Murdaugh trial and opioids

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BoardingDoc

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So there's this guy on trial for murder. Murdaugh. Don't really care about it so much, but read an article about it today where he said he had been on opioids for 2 decades (illicitly) and had been taking as much as 2000mg of oxy per day. That's 3000mmes. I mean, tolerance is a thing and I guess this is technically possible but this quantity seems bananas to me even when looking at my hardcore drug addicts that grace the ED.

Does this seem plausible? Anyone in pain or more likely palliative see anything like this?

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I had the same thought when I heard some recording from his testimony today. Even crazier than 2g of oxy a day was his statement that "most people are sedated by oxycodone, but it really energized me". Either he doesn't know the difference between oxycodone and cocaine or he's a lying sack of ****. Having read a recent article about him, the case and the upcoming trial (knowing nothing about him prior), I'd put my money on the latter.
 
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So there's this guy on trial for murder. Murdaugh. Don't really care about it so much, but read an article about it today where he said he had been on opioids for 2 decades (illicitly) and had been taking as much as 2000mg of oxy per day. That's 3000mmes. I mean, tolerance is a thing and I guess this is technically possible but this quantity seems bananas to me even when looking at my hardcore drug addicts that grace the ED.

Does this seem plausible? Anyone in pain or more likely palliative see anything like this?

Highest I’ve seen is ~4200mme/d. Patient on this for years via a combination of MS IR and ER. Patient was looking for a new practice to take over prescribing as longtime doctor (hematologist) was “considering retiring.” Patient was nice enough all things considered but an example of poor patient screening as should never have been given an appointment. Patient was not accepted into the practice.

Is it possible to slowly become tolerant to 1000s of mme/day? Yup, I suspect so. But diversion is more likely.

I had the same thought when I heard some recording from his testimony today. Even crazier than 2g of oxy a day was his statement that "most people are sedated by oxycodone, but it really energized me". Either he doesn't know the difference between oxycodone and cocaine or he's a lying sack of ****. Having read a recent article about him, the case and the upcoming trial (knowing nothing about him prior), I'd put my money on the latter.

Probably not applicable to Murdaugh, but I’ve had several older patients (>75yo) who report feeling that opioids give them energy. These are patients on low-dose stuff like tramadol qd-bid prn. And they don’t mean they feel it’s easier to do things due to less pain, they mean they feel more alert and activated.
 
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I had the same thought when I heard some recording from his testimony today. Even crazier than 2g of oxy a day was his statement that "most people are sedated by oxycodone, but it really energized me". Either he doesn't know the difference between oxycodone and cocaine or he's a lying sack of ****. Having read a recent article about him, the case and the upcoming trial (knowing nothing about him prior), I'd put my money on the latter.
Maybe he's a weird individual that gets a paradoxical reaction (like some people get hyper from diphenhydramine). Not supporting it. Just throwing it out there as a possibility.
 
So there's this guy on trial for murder. Murdaugh. Don't really care about it so much, but read an article about it today where he said he had been on opioids for 2 decades (illicitly) and had been taking as much as 2000mg of oxy per day. That's 3000mmes. I mean, tolerance is a thing and I guess this is technically possible but this quantity seems bananas to me even when looking at my hardcore drug addicts that grace the ED.

Does this seem plausible? Anyone in pain or more likely palliative see anything like this?
Yes, unfortunately, its plausible. When I first started fellowship, I inherited some patients on insane morphine equivalents like this. I didn't believe it was possible. I told this to one of my attendings, about a particular patient that was on similar doses to what you describe.
"He can't possibly be taking doses this high," I said. He suggested that I do an observed dose, i.e., witness the patient take a dose of his medicine in the clinic and observe him. "After all, you're an ER doc," he said. "We've never had a better person to be here if he doesn't have a tolerance for those meds," he said.

I watched him take the insane dose of meds and sat there in the room with him for 30 minutes getting caught up on some charting. He absorbed the "impossibly high" dose with no signs of opiate overdose whatsoever.

I could tell you more stories about insane-megadoses I witnessed that year, but just take my word for it. It's very possible they're taking those doses if they gradually build up to it over years. Of course, diversion is also possible, but that's harder to determine unless you do an observed dose, document a negative drug test or call them in one day off the street, or tell them to bring their pills in immediately and count them, none of which is practical in the ED.

By the end of my fellowship year, I had almost no patients left in my fellow-clinic, because I tapered them all off high-dose opiates and they self discharged. All the other fellows were jealous.
 
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Hey Super Pain Management Bros:

Wanna do a short review on MMEs and how to standardize/compare opioid doses?

It'd be a good academic thing to do on here,. because that's what I keep trying to steer the forum towards.
 
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Hey Super Pain Management Bros:

Wanna do a short review on MMEs and how to standardize/compare opioid doses?

It'd be a good academic thing to do on here,. because that's what I keep trying to steer the forum towards.
Aside from obvious polypharmacy considerations like concomitant benzo use, is there much more to it beyond converting to mme? I'm sure there are tables online. I just remember that oxy is 1.5 mme / mg and Dilaudid is 4 and that you can't switch someone from one drug to another at the same mme because of imperfect cross sensitivity/tolerance.

That said, I agree with rusted and would love to hear if my understanding is wrong.
 
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Hey Super Pain Management Bros:

Wanna do a short review on MMEs and how to standardize/compare opioid doses?

It'd be a good academic thing to do on here,. because that's what I keep trying to steer the forum towards.

I'll keep it simple. For oral meds:

Morphine and hydrocodone are equal (10mg = 10mg)

Oxycodone is 1.5 times stronger than those (10mg oxy = 15 mg of morphine/hydro)

For everything else, just use a conversion calculator, like this or this.

Don't mess around with methadone. Ask an expert.
 
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highest I've seen in pain fellowship was a cancer patient palliative care. he had IV dilaudid infusion through PCA 20mg/hr. he had 20mg q6m bolus and additional 20mg IV push as needed every hour.

dude was walking around the halls and chit chatting with staff like nothing was happening. we got consulted by palliative team and I looked at the chart and basically signed off the moment I met him. nothing left to do when your whole blood volume is replaced by IV dilaudid.
 
I had the same thought when I heard some recording from his testimony today. Even crazier than 2g of oxy a day was his statement that "most people are sedated by oxycodone, but it really energized me". Either he doesn't know the difference between oxycodone and cocaine or he's a lying sack of ****. Having read a recent article about him, the case and the upcoming trial (knowing nothing about him prior), I'd put my money on the latter.
A physician I know and trust who became addicted to oxycodone reported exactly the same thing.

I do know that my mom said the only time my father stayed awake for an entire TV movie was after he received morphine in the ER for a kideny stone.

Paradoxical effects are real.

As for the 2g of oxycodone, my guess is that either he can't add right (lawyers are notoriously terrible at math), and/or he was being sold something that was pretty adulterated down.
 
Highest I’ve seen is ~4200mme/d. Patient on this for years via a combination of MS IR and ER. Patient was looking for a new practice to take over prescribing as longtime doctor (hematologist) was “considering retiring.” Patient was nice enough all things considered but an example of poor patient screening as should never have been given an appointment. Patient was not accepted into the practice.

Is it possible to slowly become tolerant to 1000s of mme/day? Yup, I suspect so. But diversion is more likely.



Probably not applicable to Murdaugh, but I’ve had several older patients (>75yo) who report feeling that opioids give them energy. These are patients on low-dose stuff like tramadol qd-bid prn. And they don’t mean they feel it’s easier to do things due to less pain, they mean they feel more alert and activated.
I would strongly suspect diversion in someone on 4000+ OMEs.

Tramadol makes sense here, but that's because of it's mixed SNRI/mu receptor activity. It doesn't make as much sense for a pure mu receptor agonist like oxycodone to do that.
 
I'll keep it simple. For oral meds:

Morphine and hydrocodone are equal (10mg = 10mg)

Oxycodone is 1.5 times stronger than those (10mg oxy = 15 mg of morphine/hydro)

For everything else, just use a conversion calculator, like this or this.

Don't mess around with methadone. Ask an expert.
For the non-specialist, this is the way.

But if you're a geek like I am, there's a lot of fun nerding out to do.
 
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Tramadol makes sense here, but that's because of it's mixed SNRI/mu receptor activity. It doesn't make as much sense for a pure mu receptor agonist like oxycodone to do that.

Reasonable idea re: tramadol but I hear it from pts on low dose norco, perc, T3 etc as well. My highly scientific working theory is that it’s an old-person variant of euphoria.
 
7DA59FB5-93F9-49B8-9282-CC860AE1340E.jpeg

Actual picture of his colon holding in the largest stool known to mankind.
 
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So there's this guy on trial for murder. Murdaugh. Don't really care about it so much, but read an article about it today where he said he had been on opioids for 2 decades (illicitly) and had been taking as much as 2000mg of oxy per day. That's 3000mmes. I mean, tolerance is a thing and I guess this is technically possible but this quantity seems bananas to me even when looking at my hardcore drug addicts that grace the ED.

Does this seem plausible? Anyone in pain or more likely palliative see anything like this?

I always wonder how someone making $1M/year would still be drowning in millions of dollars in debt and committing multiple financial felonies. I guess an having expensive drug habit would do that.
 
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I always wonder how someone making $1M/year would still be drowning in millions of dollar in debt and committing multiple financial felonies. I guess an having an expensive drug habit would do that.
He is literally the most powerful person in the state of SC (and one of the richest) but the profile I read of him and the description of the crimes he's on trial for lead me to believe he doesn't even rank in the top half of the smartest people in the state.
 
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He is literally the most powerful person in the state of SC (and one of the richest) but the profile I read of him and the description of the crimes he's on trial for lead me to believe he doesn't even rank in the top half of the smartest people in the state.
Right. The truth was a lot stranger than fiction.
 
He is literally the most powerful person in the state of SC (and one of the richest) but the profile I read of him and the description of the crimes he's on trial for lead me to believe he doesn't even rank in the top half of the smartest people in the state.
I have long said that you could eliminate the entire criminal code and replace it with "stupidity, gross stupidity and aggravated stupidity."
 
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I always wonder how someone making $1M/year would still be drowning in millions of dollars in debt and committing multiple financial felonies. I guess an having expensive drug habit would do that.
I'm sure a drug habit makes you more susceptible, but that's a lot of money to spend on drugs. Seems like he also had a boat habit, which will drain an account much more quickly.
 
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I'm sure a drug habit makes you more susceptible, but that's a lot of money to spend on drugs. Seems like he also had a boat habit, which will drain an account much more quickly.
And multiple properties (which all had domestic staff) and kids who also liked to spend money.
 
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