Why is everyone so scared of morphine?

[CueDoc]

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Does anyone have problems with morphine being administered without question when you order more than 4mg? Has anyone ever had someone need reversal when only morphine was given? The worst part is that 1mg of dilaudid will be given without batting an eyelid, but 6mg of morphine to a 300lb patient is outrageous. whats up with this?

 

[Dr. Will]

Good question. Only 1 month in, I initially felt the same way but then quickly realized that it's weight based. Unless you're a little old lady, I feel comfortable starting you out with 5mg. For most, that does the trick...unless they are already asking for that IV pain medication that starts with a D.

Pain control in the ED is definately a topic that has many shades of gray. Would love to hear what everyone else's experiences have been.

 

[DrQuinn]

Where I did my residency, "you didn't give nutti'n until you get 8 mg of Morphine." One reason for the 4 vs 5 mg of Morphine is that is what it comes in, re: the vials (4 mg vials vs 10 mg vials). Anyways, I actually give far far more dilaudid than I do morphine. And I usually give 2 mg of dilaudid in most everyone except LOL.

I personally have never had a patient need narcan from an opiate alone.... yet.

Q

 

[GeneralVeers]

The actual therapeutic dose is 0.1 mg/kg, so the appropriate dose in most cases would be 7-8 mg (or 20 mg in Texas).

Typically I give 4 mg for most of the BS pain, however someone with an obvious fracture or injury will get 8 mg. The nurses usually don't argue in those cases.

 

[EM_Rebuilder]

The actual therapeutic dose is 0.1 mg/kg, so the appropriate dose in most cases would be 7-8 mg (or 20 mg in Texas).

Typically I give 4 mg for most of the BS pain, however someone with an obvious fracture or injury will get 8 mg. The nurses usually don't argue in those cases.

I am only a month in and I do about what you just said.

If I do not really believe their pain or I have not seen an obvious cause for pain, they will get 4mg....I hit 2mg on a couple of people that were either young or very old. I am cautious, recheck them in a few and give them another 2 if needed.

If they have a big fracture and we are waiting on Ortho... they get 6 or usually 8.

Toradol IM for the sprained muscles and such to get them patched up and out.. and Toradol topped with some mofine for stones.

If there is no IV and they have some minor sprain or pain complaint, its a Lortab 5... i check them in a few, and give them another if that didnt help. Baseline back pain in a re-current visit cat, they are not getting narcs from me unless the attending tells me to. They are getting Toradol at best and being told to take ibuprofren and SEE A PCP.

Thats been my pain regiment after one month; I'm still learning...


I have noted fellow interns around me being reluctant on dishing out the morphine, or everyone gets 1 or 2... but I view it as: A.) it seems like reversal is rarely needed, B.) I think I could handle what needs done if a reversal needs done, or at least there is someone always in shouting distance that certainly knows what to do, C.) its proper and humane medicine to control someones pain and thats what I believe in practicing....

 

[deleted77919]

I see most people getting 6-8 around here.

 

[deleted109597]

Ours comes in 4, 2, and 10mg premeasured syringes, so they usually end up getting multiples of 4.

As an aside, I had some ridiculous ED doc (not boarded in EM) expressly tell me multiple times that he hadn't given pain meds to my acute abdomen I was assessing, and when I told him he could, he said no.
Then my surgeon attending thanked him later for not giving pain meds (on the EM doc's behalf, he didn't sell me out for wanting to give them).
WTF is wrong with these people?

 

[EMT2RN2MD]

Ours comes in 4, 2, and 10mg premeasured syringes, so they usually end up getting multiples of 4.

As an aside, I had some ridiculous ED doc (not boarded in EM) expressly tell me multiple times that he hadn't given pain meds to my acute abdomen I was assessing, and when I told him he could, he said no.
Then my surgeon attending thanked him later for not giving pain meds (on the EM doc's behalf, he didn't sell me out for wanting to give them).
WTF is wrong with these people?

So, should it be common practice to admin narcs prior to determining a diagnosis? Is the whole "masking the pain" reasoning out the window now?

 

[kungfufishing]

There is a lot of research that suggests judicious use of pain med in patients with a surgical belly is just fine. I do it. Besides, unless they are abd. trauma with peritonitis or a 14 year old boy with fever and significant RLQ tenderness, how often are these people going to the OR without a CT anyway? I mean, wouldnt want to mask those CT findings with a little morphine....

 

[CueDoc]

So, should it be common practice to admin narcs prior to determining a diagnosis? Is the whole "masking the pain" reasoning out the window now?

Question 1. yes 2. yes both of those depending on the basis that you are using them judiciously and with good old fashion home cooked common sense

 

[EMT2RN2MD]

Question 1. yes 2. yes both of those depending on the basis that you are using them judiciously and with good old fashion home cooked common sense

Thanks! The ACSSurgery site was helpful as well.

 

[canjosh]

Good question. Only 1 month in, I initially felt the same way but then quickly realized that it's weight based. Unless you're a little old lady, I feel comfortable starting you out with 5mg. For most, that does the trick...unless they are already asking for that IV pain medication that starts with a D.

Pain control in the ED is definately a topic that has many shades of gray. Would love to hear what everyone else's experiences have been.

Just FYI, 5mg is probably a pain for nursing to give. Depends on what your facility is stocked with, but most have 4mg prefills. So dosages divisible by 4 are easiest to give in most situations. 6mg order leaves the nurse with 2mg to waste at a later time. Just something to think/ask about at your facility.

 

[DrMom]

depends on the facility. our morphine comes in 5 mg vials, so that's what we often start with. the nurses go nuts if we order 4 mg.

 

[DrQuinn]

Like I said before, ours comes in 4 mg and 10 mg of Morphine.

That's why I tend to just give 1 - 2 mg of Dilaudid. I've been using dilaudid (not personally) for about 4 years now (one of my better attendings was a huge fan). ANd I have had far less side effects from dilaudid than morphine.

Q

 

[DrMom]

My attendings would have a cow if I wrote dilaudid on any regular basis. A big cow.

 

[WilcoWorld]

I usually treat those I think needs IV narcs with 1mg of dilaudid. It has less histaminic response, AND nursing never bats an eye at the dose. Obviously I make exceptions, to this (Peds, obesity, labile BP, Hx of abuse...) but it is my pain med of choice now. Sometimes I see people giving 2mg of morphine to an adult. As our old chairman once said, "If you're going to give 2mg of morphine, you might as well squirt it OVER the patient for all the good it's going to do."

 

[bulgethetwine]

The actual therapeutic dose is 0.1 mg/kg, so the appropriate dose in most cases would be 7-8 mg (or 20 mg in Texas).

Typically I give 4 mg for most of the BS pain, however someone with an obvious fracture or injury will get 8 mg. The nurses usually don't argue in those cases.

I agree with GV - I give 4mg to most everyone, and 8 if I really think their pain is legit.

Incidentally, the therapeutic dose is usually expressed as a range from 0.1 to 0.2 mg/kg, so 0.1 is on the low end. But really I'm just adding that for completeness sake as I don't mean to trump GV... I don't pretend to be any more expert then him (Bulge tips hat GV's way).

As for the Dilaudid, I also practice like Quinn -- I give a lot of Dilaudid, and typically in 2mg aliquots. Generally speaking, you can assume that 2mg dilaudid is roughly equal to 10mg morphine and as you might imagine, the nurses don't seem to mind giving "2" of D compared to giving "10" of M.

Of course, any time you're talking dosing equivalents, well... here there be dragons. The 1:5 ratio is definately a rough gestimate depending on patient kinetics, other drug-drug interactions, the source I'm quoting from, and the direction of the prevailing wind.

If anyone is interested, here is a conversion chart that I use for converting between different opiates and routes of admin. This was my "best guess" chart when synthesizing multiple sources including Pharmacopeia, some basic pharmacology texts, and two of the "pain boys" at our institution. No doubt, if each of us were to post their own it would be slightly different; But it has stood me well for several years. You're welcome to borrow, copy, suggest edit, or just ignore. Keep in mind that my "reference" dose was chosen because I think I put it together when I was doing an inpatient month and was trying to convert/adjust for in-hospital, at-home medication regimens, etc.

--------------------------------------------------------------------

Bulge's Narcotic Conversion Chart

Reference: Morphine – 60 mg Parenteral (IV, IM, SC) Daily dose

Oral Methadone: 1/6 to 2/3x, therefore 10 – 40 mg
Oral Hydromorphone: ¾ - 1x, therefore 45 – 60mg
Oral Morphine: 1.5 – 3x, therefore 90 – 180 mg oral (naïve – chronic)
Oral Oxycodone: 2x, therefore 120 mg
Oral Hydrocodone: No consensus

Parenteral Hydromorphone (Dilaudid): 1/6 – 1/5, therefore 10 – 60 mg

Fentanyl

Parenteral: 50-100 mcg q1-2h, titrated to effect. Can use IM, too.

Fentanyl: 50-100 mcg/h patch changed q72h.
Use the higher patch strength at low oral morphine equivalents (e.g. 25 mcg patch for 45 – 134 mg morphine/24h) and a relatively lower patch strength at higher morphine doses (200 mcg patch at 675 – 764 mg/24h)

 

[Dr. Will]

Just FYI, 5mg is probably a pain for nursing to give. Depends on what your facility is stocked with, but most have 4mg prefills. So dosages divisible by 4 are easiest to give in most situations. 6mg order leaves the nurse with 2mg to waste at a later time. Just something to think/ask about at your facility.

Ours is stocked in 5mg prefills, so I wouldn't call it a pain for nursing to give. 😉 Thanks for the tip, though.

 

[Painter1]

the reason why some nurses freak out with the higher doses of morphine is because they've been around long enough to see the occassional patient who drop their BP signficantly with morphine.

i saw it twice my intern year. both were 5mg IVP. however, nothing a little fluid bolus couldn't take care of.

 

[SolidGold]

I also think that it has to do with how the nurses are educated. Nurses here have been taught a good amount about how to deal with sickle cell patients. I had a little lady (not old) with a history of multiple episodes of acute chest syndrome in a sickle cell pain crisis and I wrote for 30 mg of po morphine plus 15mg of IV morphine to be given at once, and the nurse didn't flinch. She was discharged a couple of hours after that.

 

[southerndoc]

the reason why some nurses freak out with the higher doses of morphine is because they've been around long enough to see the occassional patient who drop their BP signficantly with morphine.

i saw it twice my intern year. both were 5mg IVP. however, nothing a little fluid bolus couldn't take care of.

You can also give diphenhydramine to reverse the hypotension since it's a histamine-mediated vasodilation that causes the hypotension. Of course, everyone will look at you like you have three eyes. For some reason, people can't seem to correlate the two. (This is why fentanyl causes less hypotension: it doesn't cause as much histamine release.)

 

[hornste]

great topic.

Let's say your first round of opiods fail to produce adequate pain control. How long are you waiting to make that decision, and what's you're redosing strategy?

 

[Josh L.Ac.]

You can also give diphenhydramine to reverse the hypotension since it's a histamine-mediated vasodilation that causes the hypotension. Of course, everyone will look at you like you have three eyes. For some reason, people can't seem to correlate the two. (This is why fentanyl causes less hypotension: it doesn't cause as much histamine release.)

Thanks for that - that answers two questions for me.

 

[DropkickMurphy]

I knew that about the histamine release with morphine and about the lack of it with fentanyl, but I never thought of using diphenhydramine to reverse the hypotension. I learned something new. 👍

 

[Ceez]

I knew that about the histamine release with morphine and about the lack of it with fentanyl, but I never thought of using diphenhydramine to reverse the hypotension. I learned something new. 👍

the sicklers at my home institution actually ask for benadryl with their morphine. one of my attendings claims that it gives them a rush (??)

 

[EM_Rebuilder]

the sicklers at my home institution actually ask for benadryl with their morphine. one of my attendings claims that it gives them a rush (??)

We do that alot here with our sicklers....often with Phenergan also. As I understand, Morphine may make you itch and uneasy at the stomach. The Benadryl and Phenergan helps with this. Older nurses give a big thumbs up and really think the three together works wonders. It gets the sicklers pain tamed down and out of the ED so I will use it when I can. *shrugs*

 

[justmanda]

Does anyone have problems with morphine being administered without question when you order more than 4mg? Has anyone ever had someone need reversal when only morphine was given? The worst part is that 1mg of dilaudid will be given without batting an eyelid, but 6mg of morphine to a 300lb patient is outrageous. whats up with this?

I've never had a problem with morphine..given it a milllion times. I think the most I have given at a time was 10 mg post-op. Dilaudid, on the other hand, scares me to death! Several times after I have given this drug, my patient has had respiratory problems. Once, after 2mg, a 70ish obese lady who had been alert and screaming in pain ended up in the unit because her resps went down to 6 and her 02 sat was 70. Another old lady with a new hip got 1 mg and it was pretty much the same scenerio! Just last week, a young woman who got 4 mg was found at shift change with cheynne-stoke breathing and an unreadable o2 sat. She came out of it after two shots of narcan. Doctors typically order 2-4mg q 4hrs PRN...I always start with the lowest dose, no matter how loud my patient is screaming.

 

[coldcoldworld]

4 mg of Dilaudid?!?!?!....and you were surprised that she crumped??? That's like giving 30mg of Morphine to a presumably opiate naive person. Seems a bit reckless to me and I'm surprised you found a nurse willing to push that much at once.

 

[bartleby]

Antihistamines have a adjuvant effect (more bang for your narcotic buck) in addition to the welcome antipruritic effect given the histamine release that morphine can precipitate.

the sicklers at my home institution actually ask for benadryl with their morphine. one of my attendings claims that it gives them a rush (??)

 

[deleted109597]

Doctors typically order 2-4mg q 4hrs PRN...I always start with the lowest dose, no matter how loud my patient is screaming.

For Dilaudid, I go with 0.5-2mg usually. But hey, maybe you just have fatter patients (unlikely). Morphine 2-6mg, unless it is for breakthrough pain, then we usually use different dosages.
I swear, my new DEA number has been used for more Lortab/Percocet than any rational number should be.

 

[EctopicFetus]

I have begun to use more dilaudid in all but LOLs. Less histamine release (less giving of benadryl etc.) and I have not given anyone too much morphine or dilaudid yet. Also if Dilaudid doesnt work I usually head for Toradol, it is amazing how that can fix a ton of problems.

Also for serious traumas or serious ortho injuries one of my attendings like Fentanyl (faster onset) followed by MS or Dilaudid. I havent gotten on the Fentanyl bandwagon yet.

 

[12R34Y]

I have begun to use more dilaudid in all but LOLs. Less histamine release (less giving of benadryl etc.) and I have not given anyone too much morphine or dilaudid yet. Also if Dilaudid doesnt work I usually head for Toradol, it is amazing how that can fix a ton of problems.

Also for serious traumas or serious ortho injuries one of my attendings like Fentanyl (faster onset) followed by MS or Dilaudid. I havent gotten on the Fentanyl bandwagon yet.

pretty much give fentanyl for almost everything first line. usually start with 75-100mcg IV push for almost any size patient. Maybe LOL starts with 50mcg. It's a synthetic opiod so no histamine release, no nausea, no vomiting, no itching. no drop in BP. They did a huge study in prehospital with 900 some patients receiving fentanyl and i think 2 had some respiratory depression. no drop in bP in any patient and otherwise no other adverse effects,

Best drug out there. get them under control fast with fentanyl then switch to something longer acting like dilaudid or morphine.

can give it to the sick hypotensive trauma patients too. hemodynamically stable.

can you tell i love fentanyl........it's my first like 100% of the time now.

later

 

[chimichanga]

the sicklers at my home institution actually ask for benadryl with their morphine. one of my attendings claims that it gives them a rush (??)

Was hospitalized w/ a joint infection last year...had a PICC...I received IV benadryl to help me sleep...WHAT A RUSH INDEED!!!

Immediate and overwhelming...

Oh, and I had a dilaudid PCA (too much itching), then a morphine PCA (more itching)

I asked for toradol, and it completely relived my pain...

 

[EctopicFetus]

pretty much give fentanyl for almost everything first line. usually start with 75-100mcg IV push for almost any size patient. Maybe LOL starts with 50mcg. It's a synthetic opiod so no histamine release, no nausea, no vomiting, no itching. no drop in BP. They did a huge study in prehospital with 900 some patients receiving fentanyl and i think 2 had some respiratory depression. no drop in bP in any patient and otherwise no other adverse effects,

Best drug out there. get them under control fast with fentanyl then switch to something longer acting like dilaudid or morphine.

can give it to the sick hypotensive trauma patients too. hemodynamically stable.

can you tell i love fentanyl........it's my first like 100% of the time now.

later

Interesting. The thing is MANY people asking for pain meds dont need em. NOthing makes me happier than when a nurse gets me and says hey fetus Mrs Jones in room 8 wants some tylenol for her pain.

 

[12R34Y]

Interesting. The thing is MANY people asking for pain meds dont need em. NOthing makes me happier than when a nurse gets me and says hey fetus Mrs Jones in room 8 wants some tylenol for her pain.

I treat everybody's pain. fake or real. who am I to judge. if they have pain i give them real pain medicine. now it's not always fentanyl. i give toradol IM, I give plenty of vicodin or percocet as well.

later

 

[DrQuinn]

I treat everybody's pain. fake or real. who am I to judge. if they have pain i give them real pain medicine. now it's not always fentanyl. i give toradol IM, I give plenty of vicodin or percocet as well.

later

Fentanyl is a nice clean drug, but I dont' use it simply because of its half-life. It bugs the nurses to much to have to keep given them meds every hour. Now in a trauma setting or a sick hypotensive patient, I'll use it... but I prefer long acting opiates, and i love to document in my note "pt sleeping comfortably in NAD."

Q

 

[Arctic Char]

 

[zinjanthropus]

Interesting. The thing is MANY people asking for pain meds dont need em. NOthing makes me happier than when a nurse gets me and says hey fetus Mrs Jones in room 8 wants some tylenol for her pain.

if they ask for it they need it at some level - whether they are in physical pain or are drug seeking. nonetheless, that's not what i'm there to sort out and with the curve way on the under treatment side, i would much rather err on the curve of overtreating when not "necessary".

 

[BADMD]

if they ask for it they need it at some level - whether they are in physical pain or are drug seeking. nonetheless, that's not what i'm there to sort out and with the curve way on the under treatment side, i would much rather err on the curve of overtreating when not "necessary".

Zin, you are early enough in your career that you have had the oppertunity to be jaded by drug seeking patients. Some do have pain and some are abusing the system. The problem is that you get the feeling that you are being used and manipulated many times. Worst off, patients who are faking it are wasting time you can use to treat people who are actually sick, and will waste more time and resources in the future.

As the clinician, a certain part of your job is the appropriate use of medications. All drugs have certain side effects and potentially toxic effects. Morphine will drop someone's blood pressure. Fentanyl may cause rigid chest syndrome. People routinely accidentally kill themselves with "vicomins." Giving out strong opiates to everyone with pain isn't warranted and is potentially bad practice. Just as withholding strong pain medication is also bad practice.

While I would rather error on the side of treating pain, you have start wondering what is going on when patients with chronic back pain ask other staff when you are working next.

 

[Apollyon]

if they ask for it they need it at some level - whether they are in physical pain or are drug seeking. nonetheless, that's not what i'm there to sort out and with the curve way on the under treatment side, i would much rather err on the curve of overtreating when not "necessary".

The definition of pain: being the on-call doc when the word gets out that a "candyman" is working. Then the on-call doc gets called in, because the candyman is slow as heck and doesn't get to the overt drug seekers (like the woman whose ears looked like the TM's had spider webs on them, and who could cry on command, despite casually touching the same tear-inducing ear without difficulty, and not even bothering to take the Cortisporin Otic with her, but instead leaving it neatly on the Mayo stand when she was DCd without pain meds), and the on-call doc has to spend hours and hours cleaning up the mess the candyman made but didn't fix/finish.

Don't EVEN kid yourself - we even talk about the "sentinel back pain" in the morning - the first patient to hit fast track will scope out who the doc is, and whether narcs are in the offing or not. If they are, the drug seekers are out in droves - like flies to honey - and you can't get through them all. If not, you actually get a real patient day (mostly - someone's always trying to scam).

 

[boulux]

I've taken lots of pain meds from 5mg of morphine to 4mg of dilaudid (with my weight between 100 and 150 lbs) and 5mg of morphine works imo. It did help a little bit for pain, although an initial dose of 10mg was much more effective.

 

[oldManDO2009]

I tend to err on the side of patient safety and my a$$$. I will start off slow and take a BP and reassess pain (as a nurse). My docs (when I worked in the ER) would write morphine 2-10 mg for pain or morphine 4 mg may repeat x times . I realize this is not the policy at some institutions and you have to write for each dose.

I have had so close calls with small doses so I figure slow and go is a safer dosing method. I had a guy sit straight up after 1 mg of dilaudid and scream/gulp air - this of course scared the crap out of me....

The frequent flyers hate this idea of no rush and slow going but they get over it and the ones with the real deal get frequent assessments and pain relief.

 

[zinjanthropus]

Zin, you are early enough in your career that you have had the oppertunity to be jaded by drug seeking patients. Some do have pain and some are abusing the system. The problem is that you get the feeling that you are being used and manipulated many times. Worst off, patients who are faking it are wasting time you can use to treat people who are actually sick, and will waste more time and resources in the future.

As the clinician, a certain part of your job is the appropriate use of medications. All drugs have certain side effects and potentially toxic effects. Morphine will drop someone's blood pressure. Fentanyl may cause rigid chest syndrome. People routinely accidentally kill themselves with "vicomins." Giving out strong opiates to everyone with pain isn't warranted and is potentially bad practice. Just as withholding strong pain medication is also bad practice.

While I would rather error on the side of treating pain, you have start wondering what is going on when patients with chronic back pain ask other staff when you are working next.

But at the same time, who cares if you are getting duped sometimes if you are treating real pain most of the time?

My perspective comes from being fortunate enough to work with a toxicology trained attending who was very liberal about using morphine, BZDs, etc...her basic point is that the risks of using the meds and the potential to get "burned" were less than the positives of treating people's pain....her other point she always made was that at any given time, any of us become a "drug-seeker" (e.g. an asthmatic who needs albuterol) and thought the term was somewhat meaningless. Granted, she trained in a large inner-city community hospital and felt that she would have had to invest way too much time sorting out "real pain" if she didn't tx pts based on their presentation - not her assumptions about their motives

 

[oldManDO2009]

I have to agree with the above post about treating pain - it does take way to much energy to figure out who is on the sly. Other than the obvious addict and the kids coming in on Friday night for a lift me up (a few vicomins) I would rather err on the side that this patient may actually have pain and we need to treat it (then refer to my post abive....)

We all have our frequent flyer stories but this one just was so poorly acted out but she got away with it for the 2 years I worked in this little ER in CA, then the docs just booted her out by refusing to give dilaudid and she went somewhere else...


She would come to the ER by private vehicle and get loaded in the wheel chair where she would the adduct one arm flexed close to her body, slur her speech, roll her eyes around, and twitch. It was convincing the first time I treated her and got out the 8 mg dilaudid, 10 mg valium and 100 mg benadryl. The only IV acess she had left was in her thumb and it was frakin difficult to get. I offered IM but she went ballistic. After her "cocktail" she got up and walked out - of course I was floored and duped all in the same breath. She had burned every other person in the ER and I was the latest dumb a$$. Anyways, she played the seizure game for all she could get, there were times she would disappear for a couple of weeks (found another source). The docs sent letters, made her pain mgt doc come to the Er to treat her, but she persisted. Her family was bought into the whole addiction cycle and carted her to the ER several times a week. Finally, enough was enough and she had a pretty convincing medical record that described addiction and she was gone just like that...........


So I am probably going to hand out a pez dispenser of vicodens every once in a while for that marginally convincing LBP but then thats life in the ER.

 

[TraumaCheers]

I have to agree with the above post about treating pain - it does take way to much energy to figure out who is on the sly. Other than the obvious addict and the kids coming in on Friday night for a lift me up (a few vicomins) I would rather err on the side that this patient may actually have pain and we need to treat it (then refer to my post abive....)

We all have our frequent flyer stories but this one just was so poorly acted out but she got away with it for the 2 years I worked in this little ER in CA, then the docs just booted her out by refusing to give dilaudid and she went somewhere else...


She would come to the ER by private vehicle and get loaded in the wheel chair where she would the adduct one arm flexed close to her body, slur her speech, roll her eyes around, and twitch. It was convincing the first time I treated her and got out the 8 mg dilaudid, 10 mg valium and 100 mg benadryl. The only IV acess she had left was in her thumb and it was frakin difficult to get. I offered IM but she went ballistic. After her "cocktail" she got up and walked out - of course I was floored and duped all in the same breath. She had burned every other person in the ER and I was the latest dumb a$$. Anyways, she played the seizure game for all she could get, there were times she would disappear for a couple of weeks (found another source). The docs sent letters, made her pain mgt doc come to the Er to treat her, but she persisted. Her family was bought into the whole addiction cycle and carted her to the ER several times a week. Finally, enough was enough and she had a pretty convincing medical record that described addiction and she was gone just like that...........


So I am probably going to hand out a pez dispenser of vicodens every once in a while for that marginally convincing LBP but then thats life in the ER.

I take a pretty liberal approach with treating pain while IN THE ED. It's on discharge that I'm stingy. Maybe a few percocet... 3 or 7. Maybe.

 

[da8s0859q]

My perspective comes from being fortunate enough to work with a toxicology trained attending who was very liberal about using morphine, BZDs, etc...her basic point is that the risks of using the meds and the potential to get "burned" were less than the positives of treating people's pain....her other point she always made was that at any given time, any of us become a "drug-seeker" (e.g. an asthmatic who needs albuterol) and thought the term was somewhat meaningless. Granted, she trained in a large inner-city community hospital and felt that she would have had to invest way too much time sorting out "real pain" if she didn't tx pts based on their presentation - not her assumptions about their motives

Not that I have any room to talk since I'm a premedder, but that's an interesting point of view. Would imagine I'd agree.

 

[BADMD]

But at the same time, who cares if you are getting duped sometimes if you are treating real pain most of the time?

It isn't the duped part the concerns me that much, though I'm not a big fan. I hate wasting my time with fakers, but if they have insurance, I'll probably get paid, so even then it isn't so bad.

What concerns me is giving powerful and potentially dangerous medications to people who are likely to abuse them.

In my job, I get about 1 good acetaminophen overdose a day. Most of them are chronic supratherapeutic ingestions. Vicodin is a huge offender. Taking 6 Vicodin ES daily for 3 days puts a person at considerable risk. Yet, writing someone who has chronic pain 15-20 vicodin to cover them until they see their doctor only gives them 4 or so days to get in. Where I practice, very few can get an appointment that fast. In my population, a patient on oxycontin is just as likely to sell it as they are to take it. Hell, even clonidine and cephalexin have street value. I had one guy who managed to sell his phenytoin and was coming to the ED to get a refill so he could sell more. And as a note, if your patient overdoses on the medication that you prescribe, you may very well have significant liability, especially if drug abuse is know/suspected.

My point is not that I don't use strong opiates. I do...often. The point is that I do spend some time getting to the root of it. And I try to be aware of the risks/benefits of my prescriptions. At the same time, when I write for something, I'm going to write for something like Norco, which has far less acetaminophen in it than vicodin (especially at the 7.5mg of hydrocodone level). I also take time to get look into what prevents them from seeing their PCP and why they need a refill in the ED. If the problem is structural and they are actually having pain, it is often fixable, even out of the ED. If they are trying to get their fix it is often excuses.

So, I look at wanton strong opiate prescription as being penny wise and pound foolish. With a little bit of investigation you can a) help reduce abuse of the ED b) help someone with genuine pain into better pain control and c) reduce the abuse of potentially dangerous medications.

Again, the right way isn't to withhold strong pain medications, however neither is it right to give everyone a narc or two to go.

 

[zinjanthropus]

It isn't the duped part the concerns me that much, though I'm not a big fan. I hate wasting my time with fakers, but if they have insurance, I'll probably get paid, so even then it isn't so bad.

What concerns me is giving powerful and potentially dangerous medications to people who are likely to abuse them.

In my job, I get about 1 good acetaminophen overdose a day. Most of them are chronic supratherapeutic ingestions. Vicodin is a huge offender. Taking 6 Vicodin ES daily for 3 days puts a person at considerable risk. Yet, writing someone who has chronic pain 15-20 vicodin to cover them until they see their doctor only gives them 4 or so days to get in. Where I practice, very few can get an appointment that fast. In my population, a patient on oxycontin is just as likely to sell it as they are to take it. Hell, even clonidine and cephalexin have street value. I had one guy who managed to sell his phenytoin and was coming to the ED to get a refill so he could sell more. And as a note, if your patient overdoses on the medication that you prescribe, you may very well have significant liability, especially if drug abuse is know/suspected.

My point is not that I don't use strong opiates. I do...often. The point is that I do spend some time getting to the root of it. And I try to be aware of the risks/benefits of my prescriptions. At the same time, when I write for something, I'm going to write for something like Norco, which has far less acetaminophen in it than vicodin (especially at the 7.5mg of hydrocodone level). I also take time to get look into what prevents them from seeing their PCP and why they need a refill in the ED. If the problem is structural and they are actually having pain, it is often fixable, even out of the ED. If they are trying to get their fix it is often excuses.

So, I look at wanton strong opiate prescription as being penny wise and pound foolish. With a little bit of investigation you can a) help reduce abuse of the ED b) help someone with genuine pain into better pain control and c) reduce the abuse of potentially dangerous medications.

Again, the right way isn't to withhold strong pain medications, however neither is it right to give everyone a narc or two to go.

Oh, I completely agree that what you write for outpatient can be much different than what you give inpatient. I thought we were focusing on a pt in pain arriving to the ED.

If they are going home, it ain't an emergency anymore and the arguments I made above in support of giving strong opiates go out the window. If they want stronger meds in that scenario than you are comfortable giving, they can go to their PCP or pain specialist.

Having said that, I do think that the chronic back painer that lays around all day when not on pain meds but is able to become a functioning/working member of society when they do have pain meds, then I'm again all about giving them whatever works for them. If the high level attorney/accountant etc can only go to work after popping a little xanax in the morning to avoid a panic attack or the thought of a panic attack, then I'm fine with that person having their xanax every morning b/c the negatives of not having it are much greater than the risks that come with the person's physiological dependence. Sometimes we are treating more than pain but luckily these last scenarios - chronic management - are things we don't have to deal with too much in the ED

 

[Apollyon]

but luckily these last scenarios - chronic management - are things we don't have to deal with too much in the ED

Speak for yourself, "we". Those of us in practice will heartily disagree.

 

[zinjanthropus]

Speak for yourself, "we". Those of us in practice will heartily disagree.

Point taken - but from what I've seen, outpatient scripts for pain meds are written for a short time period and people with pain management docs are referred to those facilities or to their pain management contracts with that physician