nubain

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rohit76

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Does nubain IV leads to severe withdrawl in opiod dependent patients?
We did give it to patient with h/o chronic pancreatitis who was on methadone. As soon as he knew that we gave him nubain, he threw a fit saying that he is going to get withdrawl symptoms now.He demanded demerol for these withdrawl symptoms which we had to give.
 
rohit76 said:
Does nubain IV leads to severe withdrawl in opiod dependent patients?
We did give it to patient with h/o chronic pancreatitis who was on methadone. As soon as he knew that we gave him nubain, he threw a fit saying that he is going to get withdrawl symptoms now.He demanded demerol for these withdrawl symptoms which we had to give.
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Yes. This is one of the reasons why mixed agonists/antagonist are not particularly good pain drugs. If you want a lessor effect of a strong opioid, use a lessor dose.
 
rohit76 said:
Does nubain IV leads to severe withdrawl in opiod dependent patients?
We did give it to patient with h/o chronic pancreatitis who was on methadone. As soon as he knew that we gave him nubain, he threw a fit saying that he is going to get withdrawl symptoms now.He demanded demerol for these withdrawl symptoms which we had to give.
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Why did you have to give him demerol?
 
I did give him morphine for pain and later as he was still c/o severe pain, anxiety, I did give him demerol. I guess he made me feel guilty for giving nubain.
 
rohit76 said:
I did give him morphine for pain and later as he was still c/o severe pain, anxiety, I did give him demerol. I guess he made me feel guilty for giving nubain.
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Is this a serious thread? If so, what country do you practice in?
 
Except maybe for shivering, there's never a reason to give demerol.
 
Dr.McNinja said:
Why did you have to give him demerol?
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'cause he was allergic to all other analgesics, poor thing. Except that one that starts with a D. No, not dilaudid, that older one. Oh, and by the way, it makes me really nauseous. I'm also allergic to reglan, zofran, anzemet and compazine.

Bummer allergies, huh?

Take care,
Jeff
 
I guess we could have given methadone 10 mg IM or 20 mg po, clonidine 0.1 mg po, ativan 0.5 mg po and phenergan 25 mg po.
 
I think the reason you're seeing these responses is that this type of manipulative drug seeking behavior is very common in the ED. Plus, few of our EDs carry demerol anymore.

Take care,
Jeff
 
rohit76 said:
I guess we could have given methadone 10 mg IM or 20 mg po, clonidine 0.1 mg po, ativan 0.5 mg po and phenergan 25 mg po.
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Those all seem like really odd choices for pain in the ED or do you guys use some sort of withdrawal cocktail? Keep in mind that you've basically used pharmacology to create a withdrawal state (by the patient's report). You need to be careful trying to give a bunch of drugs to try and fix it. This isn't the same as straight up opioid withdrawal.
 
Please don't give nubain. We use it in anesthesiology at low doses to treat pruritis refractory to hydroxyzine and diphenhydramine in opioid naive patients. Nubain will absolutely precipitate in opioid withdrawal in the dependent patient. And then the primary team will call the acute pain service in the middle of the night demanding a stat, in house consult for the pain "emergency" that they created in the first place because they don't understand the drugs they're prescribing (purely a hypothetical situation of course that has never actually happened...multiple times 🙄)

Meperidine is for shivering and epidural infusions. Period. No one can even get it outside of an epidural infusion or outside of the PACU in the hospitals I rotate through.
 
pillowhead said:
Please don't give nubain... Nubain will absolutely precipitate in opioid withdrawal in the dependent patient.
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I use nubain for the drug seeking patients who swear that they don't use opioids at home regardless of how many times I ask them. If they get withdrawal, then it's their own damn fault for lying to me. And then if they get all sick from the withdrawal, I do what I have to in order to keep them alive, not to make them comfortable.
 
BADMD said:
http://www.pbs.org/wgbh/nova/doctors/oath_modern.html
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<shrug>

I am probably far more cynical and skeptical than I should be at this point in my training. But I can only work on the information that the patient gives me. And if I don't think they're being truthful, but they insist that they are and they are of sound mind, then they are complicit in their post-nubain misery.

It's like washing your kids mouths out with soap. You don't like to do it because they're screaming and biting you... and they don't like it because their mouths taste like soap... and sure, it is potentially harmful... but when done correctly, you hope that they learn from it.

I'm probably not doing a good job of explaining my rationale, and I'm only making myself look like a jerk. But then again, I'm arguing my point against the hippocratic oath. You say I'm not doing right by the oath, and I'm saying I don't think it applies in the way you're saying it does in this case, but it still makes me look like an ass no matter how cogent an argument I make.
 
I understand why. I understand the desire and the rationale.

Just understand that you are giving patients a medication where one of your goals is to punish the patient if they are lying to you.

That is pretty hard to justify, especially if you don't fully inform them of the risks, benefits and alternatives to the medication that you are choosing to use.
 
Doctor Bob said:
I use nubain for the drug seeking patients who swear that they don't use opioids at home regardless of how many times I ask them. If they get withdrawal, then it's their own damn fault for lying to me. And then if they get all sick from the withdrawal, I do what I have to in order to keep them alive, not to make them comfortable.
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There's nothing to be gained from engaged in a pissing contest with a loser patient. At they end of the day they will still be a loser; whether or not you want to join them depends on the decisions you make.
 
We have a policy as a group to not give ANY IV narcotics to chronic painers. We typically have two methods, only if we feel they are having real discomfort:

1. IM injection

2. Diluadid in 1 L of normal saline and dripped in over 30 minutes.

The ones who truly want a high will refuse both of these methods. The ones with genuine pain will act confused, but still agree to get the meds.

At any point if they are demanding, annoying, irritating, or they lie to me (I look them up on the Nevada drug registry) then they get nothing at all.
 
GeneralVeers said:
2. Diluadid in 1 L of normal saline and dripped in over 30 minutes.
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Hmm... I'll mention that to my attending next time as an alternative to the nubain.

BADMD said:
That is pretty hard to justify.
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I think we'll just have to agree to disagree on this issue and understand that there are many approaches to the practice of medicine, all of which have their upsides, downsides, strengths and weaknesses. Everyone has practices which others could view as less than the ideal standard (ie: the nurse putting 16g or 18g angiocaths in the drunk when a 20g would work just as well, because the drunk was verbally abusive, and the physician turns a blind eye to it and doesn't step in to say, no, a 20g is all we need). But if at the end of the day nobody dies, everyone goes home as healthy or healthier than when they came to the hospital, and 98-99% of your patients thank you in what seems to be a genuine manner as they leave the hospital... well, that's good enough for me.

My philosophy is geared toward the Conan Oath: to crush my patients, to see them driven before me, and to hear their lamentation as they detox.
 
GeneralVeers said:
Diluadid in 1 L of normal saline and dripped in over 30 minutes.
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I've done something similar, although a slightly different cocktail. The pharmacy goes ape.... when I do it. The nurses love it however.

I've also gotten away from antihistamines as my first line for pruritis. There is also some decent evidence for using microdose naloxone. This is the one place where I actually like mixed agonists/antagonists. A very small dose of butorphanol decreases pruritis without sacrificing analgesia.
 
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