junkie with a broken thumb

[doctorFred]

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had a patient a little while back. admitted frequent IV heroin user and pill popper, supposed to be on suboxone, comes in with an obviously deformed, broken thumb. got her thumb spica. preparing to dispo her, i have to decide what meds to send her home with. one attending wants to be hardline, motrin only. senior resident says give her percocet. i end up giving her a scrip for ultram.

thoughts?

 

[deleted109597]

Ultram could put her in withdrawal. It's also not a great pain reliever. She is a risk for diversion/OD, so a small amount of Percocet would still be safe (as in 10 or less).
While there are ****ty people out there, painful situations are painful, and you should at least give them something that will help. You can't make them not overdose on it, but there are times not to be hardline.

 

[Rendar5]

my thought is, is percocet even going to have an effect on a patient on suboxone?

 

[tkim]

non-opiods should be the first line - NSAIDS, tylenol.

another strategy would be full agonists without tylenol or motrin, since people on suboxone will require higher doses to attain adequate pain control, so the risk of liver toxicity is higher which I think most ER docs would cringe at rxing for that and the increased risk of abuse/respiratory depression on the pure opiates.

yet another strategy is dose the suboxone at lower dosages more frequently for acute pain control, which would require the patient to control their dosages, which might be the best solution since it doesn't require the addition of another med by us.

another option would be to d/c the suboxone and rx normal opiates with tylenol until you can control the acute pain with non-opiates and then resume suboxone. that might require some coordination with the suboxone prescriber.

 

[WilcoWorld]

A bit off topic, but when you really need pain control on an opioid-dependant patient in your ED (an I&D of a recent shooter's abscess comes to mind), ketamine (start low, titrate up) is a good choice.

 

[TysonCook]

...agree with WW. See too many pill heads that the resident gave 8 lbs of dilaudid to and no effect. Ketamine can be your friend.

For the pt with the thumb. Whatever pill you want in small # (10-12), ice pack, splint, and f/u w/pcp.

Druggies get hurt too 🙂

 

[Colbert]

...agree with WW. See too many pill heads that the resident gave 8 lbs of dilaudid to and no effect. Ketamine can be your friend.

For the pt with the thumb. Whatever pill you want in small # (10-12), ice pack, splint, and f/u w/pcp.

Druggies get hurt too 🙂

I realize that I'm just starting and still figuring out "my style," but when there is obvious pathology I can't under the seeming vengeance that some attendings have when it comes to people who abuse drugs. If they were not admitted drug abusers, would they still deny them percocet?

 

[deleted109597]

I realize that I'm just starting and still figuring out "my style," but when there is obvious pathology I can't under the seeming vengeance that some attendings have when it comes to people who abuse drugs. If they were not admitted drug abusers, would they still deny them percocet?

Think of it this way. Would you give an alcoholic a drink?

 

[Hamhock]

A bit off topic, but when you really need pain control on an opioid-dependant patient in your ED (an I&D of a recent shooter's abscess comes to mind), ketamine (start low, titrate up) is a good choice.

...

 

[The White Coat Investor]

How many of us have broken bones and NOT taken an opiate? Once it is splinted and well iced many fractures don't require analgesics at all. I certainly wouldn't feel obligated to give narcotics to a druggie with a thumb fracture.

 

[EctopicFetus]

Def an interesting topic. While I dont think a doc would be required I think it would be wrong to not provide analgesia. The amount depends on the specific situation.

The comment re giving an alcoholic a drink is a poor analogy since etoh wont help this person and opiates will relieve the suffering in these people.

Im pretty firm on the druggies but if you have an injury I can verify i will treat em.

 

[Flopotomist]

I am a doctor - not a cop, not a soldier in Nancy Reagan's war on drugs, and not a creature sent from heaven to end drug addiction. I treat pain. I try to make patients feel better. If a patient has a verifiably painful condition (eg a broken thumb) I treat the pain. Period. I don't care if the patient is a scum bucket child molester who shoots heroin. I am a doctor. I treat the pain.

If you are worried about diversion - you can do a few things... you can give a longer acting drug (eg oxycontin) and fewer pills. The nice thing about this strategy, she will either need those for herself, so won't divert (or can't divert as many) AND you are treating her pain.

If the patient is on suboxone, she is likely motivated to quit opiates, so you can offer to do a nerve block, tell her that she will probably feel better with just some ibuprofen (ortho can yell at me for ibuprofen and poor bone healing later) and then tell her if she still hurts you can block her again tomorrow.

Other thoughts?

 

[deleted65604]

The comment re giving an alcoholic a drink is a poor analogy since etoh wont help this person and opiates will relieve the suffering in these people.

A person in alcoholic withdrawal is suffering. A drink of alcohol will definitely relieve their suffering...temporarily.

The point is that it just takes a few more hits of their narcotic high to totally make them relapse. It is in the best interest of an addict to never be offered their preferred drug EVER again.

 

[deleted65604]

How many of us have broken bones and NOT taken an opiate? Once it is splinted and well iced many fractures don't require analgesics at all. I certainly wouldn't feel obligated to give narcotics to a druggie with a thumb fracture.

Agree. I have had three broken bones in my life. I have never had narcotics for anything, fractures included. I can see giving a vicodin at night to be able to sleep despite the aching. Long bone fractures are different, but a finger? Come on. Life is painful, society needs to come to terms with this. Do I give narcotics? Yes, way more than I think is indicated, but only because Press-Ganey exists and to encourage people that I'm on their side so they don't sue me if I screw up.

 

[doctorFred]

I am a doctor - not a cop, not a soldier in Nancy Reagan's war on drugs, and not a creature sent from heaven to end drug addiction. I treat pain. I try to make patients feel better. If a patient has a verifiably painful condition (eg a broken thumb) I treat the pain. Period. I don't care if the patient is a scum bucket child molester who shoots heroin. I am a doctor. I treat the pain.

well, i guess if you want to talk about your higher calling as a physician, you are required to "first, do no harm." some may construe giving opiates to an admitted addict as "doing harm".

 

[Flopotomist]

If the patient is in a program, and has a desire to quit, then I would talk with the patient about the risk of taking an opiate and relapsing, and let the patient decide if controlling the pain was worth risking relapse. It is paternalistic for me to make that decision for her. Again, in the scenario given, the patient has a confirmed pathology that is painful, I agree with other people who don't hand out the candy to people who are full of BS and just trying to game the system to divert.

 

[EctopicFetus]

well, i guess if you want to talk about your higher calling as a physician, you are required to "first, do no harm." some may construe giving opiates to an admitted addict as "doing harm".

Not alleviating suffering is just as bad. If the person has an acute and real injury not treating their pain at their request IMO is unfair.

I know the topic of narcs is a touchy one among EPs. My view is there are really few things we can do where we make a difference. One thing we can do is alleviate their suffering/pain.

I dislocated my pinky 3 times, never took anything for it once it was relocated. 1st time as a college kid I got a local block the next 2 times I just had it yanked. I dont disagree but those addicts are more sensitive to pain given their opiate abuse. I try not to judge (which is very hard).

I am not saying this person should get 180 percs but my standard is 12 percs.

Lets also not fool ourselves you can get opiates anywhere. I recommend googling "oxycontin express".

 

[deleted109597]

Absolutely. Remember, we are being judged by CMS, TJC, and Press Ganey. There are plenty of research papers that show that we are terrible about judging who is an addict to alcohol or narcotics, we simply go on prior prejudice.

As Floptomist said, I am not a cop. I don't have the time to look up every single person. I have personally taken joy in stopping people who divert, but if you have actual painful condition (including sickle cell), I would rather treat the pain acutely. I don't send them out with more than 14 however.

The doctors and pharmacies are both at fault when people can get thousands of pills per month. It isn't most EDs.

Watching the Vanguard video makes me sad.