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Discussion in 'Medical Students - MD' started by psiyung, Dec 4, 2005.
What medications would you recommend giving an alcoholic in severe pain?
ahh..just give him another drink..
That obviously depends on the diagnosis, and cannot be answered merely by knowing he/she is an alcoholic.
but there might be something about not giving cytochrome-inducing drugs b/c those will stress the liver s'more.
I don't really know. I just feel like posting.
that'll make 'em forget about their pain fo' sho
Shove a banana down his/her mouth and up his/her rectum to quickly absorb K+ from both ends.
Wow, 6 replies and not even 1 helpful answer.
Don't think that's an analgesic.
Morphine is nice. Despite it's respiratory depressant effects, so long as they aren't completely sloshed, it should not be a problem. I've had it work just fine...
How about a Benzodiazepine?
Again, I don't think you can prescribe any drugs without more info about the nature of the pain. If eg we are talking potential liver or kidney damage, then I suspect a large number of the usual pain medications are a bad idea. So the best answer is give him nothing until you can better elaborate on what kind of pain we are talking about. I call that a helpful answer.
so if there is kidney or liver damage, and assuming it may be a good idea to keep the patient off of pain narcotics, why not tylenol.. even cirrhotics are given tylenol. You can't just "do nothing".... you can't just let the patient be in pain, that's unethical. The other concern is tolerance and addiction to pain meds.. why not methadone?
Tylenol is probably not the best idea. There is alcohol-acetaminophen syndrome which can lead to fulminant hepatic failure. So, acetaminophen should probably be avoided. I would say morphine is the drug of choice here but as some people have said, morphine would be excluded in some circumstances and so the nature of the pain is important.
are you sure that you are amedical student?
what about Diclophenac?
In reality, you need to be more specific.
What's the clinical setting? Inpatient? Outpatient?
What's the liver function like?
I would really avoid tylenol in any known alcoholic in an outpatient seting. Could use it as an inpatient for mild to moderate pain if liver function tests okay. But an NSAID would be better if there's no risk of bleeding varices or ulcers. It would be malpractice to use either for severe pain.
Opiates would likely be most useful in most circumstances for what you describe. Alcoholic in severe pain.
Benzos can be used to prevent alcohol withdrawal and anxiety, but would also be malpractice for severe pain.
but part of the problem is understanding the source of his pain. There is not enough information here to diagnose the problem nor the patient's condition, therefore making it quite impossible to really give a proper answer. But I'd give the tylenol in limited dosages until more information was available. At least tylenol does not cause liver damage.
Why would you assume that it moght be a good idea to keep patient off narcotics if in severe pain? As you point out, it's unethical to undertreat pain, which is what you are doing if you toss tylenol at somebody in severe pain. You might as well give them a teaspoon of honey.
In terms of addiction... This is really a minor issue in treating somebody with severe pain although the lay public is classically misunderstands this issue.
1. Most people don't become addicted when supervised by an MD
2. Addiction is treatable later.
3. Unethical to undertreat pain because of a very low risk of a treatable condition - narcotic addiction.
Tylenol does not cause liver damage?
The ICU's are full of people who have OD'ed on tylenol. A good portion die or require liver transplants.
Why is everyone such a fan of tylenol on this site? You all want to give it, even if undertreats the patient or puts stress on his liver.
I truly hope you all are first years or nurses. That would explain it.
Unless there's more info on the source of the pain, and what can be prescribed without exaccerbating a potentially damaged organ or system, I say go with the honey.
With this limited information. Id give morpine/other opiate. Tylenol too dangerous w/ questions of ETOH w/ tylenol affecting liver function, and addiction potential is over stated. I think the main question is what is the pain from?
um, because i just went through treatment for liver problems and the only med I was allowed to take for severe side effects was tylenol...why? i was told it was the only thing not toxic to my liver. Obviously in this scenario we are not giving out overdosages of tylenol or any other med to our alcoholic patient.
Do a Google search. See eg. http://www.alkalizeforhealth.net/Ltylenol.htm
would you prescribe it like M & Ms? I know I wouldn't. For the one or two tablets I'd possibly recommend UNTIL we got a proper work up, it will not cause him to OD or need a liver transplant.
It all depends on what his pain is due to. If he already has liver damage --perhaps even for a Tyleonol OD -- we don't know, one more tylenol might not be a good idea and could be the straw that breaks the camel's back. But I was just giving a citation in response to your assertion that Tylenol was not toxic to the liver. Clearly in some cases it can be. Also note in the article that the combination of Tylenol and alcohol is not a good thing.
ok, point taken, thanks
Is the pain due to the alcoholism as in alcoholic neuropathy, because then I think you'll need something stronger than tylenol.
See the dope below...... (edit)
I've never been one to get on a moral high horse, but this whole thread is a little sketchy. It's completely irresponsible to offer medical advice under the guise that it's a valid opinion when there's no history, examination, or context given at all. And that would be the case even if we were pain management anesthesiologies with specific training in the treatment of alcoholic patients. Not only are we just medical students, many are just 1st years without any pharmacological training at all without even the faintest disclaimer to that effect. The OP might actually intend to use what we say on a patient, God forbid. Again, I don't mean to be a drag on an educational conversation... but consider the weight your words might carry for the OP.
Wanted to adress this post.. after doing extensive reserach in pain medication addiction, I can respond with some fair wit:
Addicts in severe pain, unless it's cancer pain or end of life care, are not normally given tons and tons of narcotics. Some docs wont even think about it. However if it acute and severe, then sure an IM would be in order, but the question is of what?
In response to 1. You are correct, absolutely.. however, those who are addicted to other items such as alcohol and nicotine have a propensity for other types of abuse, namely pain medications
In response to 2. Do you really want to go there.. what sane person would say.. wow, let's deal with the minor pain now and then have a horrific life altering addiction to overcome later, that doesn't even make sense (granted I'm playing devils advocate, so i'm going to extremes too)
3. Narcotic addiction is not easily treatable in an alcoholic. It is easy to taper someone off of narcotics who has an increased tolereance, but when a dependence forms, there is a whole other issue which includes detox similar to that of alcohol.... go talk to the oxycodone junkies hanging outside our hospital.... I'm sure Purdue would love to hear your feedback.
The placebo will do, mind over matter.
and many of us already said we'd advice the patient have a complete work up first
In response to many who are opposed to giving tylenol to liver patients. It is done all of the time on the GI/hepatology service by the fellows and attendings routinely.
Got a fever in someone with cirrhosis you give tylenol etc....
Here is a link. It has essentially been disproven that tylenol causes problems in liver patients in therapeutic doses.
Read on.......... there was a meta analysis done of the literature. Read the summary i've posted.
The therapeutic use of acetaminophen in patients with liver disease.
Benson GD, Koff RS, Tolman KG.
Department of Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, 401 Haddon Avenue, Camden, NJ 08103, USA. [email protected]
Acetaminophen has been used safely and effectively for many years to manage pain and/or fever in patients of all ages. It is commonly recommended as first-line therapy for a variety of patients and conditions, including the elderly, children with viral illnesses, and patients with osteoarthritis, gastrointestinal conditions, bleeding disorders, cardiovascular disease, or renal disease. However, its use is often avoided in patients with chronic liver disease. The perception that acetaminophen should be avoided in such patients arose from awareness of the association between massive acetaminophen overdose and hepatotoxicity, combined with a lack of understanding of the metabolism of acetaminophen in patients with liver disease. There are various theoretical mechanisms of acetaminophen hepatotoxicity in chronic liver disease including: altered metabolism and depleted glutathione stores that would be expected to increase accumulation of the hepatotoxic intermediate, N-acetyl-p-benzoquinone imine (NAPQI). Available studies in patients with chronic liver disease, however, have shown that although the half-life of acetaminophen may be prolonged, cytochrome P-450 activity is not increased and glutathione stores are not depleted to critical levels in those taking recommended doses. Furthermore, acetaminophen has been studied in a variety of liver diseases without evidence of increased risk of hepatotoxicity at currently recommended doses. Therefore, acetaminophen can be used safely in patients with liver disease and is a preferred analgesic/antipyretic because of the absence of the platelet impairment, gastrointestinal toxicity, and nephrotoxicity associated with nonsteroidal antiinflammatory drugs.
Analgesics, Non-Narcotic/adverse effects
Analgesics, Non-Narcotic/therapeutic use*
Cytochrome P-450 Enzyme System/metabolism
Liver Diseases/chemically induced
Liver Diseases, Alcoholic/metabolism
Cytochrome P-450 Enzyme System
While it is true that acetaminophen can be used in liver disease, the real point is that it should not be used specifically in alcoholics or in liver disease secondary to alcoholism. Alcohol upregulates the CYP2E1 enzyme. Normally only a small portion of acetaminophen is metabolized by this very same enzyme. When this enzyme metabolizes acetaminophen, it produces a reactive intermediate. Under normal conditions, the cell can take care of this metabolite using glutathione. However, in patients that are chronic alcoholics, the CYP 2E1 enzyme is upregulated. As a result, a larger portion of acetaminophen is not glucuronidated and is rather metabolized by the CYP system and converted to the reactive intermediate. Too much reactive intermediate can overcome the ability of the cell to respond with glutathione. When the cell runs out of glutathione, the reactive intermediate causes damage. So, this is a long winded explanation for why you do not use acetaminophen in patients that are chronic alcoholics. Very small doses can be very toxic in these patients.
Why would you give Tylenol for severe pain? I agree with Banner that it is unethical to undertreat the pain just because of the fear of risk of addiction.
You really need much more info than what the OP asked to give a pharmacotherapeutic recommendation. What were the patient's LFT's? Renal fxn? Alchohol abuse history? Illicit drug use? History of previous use of opioids, tolerance? Drug allergies? Current meds? Type of pain -- visceral, somatic, or neuropathic? Pain severity? Chronic or acute pain?
gee, take em off something that might have a bad interaction and give em something that will have a much worse one, very S-M-R-T.
As for methadone, the patient is not an opiate addict, regardless of alcohol addiction. everyone, repeat after me. Withdrawal AND tolerance are neither sufficient nor necessary to diagnose someone with addiction. Your patient wants more morphine because his intial dose isn't good enough anymore? he also gets withdrawal symptoms when u lessen his dose? give him more morphine. He's not an addict. be a good doctor. And when those sickle cell patients keep coming in and request specific drugs, don't wait, just give em what they ask for. unless it's demerol. give em something else and promise them that even though they don't feel that nice little kick, u're not giving em fake stuff cause u're not being a dick and thinking that they're trying to get that high for the day.
(yeah, yeah, i'm preaching. following a couple of my teachers' orders. one of them declared demerol to be teh eviiiil! he just didn't like the side effects and it seems it is as effective as morphine and other opioids if u already know everything i said, my apologies for preaching)
And how are you gonna treat the pain??????????
What you took that out of a book
???? don't see how. just seems like an explanation of why you don't give alcoholics tylenol. most students i know could explain it more or less in those terms without referring to books, at least after the right courses.
Thanks Rendar. That definitely was not out of a book, that was off the top of my head. But, you are right, we did just talk about this a month ago. We will see if I remember it in that detail a year from now. But, it doesn't take a book to be able to remember important things like this.
WOW! if the title of this thread was "How would you treat a person with cirrhosis in severe pain" this article would be so usefull. But when they wheel an alcoholic in the ER door and you don't know his BAC yet and you give him some Tylenol you're begging for trouble.
Depends on the cause of the pain and the amount! Are we talking chest pain here? Headache? Abd pain?
I'm going to assume it's abd pain consistent with pancreatitis.
I would give fluid, drop an ng tube, possibly 4 of morphine, cbc, chem 7, lft's, amylase/lipase, coags, ct abd, urine dip, ekg.
WIth regards to using tylenol. up to 2g max of tylenol can be given to ppl in liver failure.
liver failure isn't the issue. chronic alcohol intake is the issue. I have had it taught that you can have the tylenol-booze interaction even in the absence of booze when u're talking severe alcoholics, and that is what some people have brought up. I'm going to look up studies if i have a chance to see whether this is true.
that's a case report abstract. still gotta have an RCT in patients w/ alcoholic liver disease to prove anything, though.
long acting Benzodiazapines, fluids, and a calm quiet room