reveal drug screen

[rohit76]

This is regards to chronic pain patients visiting ED. Are we suppose to reveal their positive drug screens or fact that they have diluted their urine?
Can we just bypass this all drama of disclosing drug screens and give them ultram or ultracets on discharge?

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[kungfufishing]

why order a drug screen in the first place?

 

[rohit76]

I guess I was referring to patients whom you have not seen before but suspect prescription drug abuse. I agree about not ordering UDS on frequent visitors.

 

[Hercules]

I guess I was referring to patients whom you have not seen before but suspect prescription drug abuse. I agree about not ordering UDS on frequent visitors.

I would still ask why get the UDS in the first place? How would it change your disposition or treatment?

 

[EM2BE]

Also, if they are in the habit of pill popping, the chance of a positive UDS is nil unless you specify the special tests you want run. That is to say only for those that use pills exclusively.

 

[SoCuteMD]

Also, if they are in the habit of pill popping, the chance of a positive UDS is nil unless you specify the special tests you want run. That is to say only for those that use pills exclusively.

Sorry, but that's wrong. Some pills do show up on UDS. Not all, but some.

 

[southerndoc]

why order a drug screen in the first place?

I agree. I almost never run them unless the patient has an unexplained altered mental status, needs a psych eval, has a new onset seizure disorder, stroke at a young age, or MI at a young age.

 

[EM2BE]

Sorry, but that's wrong. Some pills do show up on UDS. Not all, but some.

Which ones? When I worked in the detox unit, all the pills they admitted to taking never showed up on the UDS.

 

[SoCuteMD]

Some benzos (I forget which ones), MS contin. No opioids - Demerol, dilaudid, hydrocodone, codeine.

That being said - I never order them, and I talked my attending out of ordering one today.

 

[EM2BE]

Some benzos (I forget which ones), MS contin. No opioids - Demerol, dilaudid, hydrocodone, codeine.

That being said - I never order them, and I talked my attending out of ordering one today.

I guess I should have excluded the benzos. I was thinking pain killers. I'm not sure if there was anyone that was taking MS Contin without the other drugs (I thought there was one that was pure pain killers including MS Contin and their drug screen was negative, but may be wrong on that one). Dilaudid, percocet (all the -cet's), codeine and things like that were the DOC around here. Percocet and oxycodone were probably MC.

 

[southerndoc]

UDS usually covers 5 drugs in most labs: THC, PCP, cocaine, barbiturates, and benzos. Some places add narcotics.

 

[BADMD]

Can we just bypass this all drama of disclosing drug screens and give them ultram or ultracets on discharge?

Why do you want to use tramadol. It is a very lousy pain killer with a fairly high side effect profile and a narrow therapeutic index. As far as I care, the druggies can have their 20 vicodin and let me get on to other patients. I'm not going to fix their problem in the ED. Playing narc cop for someone with a diagnosed pain condition ain't my problem. I only start getting annoyed when they show up too often.

 

[BADMD]

Which ones? When I worked in the detox unit, all the pills they admitted to taking never showed up on the UDS.

The urine drug screen is a drugs of abuse screen. It is based on the "NIDA 5." If it isn't a drug of abuse, it isn't likely to be in a urine drug screen.

You will usually get an opioid, marijuana, PCP, cocaine and amphetamine. Many medical facilities will extend that and add benzodiazepines, methadone, propoxyphene, and/or barbiturate. They may break out the different opioids (usually oxycodone) or differentiate amphetamine from methamphetamine.

Your screen will not pick up the full synthetic or non-morphine derived opioids (meperidine, propoxyphene, methadone, buprenorphine, pentazocine, fentanyl) without having a specific screen for them. Older benzo screen may not pick up benzo that don't go through oxazepam as a metabilite (clonazepam and lorazepam, others). The ability to pick up morphine derivatives changes with the opioid, e.g. it takes about 6 times more oxycodone, compared to morphine, to trigger a positive screen.

More comprehensive testing is available via GC/MS. This will pick up a far larger array of drug metabolites.

 

[bartleby]

If you want to give someone a pain killer stronger than an NSAID but not a narcotic, tramadol is a reasonable choice. It is very well tolerated in some patients.

If you want to talk about medications with a malignant side effect profile and a narrow therapeutic index, narcotics will be at the top of your list.

Why do you want to use tramadol. It is a very lousy pain killer with a fairly high side effect profile and a narrow therapeutic index.

It IS your problem. Aside from the fact that narcotic addiction ruins peoples' lives, given all the complications related to narcotics (falls, MVAs, fatal overdose, constipation), these are some of the most dangerous drugs you can prescribe. Would you just randomly fill prescriptions for digoxin and warfarin if people wanted those too?

Why do you think that these people come to the ED and waste your time in the first place? Because they count on "easy marks" who would rather give them what they want than be honest and tell them to beat it.

Aside from the fact that your DEA license is contingent upon it, you have a moral duty to avoid prescribing narcotics which you believe may be diverted. Secondarily, people with a diagnosed pain condition who are under the care of a pain management specialist should get their care from that practitioner rather than be trying to get narcotics outside of their agreed upon dosing. They are wrong to be there even asking you for the prescription in the first place.

As far as I care, the druggies can have their 20 vicodin and let me get on to other patients. I'm not going to fix their problem in the ED. Playing narc cop for someone with a diagnosed pain condition ain't my problem. I only start getting annoyed when they show up too often.

 

[EM2BE]

The urine drug screen is a drugs of abuse screen. It is based on the "NIDA 5." If it isn't a drug of abuse, it isn't likely to be in a urine drug screen.

You will usually get an opioid, marijuana, PCP, cocaine and amphetamine. Many medical facilities will extend that and add benzodiazepines, methadone, propoxyphene, and/or barbiturate. They may break out the different opioids (usually oxycodone) or differentiate amphetamine from methamphetamine.

Your screen will not pick up the full synthetic or non-morphine derived opioids (meperidine, propoxyphene, methadone, buprenorphine, pentazocine, fentanyl) without having a specific screen for them. Older benzo screen may not pick up benzo that don't go through oxazepam as a metabilite (clonazepam and lorazepam, others). The ability to pick up morphine derivatives changes with the opioid, e.g. it takes about 6 times more oxycodone, compared to morphine, to trigger a positive screen.

More comprehensive testing is available via GC/MS. This will pick up a far larger array of drug metabolites.

Makes more sense that it varies between institutions. I know we had opiates, barbs, benzos, THC, cocaine, meth, EtOH. Nothing was differentiated beyond that. Thanks for the info

 

[GoBuckeyes913]

If you want to give someone a pain killer stronger than an NSAID but not a narcotic, tramadol is a reasonable choice. It is very well tolerated in some patients.

I'm pretty sure Tramadol is a narcotic, being a synthetic opioid and all.

 

[BADMD]

If you want to give someone a pain killer
stronger than an NSAID but not a narcotic, tramadol is a reasonable
choice. It is very well tolerated in some patients.

If you want to talk about medications with a malignant side effect
profile and a narrow therapeutic index, narcotics will be at the top
of your list.

If you can say that tramadol doesn't have malignant side effects, you haven't spent enough time looking at it.

It isn't "narcotic" in the sense that it isn't scheduled. It is still on opioid like drug with mu receptor agonism. It is still habit
forming and has significant addiction potential. Seizures occur in overdose as does serotonin syndrome. It is metabolized by the CYP2D6 system, so there is errectic metabolism and significant drug-drug interaction. 10-20% of patients out there are going to metabolize it fairly slowly and have risk of significant side effects by taking it normally.

Risks to opioids: close to zero with normal dosing, especially with someone who is tolerant. In overdose, sure there is respiratory
depression, but I have a reversal agent. And it still takes alot, in someone who is tolerant to get significant respiratory depression.

Oh yeah...you can still get respiratory depression with Tramadol. You just usually see the other side effects and toxicity first.

It IS your problem. Aside from the fact that narcotic addiction ruins
peoples' lives, given all the complications related to narcotics
(falls, MVAs, fatal overdose, constipation), these are some of the
most dangerous drugs you can prescribe.

But you see, I'm not going to fix them by denying someone a prescription. What I am going to end up doing is denying someone who has a painful condition from getting some analgesics. So I give a liar a couple days worth of vicodin. Big deal. I'd rather do that then have someone in pain for several days because they can't get into see their doctor.

Would you just randomly fill
prescriptions for digoxin and warfarin if people wanted those too?

A semi ridiculous question. If they have the appropriate indications and I do the appropriate testing, then yes, I can and I have. I don't have a pain test yet and the indication is that someone says they are in pain. So, just as it is appropriate to prescribe someone on warfarin for a-fib a short term refill when they are having trouble seeing their doctor, it is appropriate to give someone a short term refill of their pain medication when they have trouble seeing their doctor.

And do be careful giving that Tramadol to people on Warfarin. Nasty little interaction there.

Why do you think that these people come to the ED and waste your time in the first place? Because they count on "easy marks" who would
rather give them what they want than be honest and tell them to beat
it.

Aside from the fact that your DEA license is contingent upon it, you
have a moral duty to avoid prescribing narcotics which you believe may
be diverted.

Well, if I suspect they are being diverted, then I won't write them. But if I think the person is going to take them, then I have no issues writing a 'script. The DEA isn't a going to pull your license or even investigate because you write the occasional vicodin script to someone who abuses drugs.

Secondarily, people with a diagnosed pain condition who
are under the care of a pain management specialist should get their
care from that practitioner rather than be trying to get narcotics
outside of their agreed upon dosing. They are wrong to be there even
asking you for the prescription in the first place.

You have a very jaded and Puritanical view of pain management. Most patients who are coming to the ED complaining of chronic painful conditions actually have some degree of pain. While they may be exaggerating and doing all kind of unethical/illegal things, they do actually have pain. And patients with chronic painful condition have different responses to pain than those who do not. There is a distinct change in receptor physiology and response.

Frankly, most of my patients barely have a PCP, let alone a pain management doctor. And if they are out of their meds, I'm happy to discuss treatment with their pain doc, but unless there is some information that suggests they are lying or otherwise doing something illegal that they have a "pain contract" is not, in and of itself a reason not to give strong opioids.

Why? Simple: You can't agree upon an opioid dose. The very notion is ridiculous. I actual started laughing when I read that. The dose is based on physiologic response to receptor firings. You can't negotiate that. In fact, I would question any pain docs belief about their patient's opioid use if they used those terms.

What the contract does is agree that the patient won't get opioids from another source. So, I'll look into that. You'd be amazed that the crazy stories are actually sometimes true. The last time I got a story, it turned out that the patient's doctor had actually retired and that the doc he referred my patient to had refused to see him as the guy had Medicaid. But no, the patient isn't automatically wrong just being in the ED.

Even insured patients have a 1-2 month wait to get into their doctor. Even an emergent appointment can take 1-2 weeks and that assumes my patient even has a phone to call the office. Sicklers can't get into see their hemotologists faster than 3-4 days from now. Exacerbation of chronic back pain? It is going to take a month or more.

But they are all in pain now.

So it is my moral duty to treat my patients appropriately, but my calculus is very different. Denying someone with a painful condition opioids out of a false sense of moral outrage is bad medicine. Using a high side effect drug in lieu of a lower side effect drug for the same reason is also bad too. And if I end up getting taken for a few opioid prescriptions, so be it. I don't care. Let those few have 'em. I'd much rather treat someone and provide them relief, then deny appropriate therapy while playing the smug moral crusader.

Ultimately I'm not going to fix anyone's drug habit. And I'm actually pretty unlikely to hurt anyone as they will just go somewhere else or hit the street for their fix. What I am likely to do is help those people that actually have pain. Think what you want, I can sleep soundly at night.

 

[BatmanMD]

Frankly, most of my patients barely have a PCP, let alone a pain management doctor. And if they are out of their meds, I'm happy to discuss treatment with their pain doc, but unless there is some information that suggests they are lying or otherwise doing something illegal that they have a "pain contract" is not, in and of itself a reason not to give strong opioids.

Even insured patients have a 1-2 month wait to get into their doctor. Even an emergent appointment can take 1-2 weeks and that assumes my patient even has a phone to call the office. Sicklers can't get into see their hemotologists faster than 3-4 days from now. Exacerbation of chronic back pain? It is going to take a month or more.

But they are all in pain now.

So it is my moral duty to treat my patients appropriately, but my calculus is very different. Denying someone with a painful condition opioids out of a false sense of moral outrage is bad medicine. Using a high side effect drug in lieu of a lower side effect drug for the same reason is also bad too. And if I end up getting taken for a few opioid prescriptions, so be it. I don't care. Let those few have 'em. I'd much rather treat someone and provide them relief, then deny appropriate therapy while playing the smug moral crusader.

Ultimately I'm not going to fix anyone's drug habit. And I'm actually pretty unlikely to hurt anyone as they will just go somewhere else or hit the street for their fix. What I am likely to do is help those people that actually have pain. Think what you want, I can sleep soundly at night.

So are these true Emergencies? Why are they not in urgent care centers? An ER is a very busy place, so most know that they can get their script fast and without little hesitation from certain places. Add press ganey to that, and it becomes even clearer that we have to appease the masses.

As far as strong opioids, are you talking vicodin or MS contin? Would you rx someone (no cancer/sickle cell) with chronic pain that medication? Where do you draw the line? They may be better after you give them their Dilaudid, but vicodin surely wont stop that pain at home. Admit? The medicine guys would rightfully hate us even more.

No one went into medicine to be a *****hole, but there has to be limits. I give the patient what I think they NEED, not what they want.

I'm trying to learn the delicate balance of treating/not treating pain sufferers/seekers. The ED is not a place for chronic pain. We are not a pain clinic. If this is wrong thinking, please explain.

 

[BADMD]

No one went into medicine to be a *****hole, but there has to be limits. I give the patient what I think they NEED, not what they want.

I'm trying to learn the delicate balance of treating/not treating pain sufferers/seekers. The ED is not a place for chronic pain. We are not a pain clinic. If this is wrong thinking, please explain.

No wants to be an donkey. And please don't think that I'm writing everyone who asks 200 Oxycontin 80s and a shot of medicinal whiskey. You're spot on. It is a balance.

But we take a very hardline attitude towards people with painful complaints. While people do come to the ED with the most BS of reasons, there is a reason they are there. When you can't sleep because your tooth hurts and have to go to work the next day, that 3 days old toothache is an emergency. With the economy the way it is, trying to get a day off or even a morning off, may not be possible and if you don't work, the rent doesn't get paid. Would I love to dump people off to urgent care? Heck yeah. Is that realistic? Maybe in some places, but certainly not around where I work.

It seems from my dealings with many residents that they swing too far to the "No!" side of the equation. Instead of trying to look at the patient and the complaint objectively, it becomes a test of will. Starting with "You shouldn't even be here and are wasting my time" and going downhill from there. One resident I worked with felt it was a personal insult that someone "would try to scam him." That just isn't a productive way of looking at any patient.

Instead, I try to go in with the idea that someone is here and I'm going to try and treat them. The number of people that leave after seeing me with a prescription for naproxen, instructions for ice packs and a bit of home PT is staggering. I'll write a few days worth of opioids to get someone to their doctor (usually oxycodone/APAP as it has the widest dosage variation with the least APAP). If they want something stronger, I pull up the pharmacy records to see if they've been on it before. If they are in the ED for the 3rd time in 2 weeks, I'm going to need some plausible reasoning for what is bringing them back.

I would be willing to initiate oxycontin on some patients (10 mg of sustained release oxycodone twice a day is less opioid than 2 Vicodin Q6 and has less abuse potential), but those are going to be rare. But if it is the right way to treat the patient, sure.

Ultimately the attitude shift is what is important. Instead of going in planning for a fight and trying to arm yourself to say no, I go in and evaluate the patient like every other. And if I get scammed for a script, I get scammed. It isn't an affront to moral justice in the universe.

 

[BatmanMD]

In Texas, where I'm at, we need to keep triplicate forms for anything stronger than vicodin, thats why I was asking about the different narcs. In your state, I'm assuming you don't need to do this.

The other thing I don't like about the state of Texas's DPS is they don't have a website that I can look pts up, to see if they have already received 4 other rx in the same week from other ED's. In Michigan, I could do this in residency and decide if 1) they haven't had a refill in 2 months and need one today, or 2)send home with naprosyn, as you alluded to.

 

[Hercules]

BADMD,
You sound very much like one of my attendings who shaped my thoughts on pain in the ED. I fall in with the same logic that it is a far greater evil to withhold pain medicine form someone who is truly suffering than it is to give narcotics to someone who has an addiction.

I also agree in the balance and live in a state where we can pull up the controlled substances a person has had filled. I won't give a script to the guy who has had 220 lortabs filled in the past week (true story). In fact I rarely give out scripts if the patient has a PCP. Those patients get a shot from me and instructions to call their PCP in the AM to refill their narcotics. That way I can say I've treated their pain but I haven't become their favorite supplier, so they tend to not make me their favorite Friday night stop.

 

[Jeff698]

The other thing I don't like about the state of Texas's DPS is they don't have a website that I can look pts up, to see if they have already received 4 other rx in the same week from other ED's.

My understanding is that the law that recently passed saying we had to include our DPS number as well as DEA number was to facilitate the creation of just such as system. No clue on how long it will take.

I have purposefully NOT gotten a triplicate pad. Any others out there in Texas making the same choice?

Take care,
Jeff

 

[southerndoc]

But we take a very hardline attitude towards people with painful complaints. While people do come to the ED with the most BS of reasons, there is a reason they are there. When you can't sleep because your tooth hurts and have to go to work the next day, that 3 days old toothache is an emergency. With the economy the way it is, trying to get a day off or even a morning off, may not be possible and if you don't work, the rent doesn't get paid. Would I love to dump people off to urgent care? Heck yeah. Is that realistic? Maybe in some places, but certainly not around where I work.

During residency I made an arse of myself and learned not to ever ask why a patient waited so long to come to the ED. During a rotation at a community hospital, there was a patient with a headache, which seemed like a tension headache. No vision changes, no vomiting, no photophobia, no trauma, no LOC. Started at noon, saw her at 4 am.

I asked her "why didn't you come in when your headache started?" "I did. I've been in your waiting room for almost 16 hours!"

Just for that, I CT'd her anyway even though she didn't need it. And I learned to keep my mouth shut and just treat the patient instead of finding out why they waited to come in. There comes a point where pain goes on for so long that it's not tolerable anymore. It's more of a psych concept than it is pain itself. Nobody likes to be in pain, and we can all tolerate it to a degree, but if the pain becomes too intense or if it wears out our patience/tolerance for it, then we seek help.

 

[tybalt]

During residency I made an arse of myself and learned not to ever ask why a patient waited so long to come to the ED. During a rotation at a community hospital, there was a patient with a headache, which seemed like a tension headache. No vision changes, no vomiting, no photophobia, no trauma, no LOC. Started at noon, saw her at 4 am.

I asked her "why didn't you come in when your headache started?" "I did. I've been in your waiting room for almost 16 hours!"
Just for that, I CT'd her anyway even though she didn't need it. And I learned to keep my mouth shut and just treat the patient instead of finding out why they waited to come in. There comes a point where pain goes on for so long that it's not tolerable anymore. It's more of a psych concept than it is pain itself. Nobody likes to be in pain, and we can all tolerate it to a degree, but if the pain becomes too intense or if it wears out our patience/tolerance for it, then we seek help.

Wow. I'll keep that in mind.

 

[kungfufishing]

This is my attitude as well. I think it is good for us to remember that nobody goes to the ER because things are normal for them. If you sound like you are in pain, I'll give you some pain medicine. Usually enough to get to your primary or to find one. Now, if you then decide that 15 percocet arent nearly as cool as the 40 oxycontin you came for, different story.

 

[docB]

So if a narcotic user comes to the ER wanting a script because he ran out of meds do you write it? He is in "pain." Is withdrawal pain any different than other types of pain? How about the patients who's withdrawals manifest as exacerbation of their chronic back pain or "fibromyalgia." How about the guy who come in on Friday night and says he can't see his doc 'til next week and he'll run out tomorrow? Write 'em tonight? You know he'll be in pain tomorrow.

I am pretty liberal about giving narcotics. But a healthy skepticism is still necessary.

 

[kungfufishing]

It is just impossible to convey voice inflection/body language on the internet. What meant was that if my gestalt says that you are actually hurting, I'll give you pain medicine. I suppose if you fool my gestalt sense, you win, but that is the way I do it.

 

[bartleby]

This is not a "The Mean ER Doctor Treats Pain Like It's 1963" thread. See the original quote which prompted my reply below. This suggests that you should uncritically prescribe narcotics to people who ask for them, "druggies" if you will, so that you can avoid a confrontation. This is wrong and facilitates both narcotic abuse and the "repeat offenders" everyone here is always moaning about. Furthermore, if you haven't seen anything bad happen to someone because of narcotics, you clearly haven't been practicing medicine that long.

As far as I care, the druggies can have their 20 vicodin and let me get on to other patients. I'm not going to fix their problem in the ED.

If you think someone has GENUINE pain, it should be treated. People who are sitting on the edge of the stretcher tapping their foot when you walk in and give you some sob story about how their dog ate their prescription for 200 OxyContin and how they need a refill because their doctor is on vacation in Guam for the next three months are not genuine. Neither did the guy I recently encountered complaining of back pain with a benign exam, normal vitals, and a completely implausible story putting on an oscar-worthy performance. We reach his PMD who states that he has been getting calls from EDs all over the state about this guy, who has a history of narcotic abuse coming in and trying to get drugs because he's been cut off by his PMD. Because he says he's got "12 out of 10" pain, writhing around on the bed, do I keep him in the ED and play Opium Den with him to get his "pain" under control while somebody with chest pain is sitting in the waiting room?

People with chronic pain need treatment, but it should be prescribed and monitored by a single practitioner according to WHO and evidence-based guidelines rather than done scattershot through multiple emergency department visits. If you are advocating de-stigmatizing the treatment of chronic pain and addressing it as a disease, we should also recognize that it is a chronic condition that requires outpatient treatment. In the same way we expect people utilize outpatient resources for management of hypertension or diabetes, we should expect no less of people with chronic pain.

I would be willing to initiate oxycontin on some patients (10 mg of sustained release oxycodone twice a day is less opioid than 2 Vicodin Q6 and has less abuse potential), but those are going to be rare.

Since this is also a place for learning (at least occasionally), I think that it is important to point out that starting patients on long-acting opioids, particularly those who are new to narcotics, is fraught with disaster, and that this is not a decision that you should be making without doing it in concert with the person who will be providing either further inpatient or outpatient mangement. Long-acting opioids are NOT for acute pain. Long-acting narcotics are for people with chronic, constant pain. These meds _cannot be taken PRN_. The idea is to get a consistent level of narcotic in their system to keep their pain under control. Since it takes 5 half-lives to achieve a steady state, the effect of a dosing regimen is not felt for several days. If someone starts popping oxycontin every 3 hours because they're pain isn't going away, they're going to overdose. People need education about the fact that this medication is to be taken ONLY on a scheduled basis.

I don't agree at all about oxycontin's abuse potential at all. The epidemic of abuse of this drug is widespread and well-known, prompting a legal fiasco for its manufacturer (Purdue -http://www.nytimes.com/2007/05/10/business/11drug-web.html?_r=1&scp=3&sq=purdue%20oxycontin&st=cse). Your maximum dose of percocet or vicodin is limited by the acetaminophen. You maximum dose of oxycontin is determined only by your imagination and/or level of narcotic tolerance. I took care of a drug abuser who came in suicidal who had been on a total daily dose of 300mg oxycodone by way of oxycontin. It is hard to achieve that dose with one of the combo drugs. Furthermore, since you can also crush a tablet of oxycodone for an instant high, this medication is popular with drug abusers and has a high street value if sold instead of taken by the patient. In my opinion, a far better choice for chronic pain is the transdermal fentanyl patch. The patient puts it on and they're on narcotic autopilot. While there is still overdose potential from chewing on the patch, this is more often an intentional rather than accidental phenomenon. It is difficult, but not impossible, to withdraw the pure drug from the patch. Most garden-variety abusers consider this more trouble than it's worth.

If there really is someone who is not getting control from short-acting narcotics and has a legitimate reason to have a change made, this is done in concert with his her orthopedist/surgeon/PMD, you put a fenantyl patch on them in the ED (no rx) and have them f/u with their outpatient provider in 2 days for re-eval.

 

[BADMD]

This is not a "The Mean ER Doctor Treats Pain Like It's 1963" thread. See the original quote which prompted my reply below. This suggests that you should uncritically prescribe narcotics to people who ask for them, "druggies" if you will, so that you can avoid a confrontation.

Yeah, I was a little flippant, but my basic plan going in seeing someone complaining of a painful condition, is to treat them. If I end up writing a 'script for someone who ends up diverting it, that really isn't a big deal. I'm not writing for more than a few days worth. Unless I have actual evidence of diversion prior to writing it, I'm not worried about running a foul of the law. Someone who is obviously abusing or diverting is one thing, but many people get denied mostly because they are asking for pain meds.

If you think someone has GENUINE pain, it should be treated.

My pain tester isn't working right now, can I borrow yours?

People who are sitting on the edge of the stretcher tapping their foot when you walk in and give you some sob story about how their dog ate their prescription for 200 OxyContin and how they need a refill because their doctor is on vacation in Guam for the next three months are not genuine.

How often do you really get that story. I've found the implausible stories to be fairly rare. Even more frightening is that the last two times I went to verify the implausible story, they ended up being true.

Neither did the guy I recently encountered complaining of back pain with a benign exam, normal vitals, and a completely implausible story putting on an oscar-worthy performance.

Just keep in mind that doctors suck at clinically assessing how much pain someone is in. The correlation between pain and vital signs is pretty poor. Now we can argue about the quality of the literature, but the "MDpainometer" is a poorly sensitive instrument.

We reach his PMD who states that he has been getting calls from EDs all over the state about this guy, who has a history of narcotic abuse coming in and trying to get drugs because he's been cut off by his PMD.

Did you ask why his PMD cut him off? Was he actually undertreated and exhibiting pseudoaddictive behavior? Needing more pain meds or asking for refills early isn't necessarily addiction or diversion behavior. The entire scenario is what is important. Frankly, unless his doctor offered him some sort of addiction treatment, this guy likely does need some degree of pharmacologic intervention.

Because he says he's got "12 out of 10" pain, writhing around on the bed, do I keep him in the ED and play Opium Den with him to get his "pain" under control while somebody with chest pain is sitting in the waiting room?

Obviously that depends on the scenario, but your use of the term "opium den" tells volumes. With a quick pain management plan, you can potentially treat his pain and get him out the door fairly quickly. It does require more than a cursory eval and a value judgement.

People with chronic pain need treatment, but it should be prescribed and monitored by a single practitioner according to WHO and evidence-based guidelines rather than done scattershot through multiple emergency department visits.

And every person should have insurance with caring, empathetic PCP who gives them more than 17 seconds to say why they are in the office and listens to their complaints in its entirety and devotes as much time to the visit as is necessary while addressing every single problem in the review of systems.

But that isn't the world in which we practice and certainly not the world in which I practice. One third of my patients are uninsured. Those with Medicare and Medicaid can't see their doctor for 1 to 2 months. Trying to treat to an ideal that doesn't exist isn't good medicine either.

If you are advocating de-stigmatizing the treatment of chronic pain and addressing it as a disease, we should also recognize that it is a chronic condition that requires outpatient treatment. In the same way we expect people utilize outpatient resources for management of hypertension or diabetes, we should expect no less of people with chronic pain.

See above. But I also refill meds for my patients with chronic "measurable" conditions. Are you telling me you refuse to refill blood pressure meds for people who say they are out and are having a hard time getting a hold of their doctor? How about psych meds. Believe it or not, but many of those have street value too.

Long-acting opioids are NOT for acute pain. Long-acting narcotics are for people with chronic, constant pain. These meds _cannot be taken PRN_. The idea is to get a consistent level of narcotic in their system to keep their pain under control. Since it takes 5 half-lives to achieve a steady state, the effect of a dosing regimen is not felt for several days.

You are confusing two different things here. Yes, it takes ~5 half lives to reach stead state levels, that assumes a product that has immediate absorption and then follows 1st order kinetic elimination. That is not the same for sustained release products. Those products are designed to have an release/absorption rate that tries to match its elimination. You can't apply the standard kinetic model.

If someone starts popping oxycontin every 3 hours because they're pain isn't going away, they're going to overdose. People need education about the fact that this medication is to be taken ONLY on a scheduled basis.

Yes, but that doesn't mean that long acting opioids should be relegated to chronic pain only. If someone has a painful injury or other similar condition, having background pain meds with breakthrough makes way more sense than using only IR products.

The IR products create spikes and valleys in pain control. The chance of over dose is actually very high when a person in pain tries to "catch" up with their pain. Creating a low level background helps prevent that. Additionally, it is the spikes that seem to associated with addiction. By minimizing those, you can actually reduce addiction.

Furthermore, since you can also crush a tablet of oxycodone for an instant high, this medication is popular with drug abusers and has a high street value if sold instead of taken by the patient.

Sure, but MS Contin really doesn't. Perdue made some "choices" early on that were questionable. That doesn't make oxycontin a bad drug. Nor should we automatically reject prescribing it.

It is difficult, but not impossible, to withdraw the pure drug from the patch. Most garden-variety abusers consider this more trouble than it's worth.

Not in my world. How to extract depends on what the matrix in it is. Baking it will often make it quite extractable. Freezing does the same in another matrix type. Plus, the left over patches typically have 50% or more of the available drug in when it is removed, make them great for abuse. "Grandma's old patch" has significant resale value.

 

[bartleby]

Yes, but that doesn't mean that long acting opioids should be relegated to chronic pain only.

Actually, that's exactly what it means. Long acting meds = long term, i.e. chronic pain. Short acting meds are for acute pain. There is an FDA "black box" warning in this regard:

The FDA-approved indication for OxyContin is for the treatment of patients with moderate to severe pain who are expected to need continuous opioids for an extended time.

You can prescribe whatever you like (it's your license on the line), but it is important to do so with the understanding that this is not the standard of care and that you're on your own when you do this. If you prescribe oxycontin to someone from the ED for acute pain and they overdose, you are going to get filleted.

Not in my world. How to extract depends on what the matrix in it is. Baking it will often make it quite extractable. Freezing does the same in another matrix type.

This is far beyond the average drug abuser. The reason why OxyContin is abused more often is that the steps involved for immediately releasing the drug in oxycontin are much simpler: 1. crush, 2. snort.

 

[BADMD]

The FDA-approved indication for OxyContin is for the treatment of patients with moderate to severe pain who are expected to need continuous opioids for an extended time.

You can prescribe whatever you like (it's your license on the line), but it is important to do so with the understanding that this is not the standard of care and that you're on your own when you do this. If you prescribe oxycontin to someone from the ED for acute pain and they overdose, you are going to get filleted.

I hope you remember that statement the next time you consider IV haloperidol...

And remember that 10 mg of oxycodone long acting is still 10 mg of oxycodone. If you are willing to write 2 percocet, then there is no inherent reason you'd be afraid of overdose from 10 mg of an ER preparation. Abuse is still abuse and misuse is still misuse. The problem is when high strength tablets are given to opiate naive individuals. All this "its your license" craps is just that, crap. You need to use rational dosing and actually apply thought and science to what you do and not knee jerk reactions. And if you are concerned about abuse and dependence, short acting meds, causing opiate spikes, are clearly worse than long acting.

This is far beyond the average drug abuser. The reason why OxyContin is abused more often is that the steps involved for immediately releasing the drug in oxycontin are much simpler: 1. crush, 2. snort.

I guess my poor inner city population is very advanced when it comes to drug abuse.