Real or BS

[Agast]

Alex Murdaugh claims he was taking up to 2000mg oxycodone a day

Can you really do that much without dying?

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[deleted875186]

Alex Murdaugh claims he was taking up to 2000mg oxycodone a day

Can you really do that much without dying?

If he is taking that much, how accurate is his memory of how many pills he took?

 

[Agast]

If he is taking that much, how accurate is his memory of how many pills he took?

A really, really big Days of the week pill tracker?

 

[Orin]

That's just biology and someone with access/money. 60 pills of Oxy 30 would make sense for 1800 mg/day. There's no ceiling effect on tolerance as far as I know.

Although it's a lot like asking someone how many RVUs or SCS they do, as they all round up.

 

[RM38]

I had a patient that came to us in fellowship taking about 2000mg of oxy a day. We made her sit in clinic all day and take meds under observation to prove that she wouldn’t OD. Then had to come weekly to see us and psych to slowly wean down.

 

[Doctodd]

Proven? Not that it matters….he probably developed a tolerance….except to the constipation.

 

[Ducttape]

short answer, yes. 3000 MED?

long answers:

1. i have taken care of a couple of patients on the equivalent of 3000 MED - in the form of high dose methadone, because technically 3000 MED = 80 mg methadone. the max dose of methadone i had (all inherited patients) was 160 mg daily. a bunch that were over 100.

highest dose of oxy only i have seen was 680 mg oxy a day - 80 mg oxycontin four times daily and oxy 30s 2 every 4 hours.

highest dose in the past 3 years has been fentanyl 100 mcg/hr x2 + oxycodone 30 12 a day.

2. otoh, this guy is a degenerate liar and has lied so much, that anything out of his mouth is probably a lie. he embezzled from his job, embezzled from his clients, lied to his wife, lied to the police, lied to everyone.

 

[GoBeers]

highest i've ever seen was palliative metastatic colorectal cancer patient who was managed by palliative care while in hospital. patient was on IV dilaudid infusion 20mg/hr, with q6m 20mg bolus PCA dosing and additional 20mg bolus IV injection by RN per hour. i think his MED was north of 20,000. failed celiac plexus block by IR.


as a pain fellow, I chart reviewed and signed off immediately.

 

[PainApp2021]

highest i've ever seen was palliative metastatic colorectal cancer patient who was managed by palliative care while in hospital. patient was on IV dilaudid infusion 20mg/hr, with q6m 20mg bolus PCA dosing and additional 20mg bolus IV injection by RN per hour. i think his MED was north of 20,000. failed celiac plexus block by IR.


as a pain fellow, I chart reviewed and signed off immediately.

Was there any consideration for an ITP?

 

[GoBeers]

Was there any consideration for an ITP?

no if i remember correctly his life expectancy was less than 3 months

 

[Doctodd]

Was there any consideration for an ITP?

Murdaugh didnt have one either. I had a few attorneys on Oxy80 tid i inherited in my first job out of fellowship. I dont have a high opinion of them.

 

[deleted875186]

no if i remember correctly his life expectancy was less than 3 months

This is the perfect patient for an ITP. Can quickly titrate ITP in the hosptial and get much better pain relief than all the orals.

 

[lobelsteve]

This is the perfect patient for an ITP. Can quickly titrate ITP in the hosptial and get much better pain relief than all the orals.

If you think anyone on 20,000 morphine equivalent to get benefit from any opiate whatsoever than you should not be in pain management

 

[deleted875186]

If you think anyone on 20,000 morphine equivalent to get benefit from any opiate whatsoever than you should not be in pain management

What else would you offer the cancer patient described above? Obviously very atypical, don’t know specifics, but if actually cancer pain and in a mega dose of IV opioids with no effect?

Will also add, this isn’t really outpatient pain medicine, it’s palliative care medicine.

 

[DMBandFan86]

Maybe I’m ignorant, but how could someone even obtain or afford 2000 mg oxy a day. I assume this is all off the street and the quantities would be massive as mentioned above > 60 large pills per day.

Not that I believe the guy, but I’d more believe he was eating spree and thinking they were oxy. But anyways the withdrawals must have been awful if true.

 

[wendalltwolf]

Maybe I’m ignorant, but how could someone even obtain or afford 2000 mg oxy a day. I assume this is all off the street…

Did you get a good deal? - StreetRx.com

 

[GoBeers]

What else would you offer the cancer patient described above? Obviously very atypical, don’t know specifics, but if actually cancer pain and in a mega dose of IV opioids with no effect?

Will also add, this isn’t really outpatient pain medicine, it’s palliative care medicine.

It was a strange case. like admitted 2 months prior from out of state to our academic site, metastases all over with primarily abdominal pain. managed by palliative immediately. obviously tried on all adjuncts (tylenol, neuropathics, ketamine infusion, steroids at some point) and eventually IR tried celiac plexus block (not with neurolytic). I think palliative was just at wits end but by the time they consulted us, his whole body fluid was replaced by IV dilaudid. i honestly don't think anything else could realistically be done at that point. the guy was real nice and talking to staff like nothing was happening.

the point is... tolerance is real. oh and the guy said he had 7/10 pain still . 😂😂
i think one real issue was... for any other case, how would you plan for discharge and outpatient care on doses like that.

 

[lobelsteve]

What else would you offer the cancer patient described above? Obviously very atypical, don’t know specifics, but if actually cancer pain and in a mega dose of IV opioids with no effect?

Will also add, this isn’t really outpatient pain medicine, it’s palliative care medicine.

At what point do you sayopiates aren’t working? For palliative care I would say 200-300. Never had a patient die on more than that. Comfortably. If opiate resistance then stop the insanity. It is a Portenstein’s monster. Cordotomy makes more sense. I would not accept a consult or involve myself in such a catastrophic failure.

 

[Ferrismonk]

At what point do you sayopiates aren’t working? For palliative care I would say 200-300. Never had a patient die on more than that. Comfortably. If opiate resistance then stop the insanity. It is a Portenstein’s monster. Cordotomy makes more sense. I would not accept a consult or involve myself in such a catastrophic failure.

For the sake of argument:
I agree opioids should have been given up long before then. Perhaps a palliative epidural? Spinal bupivacaine? Long before opioids were that high, if everything else failed, a real discussion should have been made for palliative sedation if he truly was miserable.

 

[MitchLevi]

Here's what I do - Refuse the consult.

Something insane like this...Haha. Not gonna see that pt.

You heros can see him and I'll sit back and listen to yalls exciting pt stories.

I would LOL at those medical records and wouldn't read past the first two or three pages.

 

[PainApp2021]

If you think anyone on 20,000 morphine equivalent to get benefit from any opiate whatsoever than you should not be in pain management

It was my (limited) understanding that once you get over 2000 OME or some arbitrary number that the receptors are saturated, and at that point you will just have increased side effects. For an end of life cancer patient, at least an ITP would help mitigate some of the ADRs. A cordotomy could certainly be an option and I've seen it work very well in the immediate post-operative course, but in my patient's course mirror pain and a new neuropathic pain emerged soon after that was more excruciating than the initial pain. That being said, the patient's malignancy did progress significantly in a short period of time and was resistant to radiotherapy.

 

[lobelsteve]

It was my (limited) understanding that once you get over 2000 OME or some arbitrary number that the receptors are saturated, and at that point you will just have increased side effects. For an end of life cancer patient, at least an ITP would help mitigate some of the ADRs. A cordotomy could certainly be an option and I've seen it work very well in the immediate post-operative course, but in my patient's course mirror pain and a new neuropathic pain emerged soon after that was more excruciating than the initial pain. That being said, the patient's malignancy did progress significantly in a short period of time and was resistant to radiotherapy.

The answer is not more opioids.

 

[Ducttape]

the conundrum for someone with end of life conditions with presumed opioid hyperalgesia is that the probable beneficial treatment - opioid cessation - would cause significant distress for the short term, which of course could mean the rest of his life...

you could put in an epidural catheter and run bupiv along with a different opioid such as fentanyl. especially if there are only weeks left.



in all my time... DREZ lesioning has only been used for brachial plexus lesions. can help in that circumstance.

 

[drrosenrosen]

At what point do you sayopiates aren’t working? For palliative care I would say 200-300. Never had a patient die on more than that. Comfortably. If opiate resistance then stop the insanity. It is a Portenstein’s monster. Cordotomy makes more sense. I would not accept a consult or involve myself in such a catastrophic failure.

I'm adding Portenstein's monster to my daily vocabulary

 

[Orin]

That's a tough case if you aren't comfortable engaging, but I would start with a tunneled epidural to temporize with local anesthetics.

IR guided Celiac plexus blocks can be hit or miss as they sometimes use lower volumes than IPM providers, and that's a volume block. In the case you're describing though, metastases into the liver capsule or diaphragm are often more somatic pain than visceral, and that's why an intercostal/epidural makes sense.

I was taught that a cordotomy for visceral pain is foolish, but the question is what the pain generator here is.

A pump would be an option, but not an opioid only device. The data on financial value shouldn't limit you from using it where indicated for inpatients and the newer data suggests you can break even at 2 months for outpatients.

It's a good academic case, but you need a team comfortable with running in when everyone else is running out.

 

[Centurion38]

IT opioids won't make a difference if someone is tolerant, hyperalgesic on high PO doses for years. Viewing IT pumps as a "salvage" for these high dose train wrecks is very 1990's

You very likely will get an infection or wound dehiscence though. Bonus points if they present to the ED and you get paged saying they can read "Medtronic" on the pump sitting in the pocket