I know there's been a lot of talk about this over the years as I've been following this forum for quite a while. I also know that practice patterns vary widely, but I would love some more discussion on this as I am having a hard time figuring out how I want to address this issue when I graduate residency. How do you approach the following from a pain management standpoint, especially regarding narcotic use including iv vs po. Looking for responses from attendings please. (No offense students and fellow residents
1. Headache refractory to the usual cocktails or in patients who report allergy to literally every non-narc option
2. Acute worsening of chronic pain (we have a policy for chronic pain, but patients often give me a mechanism for how they re-injured/ strained/ etc)
3. Recurrent belly pain specifically (they always say it's different this time)
4. New extremity injury (excluding obvious fracture). Narcs til neg film? No narcs til positive film? Home on narcs if negative film
5. New back pain. Role of benzos?
6. Abscess before/ during/ after I and D. Those things gotta hurt
6. Chest pain
7. Will leave AMA without opiates in patients who are actually pretty sick and you really want to stay but are being very manipulative/Abusive
8. Dental pain. Can't block or failed block
Also morphine vs dilaudid (considering you are actually using equivalent dosing). We are mostly a dilaudid shop but as it has more of a euphoric effect, I wonder if I should avoid this in opiate-naive patients or those I'm worried may be seekers but I want to give the benefit of the doubt.
Thanks in advance!
Great questions and something we have all struggled with.
Before getting to your specifics, let me address the overall issue. What you are trying to do is relieve pain and have patients feel you really care about them without giving them a new problem such as opiate addiction or making their symptoms worse through issues like hyperalgesia. Start with that approach and you'll end up in the right place every time. You actually ARE doing the right thing for the patient to the best of your ability.
So the first thing I do with any type of pain issue is run their controlled substance database report. No kidding I run these on 3/4 of the patients I see in a shift and if there are more than 2 or 3 narcotic scripts, I talk to them about what's on it and how to use narcotics safely.
Then I make a decision. Is this person a drug-seeker or some other person in whom treating pain aggressively with narcotics would be a bad idea? If the answer is yes, I tell them and I tell their nurse what I will and won't do. That might include, "If I find something on your work-up that I think really should be treated with narcotics, I will give you narcotics." For example, if they're in there with what sounds like bogus flank pain but a history of stones, I tell them if you actually have a stone in your ureter, I will treat your pain with narcotics, otherwise, it'll be non-narcotics only.
Now, on to your specific issues:
1) I will usually go through 6 or 7 drugs before I use a narcotic for non-traumatic headaches. Often times, I won't even give a narcotic if they don't have relief then. I'll tell them there is nothing more I can do but refer them to a headache specialist. And I do. But I bet I add on a mg of dilaudid to 6 or 7 other drugs once or twice a year. I probably add on a benzo a handful of times a year. These are patients whose reports I've run and discussed with them, remember.
2) Depends on the CSD report. If they have chronic and take tylenol for it but have an exacerbation twice a year and get 12 norco each time, then sure, I'll give them some norco. If they've had 3500 pills in the last year, they get the talk and are offered non-narcotics.
3) I always offer to work it up if they think it's different. And I do. Rectals, pelvics, ultrasounds, labs etc. I may not offer them a CT if they've had a lot of them, but maybe even that. If their CSD looks bad, I tell them I'm only giving narcotics if I find something new that needs them. If it doesn't, I'll probably give them both narcotics in the ED and to go. If they are seeing one doc for their pain meds, I'll occasionally give them a dose in the ED while doing the work-up but tell them that I won't be sending them home with any.
4) Database concerning? No narcs unless broken. Not concerning? What would you like me to treat your pain with? You'd be surprised how many times they pick tylenol.
5) I use local anesthetics to drain it if at all possible, especially if its a druggie abscess like an antecubital fossa. Sedation if not possible (occasional Bartholin's or perirectal or pediatric.) It's rare for me to give a dose of morphine or something before doing it. If their CSD isn't concerning (and maybe even if it is), then a couple of days of narcs are totally reasonable I think.
6) I try non-narcotics, then narcotics. If it seems like drug-seeking, (much less rare with chest pain than belly/back pain) then I have the talk and offer to treat with narcs if I see something that needs them.
7) Out the door dinosaur. As discussed elsewhere, I don't try to satisfy crazy. I'm not giving you dilaudid to try to keep you in the hospital. I'll simply document why you left and why I didn't think that was the right way to treat you.
8) If CSD is unremarkable I'll often given 12 norco or something to a dental pain patient along with a referral to someone who can actually help them. I have no idea what you're talking about with someone who you can't block. Maybe you need to practice some more blocks! If they say they still have dental pain after a good block, they're probably malingering. Those things are pretty darn effective, at least for 6-12 hours. This all assumes they haven't been to our ED 15 times with dental pain of course.
I'm indifferent to morphine vs dilaudid but think it's stupid that the nurses always give 4 mg of morphine and 1 mg of dilaudid. So I mess with them by ordering 8 mg of morphine and 0.5 mg of dilaudid. Patients certainly like dilaudid better, but I'm not sure whether it's less nausea, more euphoria, less flushing, drug-seeking etc.
