Drug Testing

[bodeno]

I'm sure this has been discussed a million times in this forum, but here is a recent article in the news.

http://abcnews.go.com/Health/PainManagement/story?id=6232694&page=1

Probably a good idea, however, I think we should include drug testing for the president and congress too since they also have a direct impact on the lives of many people.

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[RussianJoo]

wow 19% death rate from over dose!! I don't understand how a doctor who knows the drugs their using would ever overdose.. They would never cause an over dose on one of their patients how can they overdose themselves?


well on the bright side this might open up some residency spots for others.

 

[Trisomy13]

wow 19% death rate from over dose!! I don't understand how a doctor who knows the drugs their using would ever overdose.. They would never cause an over dose on one of their patients how can they overdose themselves?

tolerance. chasing euphoria with increasing doses and finding respiratory depression instead.

well on the bright side this might open up some residency spots for others.

tasteless, even by my standards.

 

[coprolalia]

They would never cause an over dose on one of their patients how can they overdose themselves?

Ummm... anesthesiologists "overdose" patients more than you realize. The difference is, there is usually an endotracheal tube in and a breathing machine that prevents their demise.

-copro

 

[Arch Guillotti]

well on the bright side this might open up some residency spots for others.

 

[RussianJoo]

Ummm... anesthesiologists "overdose" patients more than you realize. The difference is, there is usually an endotracheal tube in and a breathing machine that prevents their demise.

-copro

interesting why do you think that's the case? aren't amounts of drugs given recorded in the anesthesia log? and if we know the duration of action and the dosage of a drug I don't see how one could give too much to cause an overdose, unless they were careless.

 

[RussianJoo]

tasteless, even by my standards.

yes I'll admit it looking back on this post it is off-color, I apologize.

I guess I just don't have the understanding of a true addiction and personally think that any addiction can be fought and won, but what do I know the only thing I've ever been addicted was potato chips.

 

[RussianJoo]

as a side note, just an observation I had.. what's with all the anesthesia and addiction articles coming out this month? for example this article by ABC News, and the article about addiction in this months' anesthesiology journal.

Did something major just happen? is the ASA being forced to implement some kind of drug testing?

How many of you are getting drug tested? Has anyone gotten drug tested before being accepted into a residency? or a private practice group?

based on these articles it seems like this problem has been going on for years, why is it being looked at now all of a sudden? or do articles like this come out every couple of months?

 

[bodeno]

I know MGH has mandatory testing. I think if a program wants to test residents for drugs then good for them, it is their right to set the tone for their program.

As the article points out, random drug testing is very expensive so they obviously feel there is sufficient benefit despite the cost.

As to your other point, yes any addiction can be overcome but I don't think it is just a simple matter of will power. Also, I wouldn't be so confident that you are immune. I suspect most people who are addicted at one point thought they too were immune.

As to your first point, people on the ends of the PK/PD curves may recieve the "appropriate" dosage and still be over or underdosed. This is why a pharmacogenomic profile for our patients may be in the future for optimal drug dosing.

 

[Bertelman]

interesting why do you think that's the case? aren't amounts of drugs given recorded in the anesthesia log? and if we know the duration of action and the dosage of a drug I don't see how one could give too much to cause an overdose, unless they were careless.

Drugs have varying effects on a population.

When a person has high blood pressure, we don't use an algorithm to dose the meds based on their blood pressure. You try drug X, then increase the dose, then add drug Y, etc. The surgical population is not an ideal clone which reacts predictably to every drug administered. Age, substance use, metabolism inducers, and genetics all play a role in the dose of anesthesia.

Combine that with the fact that surgery is not a constant affront on the body. You need a certain amount of anesthetic to induce and intubate, then less anesthetic to maintain until incision, then more anesthetic to overcome surgical stimulus, then no anesthesia at the end of the case.

Thanks for painting Joe the Anesthesiologist as careless. I personally think you're careless for making assumptions about a profession you hardly understand.

Back to your original statement regarding how a physician specialized in drug titration can OD: Drug addiction is a disease, and I would argue that regardless of what these physicians do with their patients, they are clearly not in control of their own actions. It should be no surprise they might take too much. That, and everything Copro said.

 

[thegasman]

interesting why do you think that's the case? aren't amounts of drugs given recorded in the anesthesia log? and if we know the duration of action and the dosage of a drug I don't see how one could give too much to cause an overdose, unless they were careless.

you obviously have no experience in treating real patients. Patients respond differently - not everyone is the same - and the "dosage" is nothing more than an educated guess based on knowledge and experience.

 

[bruins2008]

RussianJoo: well on the bright side this might open up some residency spots for others.[/quote]

with an attitude like this, I wouldnt want to have you as part of my program, let alone represent Anesthesiology

 

[bruins2008]

interesting why do you think that's the case? aren't amounts of drugs given recorded in the anesthesia log? and if we know the duration of action and the dosage of a drug I don't see how one could give too much to cause an overdose, unless they were careless.


sorry, from that statement, it shows that you absolutely dont know anything about real world patient care. Maybe you should do an anesthesia rotation and experience how differently the same dose of propofol would render an elderly person apneic while it would barely phase a person in their 20's.

 

[CambieMD]

.

 

[RussianJoo]

Thank you for your explanations they were very helpful. I definitely plan on doing a rotation or two in anesthesia. You guys made some good points that I totally forgot about, i.e. the genetic part of drug metabolism. It will be nice when in the future genetic testing can reliably determine the optimal dosage to use.

 

[Noyac]

It will be nice when in the future genetic testing can reliably determine the optimal dosage to use.

Will it?

 

[Arch Guillotti]

It will be nice when in the future genetic testing can reliably determine the optimal dosage to use.

In what way?

 

[RussianJoo]

no more OD's? you guys said it. dosages of drugs to use for optimal anesthesia are unknown due to the fact that each person metabolizes the drugs at different rates because of their genetic makeup. Well if we know who the fast metabolizers are and who the slow metabolizers are by a simple screening test or a genetic makeup test then we can adjust the dosages accordingly and prevent OD's or poor pain control.

 

[bruins2008]

no more OD's? you guys said it. dosages of drugs to use for optimal anesthesia are unknown due to the fact that each person metabolizes the drugs at different rates because of their genetic makeup. Well if we know who the fast metabolizers are and who the slow metabolizers are by a simple screening test or a genetic makeup test then we can adjust the dosages accordingly and prevent OD's or poor pain control.

it isnt only genetics, drug users and abusers wheter it be alcohol or benzos also have different tolerances even if they are not "genetically susceptible." and like I said, tolerance can change with age as well. So your statement pretty much again shows how little you know about anesthesiology, sorry dude. If you are dead set on gas, do a rotation first before you come here and make false statements. Seems like you know very little at this point.

 

[huktonfonix]

+ renal and hepatic function, effects of concurrent medications, etc.... One of the most important phrases for you to learn. "You can always give more, but you cant take it away." Titrate to effect. You dont need to know the "perfect dose" and probably never will.

 

[RussianJoo]

it isnt only genetics, drug users and abusers wheter it be alcohol or benzos also have different tolerances even if they are not "genetically susceptible." and like I said, tolerance can change with age as well. So your statement pretty much again shows how little you know about anesthesiology, sorry dude. If you are dead set on gas, do a rotation first before you come here and make false statements. Seems like you know very little at this point.

actually in my statement i wasn't talking about addicts i was talking about better patient care, since people above mentioned that anesthesioligists over dose patients because there really is no known dose since each patient metabolizes drugs at a different rate knowing if they're a fast or slow metabolizer will allow for better drug dosages. I am not talking about abusers or addicts. Let the psychiatrists deal with them.

 

[RussianJoo]

+ renal and hepatic function, effects of concurrent medications, etc.... One of the most important phrases for you to learn. "You can always give more, but you cant take it away." Titrate to effect. You dont need to know the "perfect dose" and probably never will.

yes but we already have tests to determine liver function or liver damage i should say, and kidney function i.e. BUN levels and creatinine clearance. now if we only had a test to find out if the person was a fast or slow acetylator then a safer dose could be calculated.

 

[coprolalia]

... since people above mentioned that anesthesioligists over dose patients because there really is no known dose since each patient metabolizes drugs at a different rate knowing if they're a fast or slow metabolizer will allow for better drug dosages.

Yeah, and sometimes we even do it purposefully. Go sit in the cardiac room and watch as the anesthesiologist gives 500mcg of fentanyl to a patient on induction.

-copro

 

[RussianJoo]

so those patients have respiratory depression and other side effects associated with fentanyl over dose? I know that fentanyl has the least change on the myocardial performance, and thus is a good choice in a cardiac patient. Also how much did the person you gave this to weighed? Isn't a fantanyl induction dose 5 to 15mcg per kg. so if the patient weighed 100kg (not too uncommon) then that wouldn't be an "overdose" but might not even be a sufficient dose.

 

[coprolalia]

so those patients have respiratory depression and other side effects associated with fentanyl over dose? I know that fentanyl has the least change on the myocardial performance, and thus is a good choice in a cardiac patient. Also how much did the person you gave this to weighed? Isn't a fantanyl induction dose 5 to 15mcg per kg. so if the patient weighed 100kg (not too uncommon) then that wouldn't be an "overdose" but might not even be a sufficient dose.

This is pretty "standard" induction for most (if not all) cardiac patients at our institution. The "sympatholytic" dose of fentanyl is 8 mcg/kg. And, that's the goal of this strategy. You want to take the patient's sympathetic response to intubation completely out of the equation.

Sure, there are other strategies to accomplishing this, but this is the fastest, most reliable, and most cost effective way. Most of our patients undergoing cardiac bypass (for various reasons, not the least of which is CABG) do not weigh 100kg. I've seen this technique performed on 55kg little old ladies. You blast them, stick the tube in, and then support them with pressors (as necessary) until they go on bypass. It's not uncommon during a four-hour case to give 2,000 mcg total of fentanyl.

By most standards, that would otherwise be considered a massive overdose in a non-cardiac case (unless the patient has an unusually high pre-anesthetic narcotic requirement... like a chronic pain patient).

-copro

 

[RussianJoo]

Thank you for the explination. So will you be persuing a cardiac anesthesia fellowship after resdiency?

 

[bruins2008]

actually in my statement i wasn't talking about addicts i was talking about better patient care, since people above mentioned that anesthesioligists over dose patients because there really is no known dose since each patient metabolizes drugs at a different rate knowing if they're a fast or slow metabolizer will allow for better drug dosages. I am not talking about abusers or addicts. Let the psychiatrists deal with them.

dude, addicts and abusers will metabolize drugs at different rates even if they're not "genetically susceptible." that's my point. so even if we did have genetic testing and it said a patient was a slow metabolizer (but they abuse drugs and have bit a tolerance to it) youre still going to give them more drugs then you think. I'm done trying to make a point to a third year med student who hasnt even done an anesthesia rotation.

 

[dfk]

actually in my statement i wasn't talking about addicts i was talking about better patient care, since people above mentioned that anesthesioligists over dose patients because there really is no known dose since each patient metabolizes drugs at a different rate knowing if they're a fast or slow metabolizer will allow for better drug dosages. I am not talking about abusers or addicts. Let the psychiatrists deal with them.

in case you weren't aware, "them" are a part of anesthesia on a daily basis. your response of letting the psychiatrists deal with them is quite narrow to say the least.

 

[bruins2008]

. I am not talking about abusers or addicts. Let the psychiatrists deal with them.

Yet another statement from you that shows that you have no idea about real world anesthesia.

 

[RussianJoo]

dude, addicts and abusers will metabolize drugs at different rates even if they're not "genetically susceptible." that's my point. so even if we did have genetic testing and it said a patient was a slow metabolizer (but they abuse drugs and have bit a tolerance to it) youre still going to give them more drugs then you think. I'm done trying to make a point to a third year med student who hasnt even done an anesthesia rotation.

I hope you're not as short with your medical students. The residents I remember who taught well were very patient and wouldn't just call someone a ***** and move on. If you're so busy you shouldn't have posted in the first place.

 

[bruins2008]

I hope you're not as short with your medical students. The residents I remember who taught well were very patient and wouldn't just call someone a ***** and move on. If you're so busy you shouldn't have posted in the first place.

Of all the students I have dealt with I have never heard anyone say something even close to the effect of:

"well on the bright side this might open up some residency spots for others"

Come on now, these are your colleagues. Good luck with everything RussianJoo.

 

[coprolalia]

Yet another statement from you that shows that you have no idea about real world anesthesia.

Dude, he's just a med student. Granted, one that appears to be a tad overconfident and a wee bit too opinionated for his knowledge level, but cut him a little slack.

And, RussianJoo, be careful about being careless with certain comments, especially on the wards. People notice, whether you realize it or not. I had to give a vote of "no confidence" to a certain med student candidate applying to our anesthesiology program this year for similar foot-in-mouth syndrome. You can think whatever you like. No one can hear your thoughts; most people do hear what comes out of your mouth (or across the keyboard), though.

-copro

 

[RussianJoo]

Yet another statement from you that shows that you have no idea about real world anesthesia.

there are addicts who drug seek in every part of medicine. Are you saying that as an anesthesiologist you sit down with those patients and try to educate them on the dangers of addiction and how to break addiction? and then schedule another appointment with them for next week to talk some more? Some how I don't think too many anesthesiologists do that. Sure every doctor is supposed to counsel their patients. but only psychiatrists and psychologists actually have sub-specialties in dealing with addiction.

 

[coprolalia]

there are addicts who drug seek in every part of medicine. Are you saying that as an anesthesiologist you sit down with those patients and try to educate them on the dangers of addiction and how to break addiction? and then schedule another appointment with them for next week to talk some more? Some how I don't think too many anesthesiologists do that. Sure every doctor is supposed to counsel their patients. but only psychiatrists and psychologists actually have sub-specialties in dealing with addiction.

You have to know these things, especially how to recognize it, when you do your chronic pain rotations. So, the answer to your questions is "yes". You also have to know the vernacular, and how to refer them out, when appropriate.

-copro

 

[RussianJoo]

Of all the students I have dealt with I have never heard anyone say something even close to the effect of:

"well on the bright side this might open up some residency spots for others"

Come on now, these are your colleagues. Good luck with everything RussianJoo.

you're right that statement was out of line. but to be honest i only said it 1) to be funny and 2) because I have read much worse statements on this forum, so in away I wanted to fit in, because I have to admit I have gotten a lot of negative replies to some of my questions in the past. Also those off color statements that I have read on other threads kind of gave me the green light to make my statement.

on valuemd the other place where I post I would never dream about making a comment like that because the mods would force me to edit my post and would give me an infraction. This forum seems to be a lot more loose.

You're 100% right these are my colleagues and in real life I would help them the best I could. I have had friends (not in med school) where I needed to sit down and talk to them about their drinking.

 

[bruins2008]

You're 100% right these are my colleagues and in real life I would help them the best I could. I have had friends (not in med school) where I needed to sit down and talk to them about their drinking.

Sorry to be so rough on you RussianJoo, I had a really close colleague that is out of gas now due to his addiction, so your statement hit close to home.

 

[RussianJoo]

Dude, he's just a med student. Granted, one that appears to be a tad overconfident and a wee bit too opinionated for his knowledge level, but cut him a little slack.

And, RussianJoo, be careful about being careless with certain comments, especially on the wards. People notice, whether you realize it or not. I had to give a vote of "no confidence" to a certain med student candidate applying to our anesthesiology program this year for similar foot-in-mouth syndrome. You can think whatever you like. No one can hear your thoughts; most people do hear what comes out of your mouth (or across the keyboard), though.

-copro

thank you for the advise. i am very PC on the wards. but on here being an anonymous forum and seeing what other regulars post, kind of gave me the go ahead for that comment.

 

[RussianJoo]

Sorry to be so rough on you RussianJoo, I had a really close colleague that is out of gas now due to his addiction, so your statement hit close to home.

it's ok that makes a lot of sense why you acted the way you did.

 

[Arch Guillotti]

you're right that statement was out of line. but to be honest i only said it 1) to be funny and 2) because I have read much worse statements on this forum, so in away I wanted to fit in, because I have to admit I have gotten a lot of negative replies to some of my questions in the past. Also those off color statements that I have read on other threads kind of gave me the green light to make my statement.

on valuemd the other place where I post I would never dream about making a comment like that because the mods would force me to edit my post and would give me an infraction. This forum seems to be a lot more loose.

You're 100% right these are my colleagues and in real life I would help them the best I could. I have had friends (not in med school) where I needed to sit down and talk to them about their drinking.

Friend, I think we all understood your comment. Understandabley you didn't mean anything by it. However, this is subject that all of us take very seriously and just don't even really see any humor in it.

 

[RussianJoo]

ok got it.

 

[Arch Guillotti]

That plus the fact that we can be a very tough crowd in here.

 

[Gern Blansten]

...but on here being an anonymous forum and seeing what other regulars post, kind of gave me the go ahead for that comment.

The fact that you have your photo on your avatar makes you hardly anonymous once interviews begin. You will be very easy to recognize.

 

[RussianJoo]

The fact that you have your photo on your avatar makes you hardly anonymous once interviews begin. You will be very easy to recognize.

are you serious? Yes that's my pic, and Arch is really a member of the NWA.

I guess I'll have to wear my silly hat so that you can recognize me better.

 

[Bertelman]

are you serious? Yes that's my pic, and Arch is really a member of the NWA.

I guess I'll have to wear my silly hat so that you can recognize me better.

Pretty sure he was joking.


....and it's probably in your best interest to just let this thread die now.

 

[coprolalia]

The fact that you have your photo on your avatar makes you hardly anonymous once interviews begin. You will be very easy to recognize.

-copro

 

[leviathan]

if we know the duration of action and the dosage of a drug I don't see how one could give too much to cause an overdose, unless they were careless.

Would your classmates think the same thing?

 

[RussianJoo]

Would your classmates think the same thing?

I don't know what my classmates think on this matter. I haven't really talked to them about it.

 

[coprolalia]

I don't know what my classmates think on this matter. I haven't really talked to them about it.

You should talk to them about it. You should talk to your supervising faculty. You should talk with the residents. You should get as many opinions as you can.

I think what Leviathan is saying, and I'm not trying to put words in his mouth, is that you should be a little more open-minded before you decide what's really happened or what the cause/effect of a particular situation is.

There are many possible explanations for a given scenario. Rarely is someone being outright careless in this profession, and this is a pretty heavy accusation to bandy around. I've tried to give you a few examples to broaden your understanding of what goes into the decision process.

Because you see someone doing something, don't assume that you understand all the reasons why they are doing it... and then draw your own conclusion making what is, in effect, a value judgment on their action ("Wow, Dr. So-and-so just gave 10mg of vecuronium. I've never seen anyone do that before. Man, that was careless.")

This is your opportunity to learn, ask questions, figure out what the thinking process is of others by asking them in a non-confrontational way why they did something.

There are many different ways to climb a mountain, as well, in what we do. Just because you observe and have an opinion on what you think is the right thing, doesn't mean someone else doesn't have an equally valid but different way of doing things. Learn that lesson now. Your posts demontrate that you assume much at this point without knowing much. That's a dangerous combination. No one will expect you to know everything at this point.

Not rippin' on you, dude. Just making some observations and trying to help. We have an intern this year that you remind me of. She has been repeatedly "talked to" by the senior residents, faculty, her advisor, and the Program Director. She's just not getting it... and she's likely to lose her job if she keeps up her current behavior.

-copro

 

[RussianJoo]

thanks again for taking time out to explain things to me. I truely appreciate it, not too many people on this forum do that. and it's great that you do.

also when i made that statement about being careless i think i was misunderstood. When I hear people use the term over dose, i think of giving too much of a drug and not realizing it or giving it by accident or thinking that a dose wasn't that strong but then it ends up being too much for the patient and the patient has adverse effects like respiratory depression for example. When people give too much of a drug in order to get known results and expected results i personally don't think of that as overdose, that just happens to be the therapeutic dose for that particular case. Thus my original comment about being careless. So I guess it was just a miss communication on my part. I have never heard the term overdose being used in a positive way.
For example that cardiac case you talked about a few posts above with the old lady I wouldn't call that overdose because that's the dose needed to achieve a certain effect. I hope that makes sense.
I know I have a lot to learn about the field of anesthesia and I am sure I am not the only one who doesn't know much about it.

 

[Bertelman]

also when i made that statement about being careless i think i was misunderstood. When I hear people use the term over dose, i think of giving too much of a drug and not realizing it or giving it by accident or thinking that a dose wasn't that strong but then it ends up being too much for the patient and the patient has adverse effects like respiratory depression for example. When people give too much of a drug in order to get known results and expected results i personally don't think of that as overdose, that just happens to be the therapeutic dose for that particular case. Thus my original comment about being careless. So I guess it was just a miss communication on my part. I have never heard the term overdose being used in a positive way.
For example that cardiac case you talked about a few posts above with the old lady I wouldn't call that overdose because that's the dose needed to achieve a certain effect. I hope that makes sense.
I know I have a lot to learn about the field of anesthesia and I am sure I am not the only one who doesn't know much about it.

I think you're the only one in this thread that used the term "overdose" when referring to accepted clinical practice.