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Strayerisms - Something for Pain

Reuben Strayer, MD
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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EM:RAP 2017 March Written Summary 580 KB - PDF

Reuben strayer gives his ‘risk stratification’ approach to ED opioid prescribing.

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Ian L., Dr -

If there is concern I use daily pick up from pharmacy Or every two days pick up .
The pharmacies generally hate it .
However the methadone and buprenorphine programmes mandate daily pick up till patients are "stable " .
Some will pretend to swallow buprenorphine keep the tablet hidden And go out and inject :they often get nasty eye infections .

In Australia violence against doctors verbal and threatening and occasionally physical occurs when some violent types are refused .
Universal health care and the ability to visit another medical centre more permissive even burnt out " stuff them " is the safety net .

Jeffrey S., D.O. -

Dr. Strayer,
Do your cards say anything in particular on them or is it just the SAMHSA help line number? This sounds like a great idea which I will bring up at our next department meeting.
Thank you,
Jeff

Reuben Strayer (@emupdates) -

my helpcards are available for printing here:

emupdates.com/help

and I'm happy to send you some - just email me an address - emupdates@gmail.com

reuben

Gary M., Jr -

Thoughts on treatment options for people who claim to be allergic to practically everything but a specific narcotic? Other options or how to frame that conversation?

Reuben Strayer (@emupdates) -

There are numerous options depending on the situation. Many of them are laid out in table 1 and table 2 in this paper:

https://www.dropbox.com/s/6yldh34wz09ahl3/Strayer%20Motov%20Nelson%202017%20Something%20For%20Pain%20-%20AmJEM.pdf?dl=0

Allergies to multiple analgesics make opioid misuse very likely, which means that many of these patients are being harmed by opioids and are harmed when prescribed more opioids, instead of being directed to addiction treatment. If you want to describe a specific scenario I'd be happy to comment.

reuben

Donald Z., M.D. -

thanks ruben. i have noticed (many years ago) that dilaudid pills did not give euphoria. Any evidence or opinion in using dilaudid instead of morphine IR tabs? dosing?

Reuben Strayer (@emupdates) -

oral dilaudid definitely less euphoric than parenteral. we don't have good science on this, my best take after reviewing what's out there (both in the literature and on internet drug message boards like erowid and blue light) is that dilaudid has an abusability factor in between IR morphine and hydrocodone. So if you don't want to or can't prescribe MSIR, oral hydromorphone is preferable to vicodin and certainly to percocet/oxycodone, which is the most abuse prone.

Kelly A., M.D. -

Hi.....I am a New Zealander working in an NZ ED and have numerous American Board Certified ED colleagues who have chosen to live and work here because of the issues with how pain is managed in the US (amongst other issues).
One of these Drs, Dr Michael Jones, recently presented a Ted Talk on the differences between the experience and management of pain between the US and NZ.....I would hope that many of who listen to EMRAP would find it enlightening.
I think that Mike would be an excellent person for the EM:RAP team to interview for segment on the Podcast.....it sounds to me like this Opiate addiction issue is at crisis point in the US and ED Drs are in a position to lobby and act for change.
Here is a link to the talk....it is 20 minutes long and really interesting - please watch it.

https://www.youtube.com/watch?v=_zZH1QKyU64

Reuben Strayer (@emupdates) -

thanks for sharing that talk Kelly. I've heard the same thing from everyone I know who's worked in NZ.

Jason H. -

Hey Reuben,

I just had a question on the dose changes from PO morphine to oxycodone. The conversion PO morphine:oxycodone is 1.5:1, so 15 mg oral morphine is 10 mg oxycodone. I usually prescribe oxy 5 mg 1-2 tabs as needed for pain. Why the recommended dose increase?

Reuben Strayer (@emupdates) -

Thanks for this question Jason - it's come up a number of times. The simplest answer is that the conversion chart is wrong. I know that many of them say it's 1.5:1; some of them say 2:1. You know this is wrong because morphine IR is available in 15 mg tabs and 30 mg tabs - 30 mg tabs are used all the time, but who would give 20 mg oxycodone? Noting that the most dangerous phrase in medicine is in my experience, in my experience 15 mg MSIR is about equivalent to 5 mg oxycodone. But don't take my word for it–try it. Dispense a 15 mg dose of MSIR to a patient you would normally give oxy to and see what happens. Would love to hear your impression.

reuben

James C. -

Reuben,

For the "Red/Yellow flag" person who has something difficult to treat with your non narcotic alternatives , say abdominal pain, (can't do trigger points, no lido patch, allergic to everything etc etc). Do you ever take the approach "I don't think I'm going to be able to give you anything to make your pain better today".

Reuben Strayer (@emupdates) -

I don't think I've ever said that. For patients with RED flags, I really focus on being up front with them about my concerns around addiction, and I will say something like I want to improve your pain, but I will not use opioids because I think opioids are harming you. Red flag patients almost always just get up and walk out once they're convinced that they are not going to get opioids.

Otherwise, for severe abdominal pain, when I'm sufficiently concerned the patient will be harmed by opioids (red flags or significant burden of yellow flags), I use droperidol/haloperidol.

http://www.ajemjournal.com/article/S0735-6757(17)30182-1/fulltext

reuben

J. B. L., M.D. -

Where does Meperidine (Penthidine) fall on the euphoria scale? Fentanyl patches? Tramdol? Codiene?
Is there a chart available on the subject?

Reuben Strayer (@emupdates) -

Likability science is in its infancy, there's certainly no chart, wouldn't that be great. I've collected some literature on this, see this folder:

https://www.dropbox.com/sh/nyrvusd43tdgua6/AABV2-5USj4848_7-yJ1cv1Ya?dl=0

Meperidine (Demerol in the US) is thought to be highly euphoric and also burdened by a variety of interactions/adverse events, it's uncommonly used these days.

Fentanyl patches are known to be highly abusable, often by smoking their gel. Like all long-acting analgesics, should not be prescribed by acute care clinicians.

Tramadol and codeine, the so-called "weak opioids" each have their own specific of concerns. Tramadol may be the most abused opioid worldwide and has recently become a target of toxicologists for a host of problems.

https://www.dropbox.com/sh/3hlzgvay1d6mh6i/AAAKSfQ_yRXjZGSITLxER1mTa?dl=0

Codeine is probably not more effective than non-opioid analgesia and its variable metabolism (especially in children) has been the subject of much scrutiny.

https://www.dropbox.com/sh/9hry7rux4zv9c46/AACE5GL_FJdzvzJBaL80iXo3a?dl=0

reuben

Dallas Holladay -

I have to admit, prescribing oral morphine makes me uncomfortable as I am totally unfamiliar with it. Do you get any push back from pharmacies?

Reuben Strayer (@emupdates) -

Pharmacies carry what we prescribe. All pharmacies carry Percocet and Vicodin, because nearly all prescriptions are for Percocet and Vicodin. If we prescribed IR morphine instead, they would carry IR morphine. and most pharmacies do. but some don't. For the perhaps 1-2 patients per month that I send home with MSIR (I used to write maybe a half dozen Percocet scripts per shift) I tell them that not all pharmacies carry it, and that they may want to call first.

Ross B. -

I'm interested in the question of when a recurrent problem should perhaps be termed a chronic problem. Pts with chronic, recurrent back pain with no red flags in the history or exam end up generally being treated with no opioids. This is again, because we feel it is not in their best interest. Same thing with migraines and many other non-objective pain syndromes. I'm wondering about other painful, recurrent problems, specifically sickle cell crises. We all know this is a very painful condition, and the mainstay of treatment is generally opioids. In prior segments on EMRAP there was a recommendation to be careful of NSAIDS given the decreased GFR that pts with sickle cell experience and that many providers give NSAIDS. Also, we have no way to medically verify if a pt is truly having a sickle crisis or has secondary gain. Particularly with those pts who have red and yellow flags, how should we best deal with this situation.? When is is appropriate to withhold opioids? When should we use them? As you can see, we are caught in a conflict.

Reuben Strayer (@emupdates) -

Sickle Cell is a horrible, life-limiting disease that also causes terrible pain crises. On top of that, some sickle cell patients have become opioid addicts and misusers; some entered (and continue to enter) into misuse arising from prescriptions from well-meaning physicians.

Sickle cell patients with red flags or multiple yellow flags are probably harmed by opioids, just like anyone else with red or multiple yellow flags. I manage these patients without opioids. My usual approach is

1. Tell them that I think they are being harmed by opioids, and that I want to relieve their pain but will use only non-opioids to treat their pain. Many of them, once they accept that as the truth, get up and walk out. I hand them a HelpCard on their way out. In my view, they have by that action announced themselves as misusers, seeking not relief from pain but opioids in particular.

2. For those who remain, and are in severe pain, I generally administer 10 mg haloperidol IM. The majority of them fall asleep, wake up a couple hours later, and want to go home. At that point I reiterate that I think they're being harmed by opioids and offer them a HelpCard. This group is much more receptive to the HelpCard than the first group.

3. If the IM dose doesn't work, I generally start an IV and give 5 mg haloperidol IV. That works for maybe half of the remaining patients.

4. There have been a few patients still in severe pain after 10 IM and 5 IV haldol. For them, I give ~30 mg ketamine over 20 minutes. That has worked every time. I submit that if the haldol doesn't work, in makes effective treatment with ketamine more likely, because it broadens ketamine's therapeutic window by making ketamine's psychoperceptual effects less bothersome to the patient.

Sickle Cell is definitely hard, and sometimes I feel like severe HBSS patients overlap with palliative care patients, and in that case I have less concern about opioid harms. But I see lots of sickle cell patients that come many days per week, tell me to give them 2 mg IV dilaudid with 50 mg IV benadryl now, and again in an hour, and they'll leave. They're not seeking pain relief, and they are also at high risk to die from their opioid misuse syndrome. Once you accept that, it's easier to treat them with opioid alternatives.

Ross B. -

thanks very much for your thoughtful reply. I agree with all that you said and will try using Haldol with these patients in my practice.

Paul J. V., D.O. -

Dr. Strayer, thank you for this segment. I've never prescribed immediate release morphine but your reasoning is sound. Do you have any literature that discusses the euphoric effects of different opiates?

Reuben Strayer (@emupdates) -

See this comment, above:

https://www.emrap.org/episode/crashingslowly/strayerisms#comment4077

Paul J. V., D.O. -

Wow! That's quite a database. Thanks very much.

mark g. -

Thanks for the show.
You have some papers on the euphoric effects of different medications? This seems like a valid aspect of the abuse potential of medications but my brief search yielded a paucity of compelling data.
The approach I preach to my minions is to think of pain medications the way we think about antibiotics. We don't given IV Vanc/Zosyn for infections the patient rates 10/10. We use medical decision making to determine the medication, the route, and the duration of treatment. We must consider substance abuse in the ddx every time we prescribe a narcotic just as we think about possible allergic and drug reactions when we prescribe abx. We must consider the risks and benefits of every therapy.

Reuben Strayer (@emupdates) -

there is definitely a paucity of compelling data but what I have is referenced in the comments above.

I make the same point re: antibiotics, or tPA, or anything: weigh likelihood of benefit and harm with every Rx.

thanks for your comments Mark.

Alex B. -

Something you referenced in here was that an effective way to treat pain is 1 gram of acetaminophen and 400 mg of ibuprofen every 6 hours. I think this is probably more acetaminophen per dose and less ibuprofen per dose than many of us typically prescribe and/or order in the ED. I was wondering if you had any references to literature on this subject. Thanks.

Reuben Strayer (@emupdates) -

good Q, Alex.

400 mg is thought to be the ceiling for analgesia for ibuprofen, though you can achieve additional therapuetic efficacy by taking advantage of anti-inflammatory properties at higher doses. I routinely give 800 mg as a single dose in the ED but use (and recommend) 400 mg/dose for outpatient. This isn't based on good comparative evidence but here are a couple of related studies/reviews:

https://www.dropbox.com/s/eiwhffc9dkgvg4u/P%20Moore%202013%20APAP%20%2B%20ibu%20for%20dental%20pain%20review%20-%20JADA.pdf?dl=0

https://www.dropbox.com/s/vw1mfaembwiorma/Derry%202013%20Ibuprofen%20%2B%20APAP%20for%20Acute%20Pain%20-%20Cochrane%20Review.pdf?dl=0

1 gram acetaminophen every 6 hours is the maximum recommended dose. Given APAP's safety profile, I use it at that high dose.

Jonathan J., M.D. -

In Canada Morphine (immediate release) is available as Statex (morphine sulphate) 5 mg. I prescribe 1-2 tablets q 6-12 h prn for severe pain. i.e renal colic with OTC ibuprofen (if young/no renal failure/ no hypertension/ no hx NSAID gastritis or gi bleed). pus peg 3350 17 g po od with 2 glasses of water to prevent the constipation. Given that many ureteric stones can take days to pass I usually give 20-25 tabs with urology follow up 3-5 days.

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Crashing Slowly Full episode audio for MD edition 238:10 min - 332 MB - M4AEM:RAP 2017 March German Edition Deutsche 73:21 min - 101 MB - MP3EM:RAP 2017 March Spanish Edition Español 89:05 min - 122 MB - MP3EM:RAP 2017 March Aussie Edition Australian 16:33 min - 23 MB - MP3EM:RAP 2017 March French Edition Français 25:15 min - 35 MB - MP3EM:RAP 2017 March Canadian Edition Canadian 28:50 min - 40 MB - MP3EM:RAP 2017 March Board Review Answers 262 KB - PDFEM:RAP 2017 March Board Review Questions 218 KB - PDFEM:RAP 2017 March MP3 Files 316 MB - ZIPEM:RAP 2017 March Written Summary 580 KB - PDF

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