Med refills

[erdoc61]

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Anyone have a policy regarding Med refills in the ED? Particulaly when it comes to narcs...

We had a pt last night (I didn't see them, a colleague did) who came in for a refill of her Duragesic patch. She ran out and her doctor couldn't get her in to see him for a week.

Now, my policy has typically been that I don't refill narcs like that. She shouldn't have waited until she was out to try to get an appointment to see her doc. My colleague said that she legitimately needs it and we should refill it. I'm not inflexible and I could see her point, however, I don't know whether or not I'd refill her script. The pt didn't seem to be in any obvious pain, although I'm sure the need for the patch is legit.

What do you think? Does this encourage her (and others) to simply come to the ED rather than try to make an appointment in advance to she their doc? How do we deal with the pts. need for pain control (albeit, perhaps not an immediate need...)?

 

[sigep628]

I am not a physician yet, but during my training in the ER, my attending said that nobody should ever be in pain. He felt that if some was coming in with a legitimate reason for needing the narcotics then you should give it to them. Now I am not saying that running out is a legititmate reason, but I would have given the patient enough to last her until she could get an appointment with her primary physician. That is just my 2 cents worth.

 

[aphistis]

What about writing for a non-narc painkiller? It won't work as well, but it's better than nothing, and might encourage the patient to put a little more effort into getting a PCP visit.

 

[docB]

I generally regard these pts as *****s for letting this happen to them and then dumping it on me. I usually go ahead and write them for plenty of narcotic happiness because it keeps tham happy and gets them out of my ER. One of my attendings said that leaving someone who has actual pain in pain is terrible while giving a junkie one more hit in a lifetime of abuse is minor.

 

[spyderdoc]

I will never fill the heavy duty meds (fentanyl, oxycontin. MS), but I may give them a few vicodins (5) until they can see their pmd the next day....I feel a lot of these people are using their meds too fast and they are usually in "contracts" with their pain specialist to get only a certain amount of meds each month...If they use them too fast, they start seeking...If we just fill them, we are encouraging this bad behavior, and interfering with the "contract" that these folks have with their pain specialist...
The only exception I may make is a terminally ill patient...They can have whatever they want...In fact, the only time in my medical career that I wrote for Demerol (IV) was a terminally ill guy whose family was begging for him to get it because it was the only narc that really made him comfortable...The guy had like a week or so left, so I wrote him for whatever the family asked for....

 

[Kalel]

My ER used to just give people enough meds until their next possible clinic visit (even the narcs). We'd document it, and then hopefully, if they came back, we wouldn't give them anymore. I had a few patients who returned for narc refills, one had a blatantly untrue story (even showed me the percocet prescription he get from another ER the previous day by accident), but my ER resident still wrote for a few perc's for his undiagnosticable dental pain. It's a shame that you have a lot of patients who try to abuse the ER system for narcotics (it's pretty easy to do though), because I'm sure that there are a lot of patients out there with genuine pain who get under-treated because people are afraid of feeding an addiction.

 

[Seaglass]

I'm more of the "I'd rather treat pain well and give a few freebies to the junkies than undertreat pain" kinda guy. I don't think it's my job to stop junkies from getting high, and it adds a bunch of crap to my shift to try to weed them out. IMHO, just give them a few to hold them over and let the chips fall where they may.

Now if they are obviously faking or are otherwise drug seeking that's another story, but for those ones where you just aren't sure I would usually just give it to them.

I only recently learned about the whole tooth pain grift. I remember reading in Annals last summer that something like 2% of ED visits are for dental complaints, and in some places (most it seems to me) you just can't get people in to see the dentists. Last summer I saw one ED patient with the PA for tooth pain. Young 18-22 yo male etc. complains of toothache, no findings. We gave him some percocet and he left joking with his buddy. I didn't think much of it until the PA says "There he goes to get high" and I realized that maybe I just got conned (sp?). When you think about it tooth pain is a good one, not much you can do to disprove it for sure. Any thoughts on how to weed out the fakers for tooth pain?

As for this pt. I'd just give them 1 duragesic and send a letter to their doc.

 

[docB]

Any thoughts on how to weed out the fakers for tooth pain?

I'm an easy touch with narcs but one thing I do with dental pain is suggest a dental block or an apical I&D and see how they react. If they say "I'll do whatever it takes to stop this pain." then they're real. If they say, "Naw, that doesn't work on me. I just need 150 of IM Demerol with 75 of Vistiril and I'll be fine." then they're FOS.

 

[Seaglass]

Nice, filing that away in the 'ol palm pilot

 

[Kalel]

Yup, we do the local block with lidocaine thing at my school too for repeat customers. It's tough to diagnose dental pain because you can't exclude them having some bad abscess just by their gums not being inflammed. The other thing that we do is give them the phone number for our school's dental clinic, but even then, I've seen patients who come to the ER saying that they "missed their appointment". The other thing to do is to use NSAIDs and abx's more often. I don't think that you should use a narc alone for dental pain, because if it's real pain, it probably means that it's infected, so the abx may help with the pain by helping with the infection. I think that dicloxacillin is the abx of choice for dental abscesses. Anyways, I think that there was a study done recently that showed that after an ER put up a sign saying that they no longer give narcotics for dental pain, the number of dental pain visits that the had plummeted. Of course, the best way to solve this would be to have a dentist on call in the ER, but unfortunately, most patients who come to the ER for dental pain have no intention of paying their hospital bill and dentists don't work for free. We, on the other hand, do.

 

[DrQuinn]

Motrin works very well for dental pain, as does "oil of clove." I'm sure there are some EBM studies out there proving it, but I'm too tired to look for them.

Q, DO

 

[spyderdoc]

I'm an easy touch with narcs but one thing I do with dental pain is suggest a dental block or an apical I&D and see how they react. If they say "I'll do whatever it takes to stop this pain." then they're real. If they say, "Naw, that doesn't work on me. I just need 150 of IM Demerol with 75 of Vistiril and I'll be fine." then they're FOS.

I agree. THese patients usually come in at 3-4AM, so I even draw up the bupivicaine in a syringe before seeing the pt and pull it out when telling this to the patient. I basically say that this will give you 6 hours of complete pain relief, so go home, eat big meal (without pain), get some sleep, and see the dentist first thing in the AM. If they agree to this, they get the bupivicaine and no narc rx....This definetly weeds out the FOS'ers...If they disagree, I give the Motrin and still no narc Rx...They leave pissed, but it is a win-win situation for me...

 

[spyderdoc]

Boy. I read my posts...I guess I have a tendency to not take crap from seekers...Most of my posts in general reflect this I guess...Must be the skepticism I developed as a police officer, and continued to refine during my medical training!!!
I really do treat pain appropriately in the patients that truly are in pain...Really!!!

 

[Katee80]

I'm an easy touch with narcs but one thing I do with dental pain is suggest a dental block or an apical I&D and see how they react. If they say "I'll do whatever it takes to stop this pain." then they're real. If they say, "Naw, that doesn't work on me. I just need 150 of IM Demerol with 75 of Vistiril and I'll be fine." then they're FOS.

Obviously there wil be those who are obviously faking for drugs but what do you do when you get a pt that has experience with pain meds due to sickle cell, status migrainous etc....naturally they probably have an idea what alleviates their pain sufficiently and what doesn't through trial and error. Do you write them off as seeking or take their word for it?
(talking about in ER treatment bty)

 

[Apollyon]

Obviously there wil be those who are obviously faking for drugs but what do you do when you get a pt that has experience with pain meds due to sickle cell, status migrainous etc....naturally they probably have an idea what alleviates their pain sufficiently and what doesn't through trial and error. Do you write them off as seeking or take their word for it?
(talking about in ER treatment bty)

As hard as some people work for pain meds, I'll just give them to them (but short them a little bit - only write for a few days worth).

 

[DrTex?]

I will qualify this comment by stating that I haven't even started medical school yet...
I have a friend who has a rare auto-immune disease which is degenerating his spine. He is in constant pain and he has been given morphine patches to make him comfortable. In Texas the summers are hot and people sweat. When he sweats, the patches can fall off. He only has so many a month and if he runs out his doctor won't give him any more. The pain is not as big of an issue as the withdrawl. He goes through hell.
Some people really need help with pain.

 

[drpcb]

I work in an extremely busy county hospital. I LOVE when I get a simple narc med refill. Often, I ask the patient, "what will it take to get you out of here happy?" Many of them will level with me that they need a refill of vicodin, there is no acute or progressive issue that I have to evaluate, and that's it. I give them 12-14 pills and tell them to follow up promptly with their PMD or in one of our clinics. Those patients who respond otherwise sometimes get more comprehensive workups. The bottom line is that if I can get a back pain patient to convince me that all he wants is a narc refill, and that he is not hiding an epidural abscess, malignancy, AAA or some other scary cause of low back pain, then we are both happy. Now, I am not advocating that you blow off everything and ascribe it to chronic benign, issues, but with experience one can get a feel for who just wants a hookup of narcs- these are some of the easiest patients to comfortably and safely disposition out of the emergency department. Now the narcotic seeker demanding "demerol" is a whole different story entirely...

 

[southerndoc]

Where I did my core student rotation, we were required to call the patient's PMD before refilling a script. When we refilled it, it was only for 24-48 hours worth. (After calling the physician, you can usually get the patient seen in his/her office quicker.)

It was amazing the number of times that I would call a patient's physician to find out the patient just got a refill last week, is on a pain management contract, or has never even seen that physician before.

 

[docB]

Obviously there wil be those who are obviously faking for drugs but what do you do when you get a pt that has experience with pain meds due to sickle cell, status migrainous etc....naturally they probably have an idea what alleviates their pain sufficiently and what doesn't through trial and error. Do you write them off as seeking or take their word for it?
(talking about in ER treatment bty)

I write them off as seeking and still give them a few narcs as I boot them OTD. Like I said I don't want to leave a real person in pain.

 

[docB]

I will qualify this comment by stating that I haven't even started medical school yet...
I have a friend who has a rare auto-immune disease which is degenerating his spine. He is in constant pain and he has been given morphine patches to make him comfortable. In Texas the summers are hot and people sweat. When he sweats, the patches can fall off. He only has so many a month and if he runs out his doctor won't give him any more. The pain is not as big of an issue as the withdrawl. He goes through hell.
Some people really need help with pain.

Very true. They just don't need to get it in my ER.

 

[The White Coat Investor]

Motrin works very well for dental pain, as does "oil of clove." I'm sure there are some EBM studies out there proving it, but I'm too tired to look for them.

Q, DO

Agreed. I've had dental pain. I took Motrin. I've also had a cervical strain after a high speed head-on. Took motrin, went back and worked a shift that night. I'm slowly losing compassion for whiny patients. I've also lost compassion for anyone who bags on NSAIDS. (Man, dat ibupofene dunt do nuttin man.) I think they're great!

 

[The White Coat Investor]

Now the narcotic seeker demanding "demerol" is a whole different story entirely...

Why?..........

 

[The White Coat Investor]

Obviously there wil be those who are obviously faking for drugs but what do you do when you get a pt that has experience with pain meds due to sickle cell, status migrainous etc....naturally they probably have an idea what alleviates their pain sufficiently and what doesn't through trial and error. Do you write them off as seeking or take their word for it?
(talking about in ER treatment bty)

I am finding that I take their word for it more and more. Otherwise, I spend 3 hours giving IV fluids, imitrex, phenergan, toradol etc (treating their migraine the "RIGHT" way) and then end up giving them the demerol they requested in the first place just to get them out the door. It seems I can turn the bed in 45 minutes and end up with the same results just by listening to them in the first place.

 

[flighterdoc]

Agreed. I've had dental pain. I took Motrin. I've also had a cervical strain after a high speed head-on. Took motrin, went back and worked a shift that night. I'm slowly losing compassion for whiny patients. I've also lost compassion for anyone who bags on NSAIDS. (Man, dat ibupofene dunt do nuttin man.) I think they're great!

The Cox-2 inhibitors (Celebrex, et all) are even better! 👍 👍

 

[Katee80]

I am finding that I take their word for it more and more. Otherwise, I spend 3 hours giving IV fluids, imitrex, phenergan, toradol etc (treating their migraine the "RIGHT" way) and then end up giving them the demerol they requested in the first place just to get them out the door. It seems I can turn the bed in 45 minutes and end up with the same results just by listening to them in the first place.

I'm glad to see a doctor who listens sometimes to the right pt. Prior to university, I was getting migraines at least 5 times a month. Went ton Propranalol, Naprosyn at onset with Imitrex. Well once every 4 months I'll get an unretractable migraine that responds to nada. I have a letter from PCP that states I'm no seeker and may require narcs for pain relief. Is demerol the only thing that works? Hell no. I'd shoot myself. It just gets me over the hump with the torodol and maxeran to boot. 😀 STILL I got the old 10 hours of treatment that consists of a bolus of saline and stuff I'm either allergic to (and noted on the chart..a chart I need to point out to them as they attempt to push it) Then they'll get around to controlling pain. Can't stand drugs but boy do I need them sometimes.

I never ask for Rx and never go in unless I'm approaching 72 hours of that crap. I follow up every 3 months and all my ER froms get forwarded to my doctor. Is this a situation that sounds familiar?

Don't rake me through the coals please. 😉

Off to school.

 

[southerndoc]

Just what are you allergic to, Katee?

 

[Katee80]

Just what are you allergic to, Katee?

Stemetil. My doctor told me it was ok to list it as an allergy since the side effects far outweighed the benefits. I get sketchy and feel like climbing the walls naked! I shake and get spasms that are rare, but not unheard of. DHE is another one. Maxeran/Decadron=numbness on one side of my face with swelling of my tongue.That was a wierd one since we couldn't figure out which one did it since Decadron isn't known for that (according to ER doc) I never got that when I take Maxeran alone or with something else 😕 Torodol/Maxeran=shaking, spasms and outright anxiety.
(I'm a calm person otherwise)

Torodol is not so bad alone or with demerol but combos are awful. I never argue with a doctor that wants to try something new and never ask for a Rx.

I suggested one doctor (before my letter from pcp) give me some ativan to counter the inevitable and he ignored me and said to wait,then went home.

It's really annoying when people see a non medical person (until Sept) and automatically think they should be naive to meds and what works for them and what doesn't. I know that if a pt asks for a drug by name its a red flag for seeking. Why? I'd have to be a complete ***** to NOT know what the name of a drug was and how much is the norm for me and my reactions to others.

My vitals all escalate during a painful episode and I follow up all the time. when I do go in, I've exhausted my arsenol of all meds that normally work. NSAIDS 375mg x 6...Imitrex, caffeine, ice chips, dark room..all that. Why only once in a while I get one all haywire? Who knows? I weigh 145 pounds at 5 "11 and I try to eat as healthy as possible while cutting out a bunch of possible "triggers".


going on 3 months no visits. 😀 No need.

Oh yeah..the doctor that gave me the Decadron the first time and saw the reaction, wanted to do the same thing 14 weeks later AFTER the fact. This may have been due to the fact that he never even bothered to note the reaction on my chart. (all charts forwarded to my doc)

Not good. 🙄

By the way, anyone else with input is welcome to tell me their opinion

 

[Sessamoid]

I gotta say that my policy changes with my mood. In general, I don't give drug seekers what they want, though I tend to err on the side of treating potentially legitimate pain. If I'm sure they're just seeking, then they get a motrin and shown the door.

Dental pain is actually pretty easy. Pretty much nobody can really tell which tooth you're pushing on with a tongue blade. Dental abscesses will hurt with pressure on one or sometimes multiple teeth, but it should ALWAYS be reproducible. So just, go around pushing on the teeth with the tongue blade, coming back the affected teeth occasionally to assure reproducibility. True dental pain I'll treat with opiates. Fakers get motrin and the door.

For patients with true serious pain, I'll use whatever they need. I've prescribed vicodin, percocet, oxycontin, duragesic to those truly in need. Generally, those cases are obvious (radiation treatment scars, cachectic, obvious recent surgery, bony deformities, etc).

 

[drpcb]

While I am fairly liberal with vicodin, I will not administer demerol in the ED except occasionally when performing procedural sedation for the GI docs who really want me to use it. Anyone who requests demerol or states they are allergic to everything but demerol will NOT get it. On this point I am very strict.

 

[EMRaiden]

The Cox-2 inhibitors (Celebrex, et all) are even better! 👍 👍

Before you jump on the Cox-2 bandwagon--

1) There is good evidence that the Cox-2 meds are no more effective than Desperado's Ibuprofen.

2) Run a quick google search on Cox-2 and lawsuit. I got 5k hits.

 

[Sessamoid]

Before you jump on the Cox-2 bandwagon--

1) There is good evidence that the Cox-2 meds are no more effective than Desperado's Ibuprofen.

2) Run a quick google search on Cox-2 and lawsuit. I got 5k hits.

I generally don't use Cox-2 inhibitors either. Less effective at pain relief and vastly more expensive. Usually only in patients who are very old or with GI bleed or other bleeding disorder, do I deviate from po ibuprofen.

 

[southerndoc]

I generally don't use Cox-2 inhibitors either. Less effective at pain relief and vastly more expensive. Usually only in patients who are very old or with GI bleed or other bleeding disorder, do I deviate from po ibuprofen.

If you look at the manufacturers' data, after 6 months, there was no difference in incidence of GI bleeds between standard NSAID's and cox-2 inhibitors. Interesting enough, only the first 6 months of data were presented to the FDA for their review. Imagine that.

 

[Sessamoid]

If you look at the manufacturers' data, after 6 months, there was no difference in incidence of GI bleeds between standard NSAID's and cox-2 inhibitors. Interesting enough, only the first 6 months of data were presented to the FDA for their review. Imagine that.

Heh, I never prescribe 6 months of medication. I'm only concerned about the next week or so, or until they see their own primary. 🙂

 

[southerndoc]

Heh, I never prescribe 6 months of medication. I'm only concerned about the next week or so, or until they see their own primary. 🙂

Yea I know, but I don't think the FDA would have given approval for the cox-2 inhibitors had all the data been presented.