Drug seeking in the ED

[RexKD]

After reading through the "Things I Learned From My Patients" thread, it seems that a large portion of ED visits are brought about by drug seeking.

What would you say are the top 10 or 20 drugs among the drug seekers at your ED?

I'm curious if there is a regional preference and, more importantly, if substitute drugs could be prescribed which would discourage non-emergency drug seeking visits to the ED.

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[deleted6669]

vicodin, percocet, dilaudid, xanax, klonopin, fentanyl patches......

 

[southerndoc]

OC's are still big players in CT. I've had numerous patients come in saying that's all that controls their pain, they lost their prescription, a friend stole it, etc. (One actually gave me this story how her pill bottle was in the seat of her car and someone broke the window to steal the drugs. Did she file a police report? No.)

Percocet is also popular here. I've had some patients even ask us to write "brand necessary" on their prescriptions. Evidently the Percocet brand name gets more money than the oxycodone/APAP generic names on the bottle.

 

[docB]

The holy grail for seekers is Demerol. If they have to they'll take OCs, methadone or Percs.

 

[southerndoc]

The holy grail for seekers is Demerol. If they have to they'll take OCs, methadone or Percs.

My institution doesn't carry Demerol (yes that is correct, it's not on formulary at my hospital nor can you find some way of obtaining it for patients).

 

[docB]

My institution doesn't carry Demerol (yes that is correct, it's not on formulary at my hospital nor can you find some way of obtaining it for patients).

One of the ERs I work at has done this. I like it. The others might follow suit but some of the old guard really don't want to let it go.

 

[GeneralVeers]

Drug-seeking is one of the definite negatives to Emergency medicine. Most popular in Indiana are (in descending order): Vicodin, Percocet, Dilaudid, Demerol, Morphine, Nubain.

What peeves me more are the 2ppd medicaid patients who ask for a prescription for Tylenol because they "can't afford it". I politely reply that it's not hospital policy to write scripts for OTC medicines, and tell them if they quit smoking for one day they could afford the Tylenol.

 

[USCDiver]

Had a drug seeker today in the ED who had come in multiple times for this nasty rotten tooth to get pain meds. Says she can't afford a dentist (understandable), can't afford a prescription for pain meds can we give her samples (not bloody likely). Then the social history comes around..."Oh, you smoke, but you can't afford dentist or drugs? How do you afford your cigarettes?"

"My sister sends me money." She actually said that. Ay caramba!

 

[southerndoc]

Had a drug seeker today in the ED who had come in multiple times for this nasty rotten tooth to get pain meds. Says she can't afford a dentist (understandable), can't afford a prescription for pain meds can we give her samples (not bloody likely). Then the social history comes around..."Oh, you smoke, but you can't afford dentist or drugs? How do you afford your cigarettes?"

"My sister sends me money." She actually said that. Ay caramba!

My solution to toothaches is always the same: Marcaine for immediate and a few hours worth of pain relief, 3 Percocets maximum, and follow up with a dentist (or dental clinic) the next day.

 

[Sessamoid]

My solution to toothaches is always the same: Marcaine for immediate and a few hours worth of pain relief, 3 Percocets maximum, and follow up with a dentist (or dental clinic) the next day.

If I gave 3 percs to everybody with poor dentition that came in claiming to have dental pain, I'd run out of the special security prescription pads used for narcs in a few days.

It was much worse in Tampa Bay. Are there not good street drugs available there?

 

[12R34Y]

One of the ERs I work at has done this. I like it. The others might follow suit but some of the old guard really don't want to let it go.

The academic medical center that I am at has taken demerol completely and utterly off the formulary.

3 suburban ED's that I'm very familiar with have also taken demerol completely off formulary and cannot give it anymore.

i think it is a great idea and demerol probably won't be given out anywhere in a few years.

later

 

[Katee80]

Why is it such a good idea to take it out everywhere? Because people want something that works for them? What's next?

If you ask me NSAIDS have a way bigger risk factor than demerol.

What about those allergic to morphine, codeine..true allergies.

What about those who only go in to the ER ocassionally and demerol works the best? It was invented for pain remember? Wy is it such a big deal if it works better than some meds?

Once Demerol is gone.....allergic to MSO4, hydromorphone, codeine...plus they're vomiting...what do you give them then? Toradol and a prayer? Fentanyl is short acting...Toradol has its barriers too.

I am honestly curious and would really appreciate an answer from someone who won't feel the need to get mean, point out that yes..I must get demerol 4x a year for migraines, and I am also aware this is the place to vent.

Just because a regular person can pronounce the name of said drug, knows the dose they need , bla blabla... it doesn't mean they're drugseeking( and that seeking word is so annoying. Yeah they're drugseeking....some are actually in pain. Runny nose? Kleenex seeking......Allergies? Benadryl seeking..etc) . Maybe they honestly have a memory and need relief ?

Taking a drug off the market because it's a nuisance having people ask for it isn't a good enough reason. Sure it has side effects but they're moslty with prolonged use. It would be a shame for me and for others who legitimately require it ON OCCASSION ONLY. I'm not talking about the weekly visiters who "lose" their scripts.

Who knows. Maybe by the time i'm out of MS4 there will be some new and improved drugs.

 

[kedhegard]

I think the point is that if they were truly having serious chronic pain issues, they would not be repeatedly "losing" their prescriptions and pill bottles, and would thus not be coming in every week.

 

[southerndoc]

Demerol has been taken off formulary at my hospital because it's one of the few narcotics that can give you a profound euphoric effect. All narcs do this to a degree, but Demerol is well known for its euphoria.

 

[ERMudPhud]

Why is it such a good idea to take it out everywhere? Because people want something that works for them? What's next?

Jeez Katee do you have your computer set to page you whenever a demerol thread shows up?

http://forums.studentdoctor.net/showthread.php?t=132940
http://forums.studentdoctor.net/showthread.php?t=128534
http://forums.studentdoctor.net/showthread.php?t=129405
http://forums.studentdoctor.net/showthread.php?t=126936
http://forums.studentdoctor.net/showthread.php?t=124553


Seriously, I think your problem with codeine is understandable. Codeine is a prodrug metabolized to morphine in the liver. 10% of the population doesn't metabolize it at all. Thus they get all the side effects without getting any pain relief. I don't give codeine to anyone.

Most of the rest of the opiates are not prodrugs and are active from the beginning. If given IV, absorption is 100% and time of onset should be very rapid, limited only by the rate they diffuse into the CNS. So, if given in equal analgesic doses they should be equally effective. There is no pharmacologic reason that if given in appropriate doses morphine, dilaudid, fentanyl, or for that matter methadone, shouldn't be as effective as demerol in treating pain.

Have you had your med school pharmacology course yet? Ask the Pharm professor to explain that part to you. While your at it ask them why demerol has some unique euphoric properties along with some unique risks and side effects when compared to other opiates.

You have to see it from our side. When someone comes in allergic to damn near everything we know works for migraines and specifically asking for demerol, none of them ever come in demanding morphine or fentanyl, it is going to raise red flags since there is no pharmacologic reason that one opiate should be so special. Of course maybe we will someday find a special brain demerol receptor which specifically reverses migraines and then we'll all feel bad about all the "drug-seekers" we denied over the years.

We took demerol of the formulary at one of our local hospitals and most of us were all for it.

 

[Katee80]

Jeez Katee do you have your computer set to page you whenever a demerol thread shows up?

http://forums.studentdoctor.net/showthread.php?t=132940
http://forums.studentdoctor.net/showthread.php?t=128534
http://forums.studentdoctor.net/showthread.php?t=129405
http://forums.studentdoctor.net/showthread.php?t=126936
http://forums.studentdoctor.net/showthread.php?t=124553


Seriously, I think your problem with codeine is understandable. Codeine is a prodrug metabolized to morphine in the liver. 10% of the population doesn't metabolize it at all. Thus they get all the side effects without getting any pain relief. I don't give codeine to anyone.

Most of the rest of the opiates are not prodrugs and are active from the beginning. If given IV, absorption is 100% and time of onset should be very rapid, limited only by the rate they diffuse into the CNS. So, if given in equal analgesic doses they should be equally effective. There is no pharmacologic reason that if given in appropriate doses morphine, dilaudid, fentanyl, or for that matter methadone, shouldn't be as effective as demerol in treating pain.

Have you had your med school pharmacology course yet? Ask the Pharm professor to explain that part to you. While your at it ask them why demerol has some unique euphoric properties along with some unique risks and side effects when compared to other opiates.

You have to see it from our side. When someone comes in allergic to damn near everything we know works for migraines and specifically asking for demerol, none of them ever come in demanding morphine or fentanyl, it is going to raise red flags since there is no pharmacologic reason that one opiate should be so special. Of course maybe we will someday find a special brain demerol receptor which specifically reverses migraines and then we'll all feel bad about all the "drug-seekers" we denied over the years.

We took demerol of the formulary at one of our local hospitals and most of us were all for it.

I knew there had to be someone who would make a snide remark and boy I wasn't dissapointed. Thanks for going all out to bring all my posts to my attention because I wasn't aware of them.

I have an extreme interest in this topic naturally because I have an entire family plagued by this pain in a** "headache" problem. And as Phud nicely brought to the forefront for whatever reason....so do I. I believe strongly in pain control in whatever form. I also strongly believe in NSAIDS but to a certain degree. Hell..I eat the stuff like candy. I would like to go into pain management someday and I am a strong believer in pt advocacy. A little nursey but hey. Someone has to be.

Do I think demerol is the best pain med in the world? No. I believe the effect is subjective with any drug and just because pts come in requesting it....why get rid of it? It sounds ******ed. The drug works...lets get rid of it?

when I see a pt who is obviously seeking, and I know for fact...they are. I wont give it to them. Period. But to say noone should receive it EVER....doesn't make sense to me. Thats all. Its my opinion and I shouldn't have to ask people here NOT to do exactly what Phud did.

So this is my OPINION.....lets agree to disagree.

Now..can someone pleeeeease tell me the answer to my question. what do you reccomend you give when morphine, codeine and hydromorphone is not an option w/ pt vomiting and in need of extended relief?

(sorry for sp..I can't be bothered today..I have a headache )

 

[EMResident]

I would like to go into pain management someday and I am a strong believer in pt advocacy. A little nursey but hey. Someone has to be.

Remember that this is a forum regarding issues pertanent to emergency medicine. While most medical specialties (though predominantly primary care) deal with drug seeking behavior, emergency medicine is uniquely affected. We are rarely able to access old chart or records in a timely fashion that allows us to care for our 15 to 20 other acutely ill patients; people know this.

People who use emergency rooms as "convenient rooms" -- that is, a place to walk in, order meds as if from a menu, and dictate all aspects of their care -- are likely to be met with significant resistence. I am a trained professional with a unique set of skills and expertise, namely identifying and treating acute, potentially life-threatening illness. It is obnoxious for a patient to refuse to speak with me and instead insist on a dosage of a medication with a high potential for abuse.

I will use narcotics to alleviate acute pain, and do so regularly. If someone appears uncomfortable and says they have pain, I am the candyman, doling out Dilaudid with the best of them. However in the face of normal vital signs without objective tenderness OR a sleeping patient that is arousable only to sternal rub I am loathe to treat indiscriminantly.

Pain specialists are useful in an outpatient setting, and they -- appropriately -- are the physicians that should treat chronic pain and acute exacerbations of chronic pain with whatever medication they see fit. Using the emergency department to manage these issues is irresponsible.

The withdrawal of Demerol from hospital formularies is becoming rather common. Blaming emergency physicians for the actions of a pharmaceutical use committee is angry and disingenuous.

Additionally, patients are unlikely to meet anyone who will advocate as vigorously on their behalf as their emergency physician -- someone with whom they have a brief and transient, though meaningful, relationship. We will argue to get emergent MRIs, admissions, cardiac caths, surgeries. We will stake our relationships with other physicians to get the best for our patients. To insinuate that emergency physicians are anything other than tireless patient advocates indicates nothing more than a lack of experience or interaction with residency-trained emergency physicians. Spend time in a large, urban emergency department and learn this firsthand.

For relief of migraine headache pain, metaclopromide 10mg IV (Reglan) has been demonstrated to provide relief equivalent to hydromorphone 1mg IV (Dilaudid). In my experience, it often will "break" a headache. Compazine (with benadryl to minimize the agitation) is another medication that is once again available and can be useful.

 

[kungfufishing]

Of course maybe we will someday find a special brain demerol receptor which specifically reverses migraines

too late. I met the lady who discovered this receptor just a couple days back. Very unpretentious - I actually mistook her for an ex-con semiexotic dancer - but she has isolated migraine pain receptors inhibited by demerol if dosed near the onset of pain, as in "right now". After donating all the demerol left in the medpyxis to the study, I should be listed as a contributor when it is published. To think I was standing right next to genius...

 

[southerndoc]

Very well said EMResident!

I agree with Reglan being a good migraine drug. It's my firstline drug against migraines and usually resolves them the majority of times. Of course if it's a first headache, worst headache, etc. then it still buys someone a CT and possibly an LP. The idea that 30% of subarachnoid hemorrhages become painfree with Reglan alarms me.

 

[Katee80]

Remember that this is a forum regarding issues pertanent to emergency medicine. While most medical specialties (though predominantly primary care) deal with drug seeking behavior, emergency medicine is uniquely affected. We are rarely able to access old chart or records in a timely fashion that allows us to care for our 15 to 20 other acutely ill patients; people know this.

People who use emergency rooms as "convenient rooms" -- that is, a place to walk in, order meds as if from a menu, and dictate all aspects of their care -- are likely to be met with significant resistence. I am a trained professional with a unique set of skills and expertise, namely identifying and treating acute, potentially life-threatening illness. It is obnoxious for a patient to refuse to speak with me and instead insist on a dosage of a medication with a high potential for abuse.

I will use narcotics to alleviate acute pain, and do so regularly. If someone appears uncomfortable and says they have pain, I am the candyman, doling out Dilaudid with the best of them. However in the face of normal vital signs without objective tenderness OR a sleeping patient that is arousable only to sternal rub I am loathe to treat indiscriminantly.

Pain specialists are useful in an outpatient setting, and they -- appropriately -- are the physicians that should treat chronic pain and acute exacerbations of chronic pain with whatever medication they see fit. Using the emergency department to manage these issues is irresponsible.

The withdrawal of Demerol from hospital formularies is becoming rather common. Blaming emergency physicians for the actions of a pharmaceutical use committee is angry and disingenuous.

Additionally, patients are unlikely to meet anyone who will advocate as vigorously on their behalf as their emergency physician -- someone with whom they have a brief and transient, though meaningful, relationship. We will argue to get emergent MRIs, admissions, cardiac caths, surgeries. We will stake our relationships with other physicians to get the best for our patients. To insinuate that emergency physicians are anything other than tireless patient advocates indicates nothing more than a lack of experience or interaction with residency-trained emergency physicians. Spend time in a large, urban emergency department and learn this firsthand.

For relief of migraine headache pain, metaclopromide 10mg IV (Reglan) has been demonstrated to provide relief equivalent to hydromorphone 1mg IV (Dilaudid). In my experience, it often will "break" a headache. Compazine (with benadryl to minimize the agitation) is another medication that is once again available and can be useful.

I agree with you when it comes to the obvious malingerer who comes in..won't speak to you to explore options and demands narcotics. I think when I'm faced with that in practice I'll be the first one to frog march them out the door. But on the other hand I really want to keep in mind that I'm treating the person, not just the disease/illness. I was commenting on the desire that Demerol be banned from all hospitals forever. I don't understand why and I find it a little extreme. I guess I'm the only one that feels that way which is a little strange to me. Maxeran is an awesome drug to break a migraine but I'm not only talking about migraines. My question is this..what do you recommend using in place of demerol w/ known allergies and the need for extended pain control in regards to acute pain?

Thanks for your reply. I realize I will probably not understand the big picture until I'm in it.

Katie

 

[DrQuinn]

My question is this..what do you recommend using in place of demerol w/ known allergies and the need for extended pain control in regards to acute pain?
Katie

Migraines = Compazine/Reglan and/or Benadryl

Acute pain (i.e. sprain/fx, etc) = Percs/Lortabs

Q

 

[A little elf]

Unfortunately, thanks to our good friends at the FDA and their black box warning, one of the best migraine/nausea meds out there is getting harder to come by and use. Droperidol has cured more migraines/vomiting episodes than I can count. Great drug. Not to mention, it also cures agitation/crazy...

 

[Celiac Plexus]

do they make dmerol in a PR form? lol... But then they'd probably just do what they do to the percocets... crush 'em up.

have fun with your drug seekers...

 

[docB]

Demerol is a uniquely abused drug and is responsible for many ER visits and hence some of the overcrowding problem. In the rare instances when someone has so many allergies or can't get relief from any other pain medication that's unfortunate but should not force ERs to keep the poison. When those people do pop up they will just have to be refered to a pain specialist. Pain that is that refractory should not be being treated in the ER.

 

[Sessamoid]

Not having demerol in the hospital has certainly made my life tons easier. I would posit that the people with true allergy to all other pain medications are vanishingly rare.

Has anybody here had any experience with using IV haloperidol for migraine? There are a few studies which seem to indicate it's pretty effective. Given its similarity of action to other effective medications (e.g. droperidol and metoclopramide), it should work well. It should be especially useful for the migraneur with vomiting.

 

[Apollyon]

My question is this..what do you recommend using in place of demerol w/ known allergies and the need for extended pain control in regards to acute pain?

Chest pain that rules in for MI, headache and fever that are meningitis, and undifferentiated abdominal pain that is from an unsuspected ectopic are all more common than true "allergies" (more likely, "side effects")/not drug seeking to morphine, codeine, and Dilaudid. It's just the way it is - drug seekers give multiple reasons why they can't take this, that, and the other thing, but all roads lead to Demerol.

You MUST be the only person, since hospital after hospital has dropped it, and there's been no effective lobby from the migraine/"allergic" group to oppose it.

At Duke, Demerol is still available for post-op shivering. That's it. Nowhere in the ED.

Extended pain? Toradol, Reglan, Neurontin, Tegretol, anesthesia-pain or neurology-pain, psych consult.

It's unfortunate, but the analogy holds true: for every person that truly is "homeless" and "will work for food", there are 100 that aren't, and are suckering you.

If you come in, out of the blue, and tell me, "I can't take Dilaudid, morphine, or codeine, I get dystonic reactions from Reglan and Phenergan, Toradol burns my stomach/gave me an ulcer, Motrin 'just doesn't work', and the only thing my headaches respond to is Demerol", I'm showing you the door - and, like a wave breaking onto the beach, this is what you will find at hospital after hospital. Thank your fellow citizens that have ruined it for you.

 

[Katee80]

Apollyon; As usual you were very helpful and I appreciate your objectivity when it comes to contraversial subject matter

Sessamoid: The docs I spoke to about the haloperidol balked at the thought of using it for migraines. They'd rather save it for the psy pts PLUS they like their migraineurs out of the ER pretty fast and not passed out in the halls. May try it anyways.

I actually did a little asking around and it seems that the drug of choice here is Dilaudid not Demerol so much. Interesting.

But then again I live in Canada where the norm may be a little different.

After all. We can walk around with under 15 grams of pot in our pocket and not get thrown in the slammer

 

[ERMudPhud]

Not having demerol in the hospital has certainly made my life tons easier. I would posit that the people with true allergy to all other pain medications are vanishingly rare.

Has anybody here had any experience with using IV haloperidol for migraine? There are a few studies which seem to indicate it's pretty effective. Given its similarity of action to other effective medications (e.g. droperidol and metoclopramide), it should work well. It should be especially useful for the migraneur with vomiting.

I have an N of 1 for you from last weekend. I had a crazy out of control psych patient in 4 pts, trying to bite everyone, really violent. She was also complaining of a terrible migraine. I gave her 10mg of IV Haldol to make the evil spirits go away. A few minutes later the nurse came to me and said she wanted something for the headache too. I said lets wait a bit and see if the Haldol doesn't take care of the headache too. Within 30 minutes the headache was gone and she was mellow enough to take out of restraints and send back to the psych hospital.


Katee: I wasn't trying to make fun of you. I just thought it was really interesting (in a funny way) that we can go many months without hearing from you but within hours of a demerol bashing thread appearing you are back.
While teasing you a bit I was also trying to give you some useful information. You've mentioned before that codeine just makes you sick without ever getting to the correct reason for that observation. It's not that you don't absorb it or that you metabolize it too quickly. The problem is that you(along with millions of other people) don't metabolize it at all. Thus codeine (an inactive prodrug) stays codeine in your system and makes you sick. I also wanted to point out that the "I don't absorb X drug" is a bogus argument when discussing parenteral opiates which are by definition 100% absorbed upon IV injection. Likewise rapid first pass metabolism of morphine or other active drugs (as opposed to prodrugs) shouldn't be an issue since IV administration goes straight into the systemic circulation, bypassing the liver. This is one reason codeine would make a really crappy IV drug. It has to be metabolized by the liver into morphine so if you give it IV, bypassing the liver, you get very little active drug.

To answer your question: what you do when IV morphine, hydromorphone, and fentanyl aren't an option? You first have to distinguish true allergic, anaphylactic reactions from drug side effects. Nausea is a side effect, seen more frequently with PO administration, not an allergy, and if that is the patients only problem then load them up with IV antiemetics along with the IV narcs. Incidently demerol is famous for the nausea effect which is why it so often given in conjunction with antiemetics Flushing, hives, and other transient reactions are usually not true allergies in this case either. Many if not all opiates (including demerol) can directly stimulate mast cell degranulation. People with a history of idiopathic anaphylaxis are at greater risk for this but it can occur in anyone and depends somewhat on the rate of administration. Since this isn't a true allergy it isn't consistently reproducible and can occur with any opiate. So just because someone got itchy or flushed once with one opiate doesn't mean they will the next time, nor does it imply that that opiate is less safe for them than others. So, don't slam in the diluadid, give it over 10 minutes instead and give some benadryl or vistaril with it. Finally, what about people with true anaphylactic reactions to morphine and hydromorphone. In those cases I don't know that demerol is any safer than fentanyl but I would put them on a fentanyl PCA if necessary.

Now, I'll throw you a bone for your ongoing demerol lobbying effort. I wasn't being totally facetious when I proposed a CNS demerol receptor. We know that demerol is pharmacologically unlike the other opiates. The increased euphoric effect is the first bit of evidence. It also has a different side-effect and toxicity profile. Finally there are some conditions for which it alone appears to work. Post anesthesia shivering is an example. So, why couldn't intractable migraines be another example. I've sometimes wondered this myself but it still hasn't stopped me from telling the chronic headache patient allergic to everything but demerol, "sorry."

Finally, you've mentioned that you will be the first to show the drug seekers the door when you are in practice but how will you distinguish them from the people like yourself for whom only demerol works?

 

[Sessamoid]

Sessamoid: The docs I spoke to about the haloperidol balked at the thought of using it for migraines. They'd rather save it for the psy pts PLUS they like their migraineurs out of the ER pretty fast and not passed out in the halls. May try it anyways.

Yes, similar reasons to the ones I have for not having tried it before. Basically, that boils down to habit and comfort level. "Saving" it makes no sense, as we have tons of the stuff and it's cheap as hell. Using opiates instead certainly doesn't make it easier to get patients alert and ambulatory, so that's not really a good argument against it either. The incidence of akathisia may be greater for haloperidol than for the traditional anti-emetics, but I don't have those numbers off the top of my head. At the same time, many were using droperidol for migraines before the black box warning, and it's not so different pharmacologically nor clinically.

 

[Katee80]

I have an N of 1 for you from last weekend. I had a crazy out of control psych patient in 4 pts, trying to bite everyone, really violent. She was also complaining of a terrible migraine. I gave her 10mg of IV Haldol to make the evil spirits go away. A few minutes later the nurse came to me and said she wanted something for the headache too. I said lets wait a bit and see if the Haldol doesn't take care of the headache too. Within 30 minutes the headache was gone and she was mellow enough to take out of restraints and send back to the psych hospital.


Katee: I wasn't trying to make fun of you. I just thought it was really interesting (in a funny way) that we can go many months without hearing from you but within hours of a demerol bashing thread appearing you are back.
While teasing you a bit I was also trying to give you some useful information. You've mentioned before that codeine just makes you sick without ever getting to the correct reason for that observation. It's not that you don't absorb it or that you metabolize it too quickly. The problem is that you(along with millions of other people) don't metabolize it at all. Thus codeine (an inactive prodrug) stays codeine in your system and makes you sick. I also wanted to point out that the "I don't absorb X drug" is a bogus argument when discussing parenteral opiates which are by definition 100% absorbed upon IV injection. Likewise rapid first pass metabolism of morphine or other active drugs (as opposed to prodrugs) shouldn't be an issue since IV administration goes straight into the systemic circulation, bypassing the liver. This is one reason codeine would make a really crappy IV drug. It has to be metabolized by the liver into morphine so if you give it IV, bypassing the liver, you get very little active drug.

To answer your question: what you do when IV morphine, hydromorphone, and fentanyl aren't an option? You first have to distinguish true allergic, anaphylactic reactions from drug side effects. Nausea is a side effect, seen more frequently with PO administration, not an allergy, and if that is the patients only problem then load them up with IV antiemetics along with the IV narcs. Incidently demerol is famous for the nausea effect which is why it so often given in conjunction with antiemetics Flushing, hives, and other transient reactions are usually not true allergies in this case either. Many if not all opiates (including demerol) can directly stimulate mast cell degranulation. People with a history of idiopathic anaphylaxis are at greater risk for this but it can occur in anyone and depends somewhat on the rate of administration. Since this isn't a true allergy it isn't consistently reproducible and can occur with any opiate. So just because someone got itchy or flushed once with one opiate doesn't mean they will the next time, nor does it imply that that opiate is less safe for them than others. So, don't slam in the diluadid, give it over 10 minutes instead and give some benadryl or vistaril with it. Finally, what about people with true anaphylactic reactions to morphine and hydromorphone. In those cases I don't know that demerol is any safer than fentanyl but I would put them on a fentanyl PCA if necessary.

Now, I'll throw you a bone for your ongoing demerol lobbying effort. I wasn't being totally facetious when I proposed a CNS demerol receptor. We know that demerol is pharmacologically unlike the other opiates. The increased euphoric effect is the first bit of evidence. It also has a different side-effect and toxicity profile. Finally there are some conditions for which it alone appears to work. Post anesthesia shivering is an example. So, why couldn't intractable migraines be another example. I've sometimes wondered this myself but it still hasn't stopped me from telling the chronic headache patient allergic to everything but demerol, "sorry."

Finally, you've mentioned that you will be the first to show the drug seekers the door when you are in practice but how will you distinguish them from the people like yourself for whom only demerol works?

Hey there. Well I'll try to answer everything here. Keeping in mind I'm no where near finishing school (taking the looong bridging route)...and I see a topic of interest, many times I don't feel knowledgeable enough to post. I even go as far as writing a response only to delete it after realizing how dumb I probably sound. It can be very intimidating here ya know So I lurk around..reading everything..sometimes learning.....gaining insight to the different areas of practice..and I do a lot of laughing. Naturally when the pain/drugseeking/ thread pops up I will respond partly due to my personal experience and partly because of my interest in pain management. I have actually posted here and there in OB/GYN and the hilarious blurbs that pop up here.

I agree with you when you say an "allergic " reaction may not occur a second time. I've actually insisted on being given a drug a few times over to make sure I couldn't take it. I gave up but my doctor is convinced I'm a loony toon.

I've often wondered about allergies, sensitivities and the difference between them and you've clarified some long standing questions. Thank you very much. I'm going to copy paste this in my notes.

Since I've received so many different meds over a period of many years, my list of so called allergies are a little longer than your average joe's but I still hesitate to call them allergies. I've approached my doctor about this as well and all he said was "Call them what you want. You can't take them." I have some pretty unusual reactions that go far past itchy and rashes. Decadron=swelling of the tongue (strangest one but may be because it was mixed w/ maxeran), Stemetil=extreme agitation and shaking, morphine=hives(rash, swelling), hydro=same thing, codeine..well you know, DHE=extreme agitation, sulfa=hives. Some say allergies others say sensitivity and others say counter it when administering it. I asked a doc to give me some ativan or something if he insisted on giving me stemetil w/ toradol and maxeran .......the man went home. Left me climbing the walls for 2 hours waiting for the next shift.
Thats another reason for listing it as an allergy. If I say its only a sensitivity and they don't listen to me when I ask them to treat the reaction I KNOW I'm going to have, I'm back on the wall.
I start Pharm next semester so the differences between allergies and classes of sensitivities are still confusing to me dispite Medline.
Demerol isn't perfect either as no drug is but it is the lesser of all evils for me.
It makes me tense and sometimes twitchy , dizzy but unfortunately I've never experienced extreme euphoria and yes like you said ...major nausea. It is not however the only thing that works for me. I find NSAIDS, and Imitrex are great! I take them for all my migraines and 96% of the time they work within 12 hours.

How will I distinguish drugseekers from people like myself. That's a tough one.
I guess the most obvious one would be vitals, the number of visits, their appearance (grimacing, tense look, bla bla bla). I 've sat in the waiting room a couple of times and observed a couple of "migraineurs" drinking coke, laughing, walking around, SMOKING!!!!! So I think I'll be able to pick them out. As for other pts with acute or chronic pain? I don't know. I'll learn and hopefully not at anyone's expense. I would hate to send someone home in genuine pain because of a long list of fishy sounding allergies. Of course if they start off the interview with "I- want -this -and -that- and- that's- all -go- get- it". Like you and another poster said. I guess I'd want to say sorry too.
On the other hand, if I didn't let the doctor know what I can't take or what works and what I've tried in the past up front, I may get something I know will be useless. Why waste our time? Just a note..when this all started I was gung ho about trying everything. Even going as far as to argue with the doctor to NOT give me narcotics since I wanted to find a long term solution. If something comes up that's new and I haven't tried it..bring it on

Except haldol. It doesn't look like an option here. But I will suggest it and see what they say.

Anyways..enough about demerol Katee

Thanks for taking the time to clarify things ERMudPhud, and I apologize for overeacting.

Katee

PS: If anyone can make heads or tails of the Decadron /Maxeran/ Toradol reaction I'd like to hear about it. All onboard at the same time BTW.

 

[RexKD]

I believe anesthesiology has a "pain" fellowship. Would that entail them dealing with patients who come to them directly for chronic pain? If so, maybe the drug-seeking could more effectively be offloaded on pain specialized anesthesiologists.

 

[rdennisjr]

While we have not eliminated Demerol from the formulary, it is probably something that will come down the road. Seekers are certainly one part of that decision, but the other part is that it is becoming more clear that demerol is not as safe as it has been thought to be. The metabolite from it causes several problems, the most important being seizures. This is not exactly a rare side effect. In our institution, demerol is less than 10% of all pain-relieving drugs, but it results in about 40-50% of all side-effect issues. That's the main reason the institution is going down that road.

As for personally - other drugs work as well is what it comes down to. In the ED i'm not working on long-term control of pain, just the acute issue and close follow-up. Since I don't know the patient from joe-bob, it comes down to the fact that I'm not trusting enough. I know the drug has addiction issues, and if I'm the 4th or 5th provider this guru has seen in the last 3 days and I do give them the demerol and it is the straw that breaks the back and the guy starts seizing on me (and these do tend to be very difficult to break seizures) then I'm in a world of hurt - one that I can easily avoid through the use of other meds.

D

 

[Katee80]

While we have not eliminated Demerol from the formulary, it is probably something that will come down the road. Seekers are certainly one part of that decision, but the other part is that it is becoming more clear that demerol is not as safe as it has been thought to be. The metabolite from it causes several problems, the most important being seizures. This is not exactly a rare side effect. In our institution, demerol is less than 10% of all pain-relieving drugs, but it results in about 40-50% of all side-effect issues. That's the main reason the institution is going down that road.

As for personally - other drugs work as well is what it comes down to. In the ED i'm not working on long-term control of pain, just the acute issue and close follow-up. Since I don't know the patient from joe-bob, it comes down to the fact that I'm not trusting enough. I know the drug has addiction issues, and if I'm the 4th or 5th provider this guru has seen in the last 3 days and I do give them the demerol and it is the straw that breaks the back and the guy starts seizing on me (and these do tend to be very difficult to break seizures) then I'm in a world of hurt - one that I can easily avoid through the use of other meds.

D

How many healthy young pts with no renal impairment have seized on you? Just curious. Looking at the other side of the coin is all.

 

[NinerNiner999]

For what its worth, when I was in medical school I worked at two different ED's - one of which had Demerol (my home ED), and one which discontinued it halfway through my fourth year (across town). Around the same time that it was discontinued, there was a documented increase in the number of patients with "intractable pain" who began coming to our ED, staying for hours on end taking morphine and dilauded "without effect" (I remember one abdominal patient I had who could barely maintain coherent speech, let alone see me through his pinpoint pupils) but demanded Demerol for relief. It was so bad at the time that staff from the other ED were invited to our ED to identify their frequent fliers and bring old charts for our records. One random day when visiting staff came by, there were 7 "chronic pain" patients who were known to the visiting attendings. SEVEN in one day!! An internal study of our department later revealed a surge of nearly 11% over a four month window, with electronic chart review of the words Demerol and pain showing a concordant increase over months past. We eventually discontinued Demerol in our ED and from what I hear, visits are on the decline. Take from this what you will.

I know that the topic of pain control and chronic pain management can be a powder keg for some people, but in general and in our field - it can also be a huge medicolegal landmine that brings up other questions - should EDs be responsible for chronic pain management? To what extent do educated addicts warrant their workups (what do we do with the Demerol seeker with the "worst headache of his life" who "hit his head" ). I can see Katee's point and I can also see MudPhud's point, but truthfully, I don't think anything I read will ever influence my decision to dispense pain medications, aside from clear FDA and evidence-based medicine suggesting the contrary (or a cruise and a steak dinner from Glaxo , j/k).

I'm not educated enough to truly tell anyone that they don't have pain - and I don't think I will ever be (unless we put polygraph machines in the rooms), but I'm learning to refine decision-making regarding ordering CT's and performing LP's. I'm also aware that the patient who ties up my bed for hours with "intractable pain" needs admission to the hospital, discharge home, a properly documented set of AMA papers, or an eventual administrative discharge from my facilty for numerous bogus complaints. These unfortunately are not blanket decisions for a subgroup of patients, but are in the differential of disposition for everyone who names a drug in their allergy list or by request. Pain is one thing, but once I've ruled out the bad things that can actually kill a patient (and pain is actually quite far from my list), its time for the next sick patient to have their turn.

 

[Sessamoid]

In my experience, Demerol induced seizures are rare to non-existent in acute pain dosages. I've given a crapload more Demerol than I have Ultram, and I've never seen a seizure from it. I've seen one Ultram-related seizure, and it wasn't even my prescription.

 

[Katee80]

For what its worth, when I was in medical school I worked at two different ED's - one of which had Demerol (my home ED), and one which discontinued it halfway through my fourth year (across town). Around the same time that it was discontinued, there was a documented increase in the number of patients with "intractable pain" who began coming to our ED, staying for hours on end taking morphine and dilauded "without effect" (I remember one abdominal patient I had who could barely maintain coherent speech, let alone see me through his pinpoint pupils) but demanded Demerol for relief. It was so bad at the time that staff from the other ED were invited to our ED to identify their frequent fliers and bring old charts for our records. One random day when visiting staff came by, there were 7 "chronic pain" patients who were known to the visiting attendings. SEVEN in one day!! An internal study of our department later revealed a surge of nearly 11% over a four month window, with electronic chart review of the words Demerol and pain showing a concordant increase over months past. We eventually discontinued Demerol in our ED and from what I hear, visits are on the decline. Take from this what you will.

I know that the topic of pain control and chronic pain management can be a powder keg for some people, but in general and in our field - it can also be a huge medicolegal landmine that brings up other questions - should EDs be responsible for chronic pain management? To what extent do educated addicts warrant their workups (what do we do with the Demerol seeker with the "worst headache of his life" who "hit his head" ). I can see Katee's point and I can also see MudPhud's point, but truthfully, I don't think anything I read will ever influence my decision to dispense pain medications, aside from clear FDA and evidence-based medicine suggesting the contrary (or a cruise and a steak dinner from Glaxo , j/k).

I'm not educated enough to truly tell anyone that they don't have pain - and I don't think I will ever be (unless we put polygraph machines in the rooms), but I'm learning to refine decision-making regarding ordering CT's and performing LP's. I'm also aware that the patient who ties up my bed for hours with "intractable pain" needs admission to the hospital, discharge home, a properly documented set of AMA papers, or an eventual administrative discharge from my facilty for numerous bogus complaints. These unfortunately are not blanket decisions for a subgroup of patients, but are in the differential of disposition for everyone who names a drug in their allergy list or by request. Pain is one thing, but once I've ruled out the bad things that can actually kill a patient (and pain is actually quite far from my list), its time for the next sick patient to have their turn.

I don't know ...I agree chronic pain is not the responsibility of the ED. Acute pain is. I witnessed something tonight that really got me angry so I'll share.
35 yo woman presenting with acute lower abd pain in RLQ. Pressure 158/103, HR 112, R 21, temp 36.9., vomiting writhing in agony. I knew her as one of my old babysitters. Totally cool, proffesional woman with 2 kids and an awesome hubby. She was crying, and I was sitting a little bit away from her waiting for my instrutor to show up so I heard the whole conversation.
doc: So you're having some pain huh?
girl: Yes..too much..its excrutiating.
Doctor went on to do his assessment, palp, blablabla
girl: Can I please have something for pain?
Doc: Well you look like you're allergic to quite a few things but I'm willing to bet they're just sensitivities right?

(ends up she was allergic to morphine and hydromorphone and some food allergies and penecillin)

Doc: what helped with your pain in the past since you were here 5 years ago for the same thing.(suspected ovarian cyst)
Girk: I got Demerol and it worked very well
Doc: Well unfortunately for you I don't give Demerol so I 'll have to give you toradol.
girl: It wasn't enough the last time! (a litle frantic now)
Doc: Well theres a lot of things that are wrong with that drug so I don't give it anymore. Tough luck for you though.I'm sorry.
Girl: starts crying.

She eventually got toradol, gravol and a shot of fentanyl but ..you guessed it....it didn't last 45 minutes.

Now according to me that was a totally cruel thing to do. Our hospital still uses demarol ...alot. For him to withhold it from this poor lady was just plain mean and totally uncalled for. She has no renal impairment, no hx of seizures, shes only been to the hospital 2x for this before and is an avid runner. She hates drugs but she asked for relief by the one person with the power to do it and he refused. It was really busy tonight.....everybody has to run around like their heads were cut off, including the doctor and he has to reasess her every 40 minutes, order more med and waste time when he could have bought time and gave her the damn drug and it would have been all good for at least 2or 3 hours. Demerol was made as an option for pain for petes sake. Its there...freaking use it!!!!!

I found it a little bizarre to witness since we've been discussing it here.

And to top it all off I overheard him telling a nurse to give another pt a script for 10 percocet. freaking 10. The poor guy cant go to a dentist until monday becasue he gets paid and can't afford to go sooner! 10! What an insult! The guy was again a good upstanding citizen with no chart. Hes never been there before. He goes to school too. My school The doctor didnt even ask how many he will need to take and base the script on that. 10.

This doctor was definatly not treating the person and barely treating the pain A real opiophobic if you ask me.

I understand your points that its just too much hassle to treat all the druggies but please folks...keep an open mind. If the pt seems to NOT be one of "those"........and they ask for something they know will work better than something else. Dont freak out because they can pronounce it and automatically think drugseeker, secondary gain.

Thanks for letting me vent. I welcome consructtive feedback. I'm trying hard to understand his actions but I'm really struggling. What will I do when I'm doing an ER rotation ? I'm gonna freak out if I see that again!!!!!

Didn't her vitals reflect pain?

Ended up having an appendectomy

PS: I'm learning alot by asking questions so I'm not exactly argueing with you. THank you for reading.

Katee

 

[NinerNiner999]

I'm not arguing either, just speaking from experience. Individual cases abound, but the correct EM pathway toward diagnosis will usually (if not close to always) expose the true emergency. You mention serial abdominal exams (every 40 minutes I think you stated). By this inference, your doctor did not immediately discount the patient's pain, but gave her adequate pain medication between exams (you will be taught that surgeons are notoriously picky when it comes to masking serial abdominal pain with potent narcotics). You will also find that for every one patient with true NEED for "demerol" and with a narc list of allergies longer than their PMH, there will be 100-200 drug seekers who get their prescriptions and OD or sell them for street value to others who will OD. Suddenly that one patient becomes 5-10 patients who get pumped with narcan and are intubated for cardiorespiratory failure after being found down.

I'm not sure why you are so opinionated about this topic and find it interesting to comment upon. Perhaps a simple formula for future use would help to straighten out the problem:

Age of patient + (number of items on PMH / number of true drug allergies) - number of accessible old charts for same complaint + (heart rate - diastolic BP) * .85 = Likelihood of need for stated medication (percentage)

** Correction factor: add 2 points for each estimated 15-minute period it will take your patient to leave the emergency department.

Example 1: 20yo patient with PMH of migraines and allergies to fentanyl, morphine, codeine, and hydromorphone. 12 prior admissions for same complaint in last 2 months. Vitals 37.1 88 16 135/80 99% RA. Patient walked in from the street and seems anxious. In this case, I would say liklihood of, oh, 14% with zero points for time to leave- see ya.

Example 2: 76yo patient brought in by EMS with PMH of appendicitis, cholecystecomy, kidney stones, hypertension, renal disease, migraines, and depression. Allergies to morphine, toradol (NSAIDS), hydromorphone, codeine, and risperdal. 4 prior admissions to ED in past for similar complaints. Vitals 37.1 91 145/80 98% RA. This patient gets a score of 72% plus a correction factor of 16 because of dispositional concerns (total score 88%) and gets meds.

Note: These treatment modalities have not been evaluated or approved by the FDA or any other governing medical board. Side effects may include constipation, bloating, loose or fowl smelling stools, muscular cramping, ejaculatory malfunction, bleeding from eyes or gums, headache, fever, excessive sweating, and halitosis. Please consult with your physician prior to using this formula. This formula may be helpful but may not provide results shown such as hiking, kayaking, skiing, or high-fiving your friend's sister while walking on the beach because her menopausal symptoms have improved and she no longer has oral herpes. Results of this formula may improve or reduce your diagnostic ability.

 

[deleted6669]

Or you could just use this tried and true method: if the potentially drug seeking pt agrees to a potentially helpful procedure ( such as dental block or trigger point injection) that does not require a narcotic give them a script for a resonable # of narcotic tabs at d/c. if they refuse or give a bs excuse like "dental blocks don't work on me" then out the door with a script for nsaids.
suggestion #2 used at a friend's em residency: if your headache is bad enough to bring you to the er you WILL get an lp and ct scan. if you come back tomorrow you will get another lp and another ct. they have very few drug seekers using headache as an excuse at his facility. folks who really have a s.a.h. want the lp and ct because they want an answer. people who want meds don't want an lp every time they need a fix.....and the residents get to do plenty of lp's.......

 

[Sessamoid]

Or you could just use this tried and true method: if the potentially drug seeking pt agrees to a potentially helpful procedure ( such as dental block or trigger point injection) that does not require a narcotic give them a script for a resonable # of narcotic tabs at d/c. if they refuse or give a bs excuse like "dental blocks don't work on me" then out the door with a script for nsaids.

I had one drug seeker that had no problem getting unnecessary dental blocks. He had horrible teeth, any of which looked like they could be a problem. Turns out he was well-known by the nurses who worked at other hospitals for giving the same story (my dentist is out of town, it's the weekend, etc.), then getting dental blocks with a prescription for narcotics.

 

[Katee80]

I'm not arguing either, just speaking from experience. Individual cases abound, but the correct EM pathway toward diagnosis will usually (if not close to always) expose the true emergency. You mention serial abdominal exams (every 40 minutes I think you stated). By this inference, your doctor did not immediately discount the patient's pain, but gave her adequate pain medication between exams (you will be taught that surgeons are notoriously picky when it comes to masking serial abdominal pain with potent narcotics). You will also find that for every one patient with true NEED for "demerol" and with a narc list of allergies longer than their PMH, there will be 100-200 drug seekers who get their prescriptions and OD or sell them for street value to others who will OD. Suddenly that one patient becomes 5-10 patients who get pumped with narcan and are intubated for cardiorespiratory failure after being found down.

I'm not sure why you are so opinionated about this topic and find it interesting to comment upon. Perhaps a simple formula for future use would help to straighten out the problem:

Age of patient + (number of items on PMH / number of true drug allergies) - number of accessible old charts for same complaint + (heart rate - diastolic BP) * .85 = Likelihood of need for stated medication (percentage)

** Correction factor: add 2 points for each estimated 15-minute period it will take your patient to leave the emergency department.

Example 1: 20yo patient with PMH of migraines and allergies to fentanyl, morphine, codeine, and hydromorphone. 12 prior admissions for same complaint in last 2 months. Vitals 37.1 88 16 135/80 99% RA. Patient walked in from the street and seems anxious. In this case, I would say liklihood of, oh, 14% with zero points for time to leave- see ya.

Example 2: 76yo patient brought in by EMS with PMH of appendicitis, cholecystecomy, kidney stones, hypertension, renal disease, migraines, and depression. Allergies to morphine, toradol (NSAIDS), hydromorphone, codeine, and risperdal. 4 prior admissions to ED in past for similar complaints. Vitals 37.1 91 145/80 98% RA. This patient gets a score of 72% plus a correction factor of 16 because of dispositional concerns (total score 88%) and gets meds.

Note: These treatment modalities have not been evaluated or approved by the FDA or any other governing medical board. Side effects may include constipation, bloating, loose or fowl smelling stools, muscular cramping, ejaculatory malfunction, bleeding from eyes or gums, headache, fever, excessive sweating, and halitosis. Please consult with your physician prior to using this formula. This formula may be helpful but may not provide results shown such as hiking, kayaking, skiing, or high-fiving your friend's sister while walking on the beach because her menopausal symptoms have improved and she no longer has oral herpes. Results of this formula may improve or reduce your diagnostic ability.

As I mentioned before I find this topic of particular interrest because I've been on the receiving end of all the drama surrounding the administering of narcotics in the ER for chronic and acute pain. I've aslo been treated like a drugseeker on a few occasions. Pissed me off and humiliated me like you have no idea. It sucks to be on the receiving end of it but you would only understand if you experienced this kind of treatment which I hope none of you ever will. But I also want to get into pain management someday and I'm trying to get a grip on both sides so I don't become too biased to one train of thought. The feedback I have received here has been extremely helpful and I am beginning to understand the whole picture the more I reflect on these answers. I register for Pharm today and looking forward to it. Many of my questions could have been answered in my ANP class but we skipped over the pain section if you can believe that!

Thanks for your input. I ran off some of these answers to bring to class. My friends think you guys are the bomb!

Katee

PS: Do you really use that formula? Did you make it up? Pretty nifty Niner!!!
Although ....nifty as it is...let's say the dude with the migraine is a normal dude..like say my dad. Long hx of migraines. Keeping in mind treating and getting migraines under control is an art..not necessarily textbook.. and takes sometimes months to reach a somewhat perfect combo while going through many meds, aren't the chances of multiple allergies or sensitivities going to go up? So even if the PMH is low and the allergy list is high...so what? It is easily explained right? *nifty niner shakes head here

And I just thought of something. Can't I just do a UTS for street drugs? Can I do a blood test without telling the pt what I'm looking for? If a pt comes in and I'm suspicious..that's the first thing I'd do after taking his hx. If I find narcotics of any kind in his blood and it doesn't add up to what he's told me..well there you go. Problem solved

*Katee is feeling pretty good right now about solving problem but there's probably a catch to this approach isn't there?

 

[NinerNiner999]

Perhaps I came across as too serious (something I'm rarely accused of doing) and my sarcasm was misconstrued as dogma

Tox screens are reasonable for this purpose if the patient agrees to having it done. If they refuse angrily, then red flags could be raised or they could just be insulted. Also, if they give a history of trying "every narcotic without relief" and the tox is negative - a red flag should be raised for the potential dealer who is obtaining meds to sell. Either way, it couldn't hurt.

As I mentioned before I find this topic of particular interrest because I've been on the receiving end of all the drama surrounding the administering of narcotics in the ER for chronic and acute pain. I've aslo been treated like a drugseeker on a few occasions. Pissed me off and humiliated me like you have no idea. It sucks to be on the receiving end of it but you would only understand if you experienced this kind of treatment which I hope none of you ever will. But I also want to get into pain management someday and I'm trying to get a grip on both sides so I don't become too biased to one train of thought. The feedback I have received here has been extremely helpful and I am beginning to understand the whole picture the more I reflect on these answers. I register for Pharm today and looking forward to it. Many of my questions could have been answered in my ANP class but we skipped over the pain section if you can believe that!

Thanks for your input. I ran off some of these answers to bring to class. My friends think you guys are the bomb!

Katee

PS: Do you really use that formula? Did you make it up? Pretty nifty Niner!!!
Although ....nifty as it is...let's say the dude with the migraine is a normal dude..like say my dad. Long hx of migraines. Keeping in mind treating and getting migraines under control is an art..not necessarily textbook.. and takes sometimes months to reach a somewhat perfect combo while going through many meds, aren't the chances of multiple allergies or sensitivities going to go up? So even if the PMH is low and the allergy list is high...so what? It is easily explained right? *nifty niner shakes head here

And I just thought of something. Can't I just do a UTS for street drugs? Can I do a blood test without telling the pt what I'm looking for? If a pt comes in and I'm suspicious..that's the first thing I'd do after taking his hx. If I find narcotics of any kind in his blood and it doesn't add up to what he's told me..well there you go. Problem solved

*Katee is feeling pretty good right now about solving problem but there's probably a catch to this approach isn't there?

 

[EMResident]

Regarding the use of Demerol and its being withheld:

The physician is solely responsible for what happens to his/her patient. Prescribing medications is up to the professional discretion of the physician and should s/he choose to use or not use a medication that is their medical opinion. When people present to an emergency department they are requesting a medical opinion in regards to diagnosis and treatment. Again, the ED is not the "convenient room" nor does it provide a menu from which to choose one's drugs of choice.

Regarding the dispensed number of narcotics:

The ED is a temporary solution. I never prescribe more than 20 tablets of any pain medication, and I inform the patients of my reasoning. If their pain is so severe that they require more than that (after explaining their dosing and how many days worth are provided), the need to know to return to the ED for re-evaluation OR see the physician who will provide the long-term care for this clearly chronic condition. That physician may then prescribe as s/he chooses. As part of the public health system (either explicitly, as in a county hospital, or implicitly, as all emergency departments are), the ED bears responsibility to both its patients but also those outside our doors: the person held up to get cash to buy Percocets, the pedestrian killed by the opioid-intoxicated driver (despite instructions not to drive).

Not an easy issue by any means, but an issue fraught with varying viewpoints and yet another example of the ED functioning as a fishbowl.

 

[Katee80]

Perhaps I came across as too serious (something I'm rarely accused of doing) and my sarcasm was misconstrued as dogma

Tox screens are reasonable for this purpose if the patient agrees to having it done. If they refuse angrily, then red flags could be raised or they could just be insulted. Also, if they give a history of trying "every narcotic without relief" and the tox is negative - a red flag should be raised for the potential dealer who is obtaining meds to sell. Either way, it couldn't hurt.

Are you telling me I've been sitting here working out a few case scenarios for nothing? That there's no actual literature on this formula?

I kinda figured it was for fun but I thought I'd try it out anyways.

that's my story and I'm sticking to it

 

[docB]

I just spent a huge chunk of time catering to two drug seekers. Both are addicted to Dilaudid. One comes in with the complaint that about once a month he has this horrible belly pain that only goes away with Dilaudid and “Phenergren.” He looked really uncomfortable and screamed when I touched his belly so I ordered up the works (labs, CT, IVF) and gave him his Dilaudid. The nurse came and told me that about 30 min after getting his fix he jumped up ripped out his IV and eloped.

The second was a woman who came in with 3 years of belly pain and a lot of garbage diagnoses like irritable bowel and endometriosis. She came in screaming and I couldn’t even do an exam initially. She bellowed that she can only get relief from Dilaudid and “Phenergren” and that she gets a rash with morphine. So I gave it to her. From then on she slept but every time she’d wake up she’d say, in a perfectly normal manner, “I’m having that 10/10 pain again. I need more Dilaudid. You really should give me 4 this time.” The daughter was with her and reported multiple normal workups with CTs in the last 2 months, a history of this dating back 3 years and a negative exploratory laparoscopy 3 months prior. I found that the patient had a WBC of 17 so I felt compelled to work her up. The daughter thought that this might be some infection from a uterine biopsy she had weeks ago so she basically forced me to dig around in this woman’s crotch for good measure. The whole workup was negative except for the WBC which was probably margination from her acute Dilaudid withdrawals.

Now aside from the wasted time on my part and the wasted beds for the ER while actual sick people sat in the waiting room and the repeated useless workups with CTs and exposure to the dye and every thing else that was wrong about these pictures does anyone think medicine has made life better for these people by providing them with a drug to which they have become addicted? Demerol and Dilaudid ruin lives and turn people into trolls whose lives become one long trek from ER to ER for their fix. I’m basically a stinking drug dealer who’s forced to keep dealing by EMTALA. I need a hot shower.

 

[Sessamoid]

Demerol and Dilaudid ruin lives and turn people into trolls whose lives become one long trek from ER to ER for their fix. I’m basically a stinking drug dealer who’s forced to keep dealing by EMTALA. I need a hot shower.

Katee, you want to know why some of us feel the way we do about opiates and Demerol in particular? I've worked in a hospital where the above cases were a daily occurrence. Daily. That gets old fast, and it can get difficult to tell the real from the bogus. Even a known drug-seeker will get sick eventually too. I had a known chronic drug-seeker come in for the typical abdominal pain story as above a few months ago, only this time she really had appendicitis.

 

[Katee80]

Katee, you want to know why some of us feel the way we do about opiates and Demerol in particular? I've worked in a hospital where the above cases were a daily occurrence. Daily. That gets old fast, and it can get difficult to tell the real from the bogus. Even a known drug-seeker will get sick eventually too. I had a known chronic drug-seeker come in for the typical abdominal pain story as above a few months ago, only this time she really had appendicitis.

I understand Sessamoid. It must piss you off something awful. I got pissed off just reading the post you quoted from. I'm not a lost cause y'a know. There is hope for me yet.

 

[la gringa]

docb,

"phenergren" cracked me up... i was on a rotation with a PA student during my 3rd year who said phenergren every freaking day. it is to be noted as well that she wasn't a whole lot more competent at anything else. ugh...

 

[docB]

docb,

"phenergren" cracked me up... i was on a rotation with a PA student during my 3rd year who said phenergren every freaking day. it is to be noted as well that she wasn't a whole lot more competent at anything else. ugh...

I should add it to the "Medical Ebonics" thread.

 

[spyderdoc]

I should add it to the "Medical Ebonics" thread.

It's already there....Just read