, we don't have it, but I try to avoid going upstairs so I don't know if the gas passers use it.

 

We have it available, but the only time I've ever given it is for sickle cell patients that had it as part of their treatment protocol.

 

Not on the formulary at my primary hospital, and is on the formulary at my part-time hospital but it's not in the ED Pixis.

 

Have it, have given it once in the past 6 months.

 

My 5 hospitals all banned it from the EDs. It can be used in the rest of the hospitals. It was puerly to discourage the seekers. It worked for a while. Now everyone just asks for Dilaudid.

 

We dont have it. I have myself received it once for kidney stones, loved it

 

Enough pain meds to choose from without worrying about demerol.

 

This is the case with my primary hospital. Dilaudid has become the drug of choice.

At the rural hospital where I've been rotated to, they like Demerol a lot. But interestingly, Lortab is the primary abuse problem down here.

 

Got to aggravate a seeker the other day for this.

Pt: I got's migraines.
Me: For how long
Pt: Long as I can remember
Me: So what do you take for it at home
Pt: Nothin'
Me: What do they do for you at the hospital
Pt: I get Demerol.
Me: I can't give you that.
Pt: Why not?!?
Me: It isn't carried by the hospital because people would come in asking for it
Pt: Oh.....
Pt: Can I have some Dilaudid? I'm allergic to Reglan, Toradol, and Phenergan.

 

This is an interesting thread. My understanding of the demerol issue is that the hospital based pharmacy sages became concerned with the metabolite, normeperidine, in older patients with decreased cr. cl.(read: Those who could be assumed for same) and the potential for neurotoxicity. Never heard of the "seeker" angle. Granted, there are plenty other of opiates that work well, but what gets under my saddle is taking away a perfectly legitimate option for analgesia. Will they remove toradol for similar reasons? I don't know how much droperidol was used in the A and E here, but THAT is a perfect example of a pharmacist taking risk out of context and dictating practice (it has been taken off of many if not most formularies in the states). Excellent drug for PONV. Gone.

 

Morphine and dilaudid produce no euphoria? Are they next on the seeker list? (I am in the US, not in EM. "A&E" a bit of a relflex)

 

The degree of euphoria created by Demerol created real problems for us. Dilaudid is less of an issue but it has a similar following. Morphine even less so than Dilaudid.

As for Toradol I'm not a big fan of it. High nephrotoxicity and cost but similar effect as Motrin. Unless the patient can't tolerate po I just give Motrin. The fact that many patients believe that Toradol is better than Motrin because real pain relief can only come in a shot just shows the subjectivity of the whole issue.

 

I'm disappointed in my communication skills that you took my first post to be a defense, per se, of demerol. I can take it or leave it. Most often, I leave it. The intent was to publicly lament the ability of a non-physician (pharmacists) to dictate a medical decision. I used demerol and droperidol as two examples. I of course am familiar with seeking behavior with narcotics in general, not just demerol. I was just under the impression that it had been made unavailable based on the belief that normeperidine neurotoxicity was a bigger problem than it is, not opiate seeking behavior. I have voted in the poll; I chose the last statement.

 

We don't have it at our hospital. I think most in the state (New York) have it under the guise of anesthesia, though.

 

Thanks for the clarification. The reality for me is (I'm an anesthesiology visitor) that when I give any longer lasting opiate such as morphine or dilaudid, it is most usually with real euphoria inducers such as sufentanil or fentanyl. Add versed and propofol and everyone is quite stoned. While these shorter acting agents are frequently close to being "gone" once the patient is awake, it is difficult to attribute the euphoria to any one agent. I do favor dilaudid, as it seems to make healthy patients almost giddy after having been carved upon.

 

I think you have a valid point about not having pharmacy dictate prescribing practices. I certainly echo your point about droperidol. However in most of the cases I'm aware of where Demerol was restricted it was not due to pharmacy, it was due to the EDs wanting it gone.

The issues about the metabolite toxicity tended to cause restrictions to the inpatient use such as saying patients shouldn't be on PRN Demerol for more than 48 hours or restricting the dosage. The toxicity issue didn't cause much concern in the EDs because we usually only give a few doses.

 

I just love it when the seekers come in requesting their typical cocktail. Dilaudid, Phenergan, and Benadryl -- all requested to be pushed fast "because that's the only way it works." When they ask for it to be administered fast, I give it to them individually and over 10 mins in a 100 mL normal saline mixture.

 

Generally, we gently suggest rather than dictate.

Formulary decisions are a collaboration between medicine and pharmacy. Besides, if we tried to dictate to you guys, you'd tell us to get stuffed.

You're dead-on about the neurotoxicity of the metabolite. After my surgery, I remember walking with the IV pole, staring at the floor, as the speckled tile pattern seemed to swirl around my feet with each step. Pretty awesome.

 

I have to say that I've rarely seen pharmacy "dictate" anything. I am grateful for any input from the pharmacy, as they know drugs far better than I ever will. I know that anesthesiology has this love/hate relationship with other providers, but please don't bring it over here to the EM forum.

 

Most of the time it's not a pharmacist that dictates what is available in the hospital. Most hospitals have P&T committees (pharmacy and therapeutics) that are composed of physicians, pharmacists, nurses, etc. The committee decides what meds are on formulary.

 

Quite right here. Apologies all around, especially to our pharmacy contributors. I left a broad swath, with pharmacy in the way and it wasn't fair. That said, the way it happened where I am was with what I considered an overly zealous dept of pharmacy influence. P&T was precisely the mechanism but we felt that our use of the drug (droperidol) was not taken into consideration. Meetings were called at 0730, which is when we're placing our patients on the table. We felt somewhat "rail roaded". When demerol was on the block, we resolved to not let the same thing happen and were successful in retaining it. In retrospect, it would have been a silly hill to "die on", but it was felt that were we to aquiesce on this point, we'd regret it again. So there.

 

No worries

Sounds like maybe you were having to deal with jerks.