October Hotsheet - C3, Coins, and Autoinjectors

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Sean G., M.D. -

I love EMRAP. I have ben a subscriber for years. I think 99% of all the discussions are excellent. The only discussions I have ever had issue, in fact have nearly brought me to vomit...is the pain stuff. Since the late 90's I have been well aware of the high incidence of Rx opioid abuse, largely due to the fact I was engaged to a woman who got hooked on heroin stemming from a percocet addiction stemming from treatment by medical professionals for endometriosis. Also I worked as a bouncer in college and had many friends who used cocaine and percocets etc. So I believe my life outside of my medical education exposed me to a side of life most doctors are less familiar with. Having taken a beautiful young woman to rehab multiple times and picked her up after NA meetings and shared coffee with her and her cohorts after said meetings and spending hours in Alanon meetings myself I believe gave me a unique perspective. I had to sit thru hours of lectures at AAEM and ACEP and on emrap with your pain guy Jim (? sp duschwamm????) and be told that the incidence of actual addiction in these individuals with chronic pain showing up in my ER at 3 am because their percocet Rx somehow "burnt up in a fire" or "fell down the drain" was "vanishingly low....like 1/1000 that most of these pts had real pain that just wasnt being properly managed....when I knew the reality was he was VERY wrong. I was told by my ex fiance and her numerous addicted friends how EASY it was to "hit the ER doc up" and their multiple clever reasons why that was so( we were busy, kind, understanding and non judgmental poor record keeping in the 90's etc). I tried to voice a counter opinion that Rx opiate abuse WAS a big deal and NOT vanishingly small only to be verbally back slapped by Jim that I was somehow just being closed minded, judgmental and basically a jerk. I quietly(and some times not so quietly) knew otherwise. Now more than a decade later, with Dateline specials addressing the issue, and it now painfully obvious that it IS a serious epidemic....God pts now routinely take the equivalent of nearly 100 percocets a day(30 oxy IR q 4, 60 oxy ER q 8) for "Fibromyalgia" or "chronic back pain" at 25.... Now I am listening to a very similar mind set AGAIN making IMO a mistake in assessment of an issue. OK Narcan auto injectors for opioid OD are not the "same kind of thing" as epi auto injectors for anaphylaxis. The cohorts are completely different. And this is not because I am a judgmental non liberal jerk...its because I am being reasonable. To my knowledge there was ONE decent study proving the efficacy of the utilization of the auto injectors, the one done in the Boston area, and covered on EMRAP. That study did a very comprehensive approach getting the local community involved, including educational classes in the recognition of opiate OD, cpr, use of the auto injector etc...it wasnt simply handing injectors out in the ER with some teaching. Yes I believe there may be a role for this approach but it needs to be modeled after the Boston study. I have at least 5 friends who have either died themselves or had a son, wife or husband die from accidental OD. The problem is huge. I am not "being judgmental" when I am hesitant to buy into this. You can not compare the kid with the peanut allergy to the opiate addict. The cohorts are dramatically different. About 99% of kids with peanut or other allergies come to the ER with a concerned family they are not suffering an addiction, they do not suffer with the "addict mindset" which is a real phenomenon, they are simply unfortunate enough to have this allergy....even then we do not give the epi pen and say..."hey if you still want to have peanuts because you love them so much...no worries, here is you antidote.... we give them the epi pen in the event of an unforeseen accidental ingestion. The opiate addict is far more complicated, and the addictive psychology complicates the picture as does the social issues involved...for example rather than having a concerned mom and dad with the addict, they are often "dumped at the ER door" by an individual who takes off....yeah sometimes they do have concerned family present, but very often they don't. The kid with the allergy can give himself the shot...the OD victim can not. The psychology is important too....when an addict is given the antidote there is an addictive mindset that is a danger of speaking to the addict..."its cool u got the antidote now" I could go on for hours...but the fact of the matter is it is not nearly as simple as you are making it sound here, and the analogy with the peanut allergy is very poorly thought thru, the opiate addiction is like comparing apples and oranges and not even that close and as such means the use of this approach of lay person rescue is far more complicated and it is not ready for prime time. I would say in a very small portion of our patients...the ones where we have a reliable family or friends who are sober available, and motivated to help...there may be a successful way to implement this...but doing it more cavalierly IMO is a mistake. I buried a best friends 29 year old son last year who OD'd in their bathroom, and cpr by his own brother and 911 for about the 5th time in his life was too late this time...so please do not tell me I am hesitant because I am "judging" the pt. I am being rational. This type of approach needs full community buy in. as done in the study in Boston to work....or we may be potentially exacerbating the situation...for many many reasons...and as a two fingered keyboard warrior with carpal tunnel...I am done for now....but pump the breaks kid....lets put some more thought into this before we start comparing it to epi shots.

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October Hotsheet Full episode audio for MD edition 18:49 min - 16 MB - M4A