# Seekers who are good actors!



## Tone (Jan 17, 2011)

What kind of detailed schemes have you seen drug seekers pull? 

Fake allergy to acetaminophen so they get oxycontin and arthrotec instead of oxycocet? 

Chronic pain that a cause can't be seen on any diagnostic imaging? 

Lets hear stories of seekers who are actually GOOD at acting, and that would probably fool even the most experienced medics.


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## Shishkabob (Jan 17, 2011)

"Ow"

"It hurts"


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## medic417 (Jan 17, 2011)

Not my job to decide who's faking.  It's not your job either.


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## Tone (Jan 17, 2011)

Linuss said:


> "Ow"
> 
> "It hurts"



yeah this is the majority!! but I'm talking about the patients who are GOOD at it.


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## usafmedic45 (Jan 17, 2011)

> Fake allergy to acetaminophen so they get oxycontin and arthrotec instead of oxycocet?


If someone lists an allergy to a non-narcotic analgesic other than aspirin, I suspect a drug addict.  If they list an allergy to ALL non-narcotic pain meds or to Toradol specifically, they are a drug seeker until proven otherwise.  

A great way to separate the true drug addicts is to pull out a vial of naloxone, ask them if they know what it is.  You'd be amazed how many of these low-lifes have experienced Narcan and will cut the crap if you "threaten" them with it. 



> What kind of detailed schemes have you seen drug seekers pull?


99.9% of drug addicts are not smart.  The remaining 0.1% have better established sources of the pain meds than pulling fast ones on the paramedics and ED staff. 



> Chronic pain that a cause can't be seen on any diagnostic imaging?


"Drug addict" and "fibromyalgia" (read as "psychiatric diagnosis with psychosomatic symptoms" usually in a very tightly wound fat woman) jump to the top of my list if a patient gives me that "history".  

Since when do we do diagnostic imaging in the field?   



> Lets hear stories of seekers who are actually GOOD at acting, and that would probably fool even the most experienced medics.


In 15+ years, I've never encountered one.  Then again, unless someone is burned or obviously have something broken, they get nitrous or Toradol.


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## Veneficus (Jan 17, 2011)

The best seeker act I ever saw was a guy with sickle cell who came into the ED complaining of priapism. He got several doses of hydromorphone before the doc handling him walked in and caught him masturbating to keep his erection going.

His narcotics were stopped and miraculously despite being brought in by EMS, he was well enough to sign out AMA and walk out. 

I agree it is not the role of EMS to decide who is seeking nor to hold medication based on those suspicions. Unless you have the ability to provide the proper rehab both short and long term, moral convictions are of no value. 

Narcotic withdrawel can be life threatening. Under what medical risk/benefit analysis can an EMS provider determine withholding the drug is more beneficial than giving it?

From the standpoint that pain is a subjective finding, if you suspect the patient is a seeker and you give the drug, so what?

What if you suspect the person is a seeker and you withhold the drug and you are wrong? 

What if the person is a drug addict and having pain for an actual medical complaint? Does the fact the patient also has an addiction problem preclude him/her from having their pain treated?

Deciding who is worthy of what treatment is a very slippery slope to start down.


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## MMiz (Jan 17, 2011)

This thread has been cleaned and members have been warned appropriately.  As a reminder: _While we promote debating and discussion, we  will not tolerate rudeness, defamatory or insulting posts, personal  attacks or purposeless inflammatory posts._


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## firecoins (Jan 17, 2011)

I had a drug seeker recite Hamlet for me.   Excellent actor!  Got a standing ovation at the ER. When he said "to be or not to be" we really thought he was suicidal.


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## MediMike (Jan 17, 2011)

Read a recent article (I'll try to dig it up) discussing how chronic opiate abusers actually have severely decreased px tolerances due to their unfamiliarity with "pain".  I'm very loathe to withold drugs from anyone, I see no point in it. I'd rather give 10 "seekers" their fix than not provide some palliation from someone who needs it.


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## medicRob (Jan 17, 2011)

medic417 said:


> Not my job to decide who's faking.  It's not your job either.



Absolutely 100% correct. I feel the same way.

Which is worse, giving a junky a fix or withholding meds from someone in real pain because you thought they were a drug seeker?


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## usafmedic45 (Jan 17, 2011)

> I'd rather give 10 "seekers" their fix than not provide some palliation from someone who needs it.



I'd rather give a junkie a dose of Narcan than a dose of morphine.  As they say, mileage may vary.


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## Tone (Jan 17, 2011)

usafmedic45 said:


> If someone lists an allergy to a non-narcotic analgesic other than aspirin, I suspect a drug addict.  If they list an allergy to ALL non-narcotic pain meds or to Toradol specifically, they are a drug seeker until proven otherwise.
> 
> A great way to separate the true drug addicts is to pull out a vial of naloxone, ask them if they know what it is.  You'd be amazed how many of these low-lifes have experienced Narcan and will cut the crap if you "threaten" them with it.
> 
> ...




Good post, I agree with the exception that there are lots of smart addicts. Probably they have a source established at a family MD, and we don't see the smart seekers in ER? its more that we just see the desperate ones.

Is that pretty much what your saying too?


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## Tone (Jan 17, 2011)

MMiz said:


> This thread has been cleaned and members have been warned appropriately.  As a reminder: _While we promote debating and discussion, we  will not tolerate rudeness, defamatory or insulting posts, personal  attacks or purposeless inflammatory posts._



My threads always get people excited!

did you all miss me?


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## JPINFV (Jan 17, 2011)

Tone said:


> Chronic pain that a cause can't be seen on any diagnostic imaging?




...because chronic pain will always show up in diagnostic imaging?


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## JPINFV (Jan 17, 2011)

MMiz said:


> This thread has been cleaned and members have been warned appropriately.  As a reminder: _While we promote debating and discussion, we  will not tolerate rudeness, defamatory or insulting posts, personal  attacks or purposeless inflammatory posts._



Gorram! (for the record, this is my new favorite fracking pop-sci-fi exclamation).

I go and study outside for a significant part of the day and I miss a thread filled with fun? Grr!


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## medicRob (Jan 17, 2011)

> 99.9% of drug addicts are not smart.


Wrong. Just look at some of the drug sites on the internet where individuals are speaking of complex means to convert Safrole and other pre-cursors to MDMA, or some of the sites outlining the use of entheogenical bioderivatives, or talks of individuals using column chromatography and other advanced procedures  to separate an alkaloid from its other constituents, or the acid/base extractions of the Peruvian torch cactus by way of the solvent xylene to end in Mescaline Hydrochloride, or the extraction of the Alkaloid N,N-Dimethyltryptamine from the inner root bark of the mimosa hostillis by way of acid/base mechanisms using NaOH basified H20 to pull the alkaloid from the bark, adding VM&P Naptha to the mix to pull the N,N-DMT into the solvent,  evaporating it, and performing CFC Precipitations to result in a crystalline solid of the product... or if that doesn't convince you, read on how some are growing their own Papaver Somniferum and extracting the various constituent alkaloids and carrying out patented chemical procedures to result in the alkaloid of their choice... My friend, most addicts are smarter than you give them credit for. 

I will not link the sites openly here as I do not want to provide individuals with information that would promote the manufacture of scheduled substances, nor would I want anyone without a working knowledge of chemistry to attempt any of the procedures.. However, I will more than happily send them via PM to the individual who posted this skewed statistic.

Two of the most common books in the possession of addicts are PIHKAL (Phenythalamines I have known and loved), and TIHKAL (Tryptamines I have known and loved) by the famed biochemist Dr. Alex Shulgin, of MDMA fame. These are his chemical notebooks written after the time he was one of the top researchers with the DOW chemical company outlining the mechanisms and synthesis of hundreds of psychoactive compounds, along with an assay of their effects.


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## JPINFV (Jan 17, 2011)

If I posted an equally skewed statistic, could I get the link via PM anyways?


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## medicRob (Jan 17, 2011)

JPINFV said:


> If I posted an equally skewed statistic, could I get the link via PM anyways?



Nope, you and me are cookin crystal meth in the kitchen later, buddy. Start scraping matches.


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## ffemt8978 (Jan 18, 2011)

medicRob said:


> Nope, you and me are cookin crystal meth in the kitchen later, buddy. Start scraping matches.


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## JPINFV (Jan 18, 2011)

ffemt8978 said:


>



Well, if you're outside watching us, why don't you come in and join us?


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## medicRob (Jan 18, 2011)

ffemt8978 said:


>



No need, this is the end of my posts in this thread. These posts were originally made to prove a point that all addicts aren't stupid, not to promote anything to do with drugs. I'm sure the members here know this.


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## firetender (Jan 18, 2011)

You don't catch the smart ones.
The rest are obvious.


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## usafmedic45 (Jan 18, 2011)

> Probably they have a source established at a family MD, and we don't see the smart seekers in ER? its more that we just see the desperate ones.



Yeah, read the rest of that paragraph.  I said exactly that. 



> Wrong. Just look at some of the drug sites on the internet where..... and carrying out patented chemical procedures to result in the alkaloid of their choice... My friend, most addicts are smarter than you give them credit for.



Stupidity and a lack of intelligence are not necessarily the same thing.  Even the most intelligent person can be very stupid at times.  Besides, your average addict isn't cooking this crap otherwise EDs and docs in a box would have a lot fewer clients.


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## Sandog (Jan 18, 2011)

usafmedic45 said:


> If someone lists an allergy to a non-narcotic analgesic other than aspirin, I suspect a drug addict.  If they list an allergy to ALL non-narcotic pain meds or to Toradol specifically, they are a drug seeker until proven otherwise.
> 
> A great way to separate the true drug addicts is to pull out a vial of naloxone, ask them if they know what it is.  You'd be amazed how many of these low-lifes have experienced Narcan and will cut the crap if you "threaten" them with it.
> 
> ...



Your attitude is typical of most health care providers. The addict is seen as a screw up, a loser, one with no self control, one who is lacking intelligence. As a former addict and now a speaker at addict meetings, I can tell you, addicts are not those things mentioned above.

The AMA has determined that addiction is a disease, yet addiction still carries a stigma and the accompanying disdain. You have cancer and everyone supports you, your an addict and screw you, it is your fault.

This stigma will carry on for years to come, but health-care providers should educate themselves about this disease as it is at pandemic levels. 

Addicts are not bad people, they are not losers as many of you think, they are people in turmoil, they suffer and they hurt.

Genetic research has unraveled many of the mysteries of the addict, as science and biology continues to progress this baffling disease may be eradicated in our lifetime. Until then, how about a little tolerance?


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## samiam (Jan 18, 2011)

*Psuedoseizures*

Had a guy come into the ER via ems with an AMAZING seizure (he had LOTS of practice) the doc who had never seen him before gave ativan and after about thirty seconds it was over and he was complaining of back pain so the doc ordered 50 of fentanyl and the guy with out missing a beat said "doc 50 is not enough give me 100" the doc said ok give him 100 and continued charting. Once he got halfway thru his history he said "mr smith..are you sure it was a real seizure this time.. it says here you like to fake them" Patient: of course doc it was real.


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## Veneficus (Jan 18, 2011)

Sandog said:


> Your attitude is typical of most health care providers. The addict is seen as a screw up, a loser, one with no self control, one who is lacking intelligence. As a former addict and now a speaker at addict meetings, I can tell you, addicts are not those things mentioned above.
> 
> The AMA has determined that addiction is a disease, yet addiction still carries a stigma and the accompanying disdain. You have cancer and everyone supports you, your an addict and screw you, it is your fault.
> 
> ...



While I am sure his opinion is he would like to give them narcan, he didn't say that he did. 

He also likes to stir the pot so to speak.


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## medicRob (Jan 18, 2011)

samiam said:


> Had a guy come into the ER via ems with an AMAZING seizure (he had LOTS of practice) the doc who had never seen him before gave ativan and after about thirty seconds it was over and he was complaining of back pain so the doc ordered 50 of fentanyl and the guy with out missing a beat said "doc 50 is not enough give me 100" the doc said ok give him 100 and continued charting. Once he got halfway thru his history he said "mr smith..are you sure it was a real seizure this time.. it says here you like to fake them" Patient: of course doc it was real.



Nice. lol


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## usafmedic45 (Jan 18, 2011)

> one with no self control



Technically isn't that the definition of addiction?  Where the desire to use the substance overwhelms whatever self-control the addict has.



> While I am sure his opinion is he would like to give them narcan, he didn't say that he did.



Only once, and only because the guy was technically meeting the requirements of the protocol that allowed me to have medical reasons (altered mental status) for doing so.   He started checking the ambulance building parking lot to see who was working before coming to the door after that.  It also dropped the frequency of his visits to our station by about 75% and he started riding his bicycle the 19 miles to the next town over for treatment for his "back pain".

As for the "show them the Narcan" trick.  I've lost count of the number of times I've used that one.  It's a good way of getting the really hardcore junkies to back down.  Technically, it's not illegal and it's less unethical than feeding someone's habit.



> The AMA has determined that addiction is a disease, yet addiction still carries a stigma and the accompanying disdain.



And you don't see a stigma associated with any of the following other diseases?:
-Syphilis
-AIDS
-Gonorrhea
-Chlamydia
-Herpes
-Leprosy
-Tuberculosis
-Scabies
-Lice
-Crabs

So please, get off the high horse and let's not act like addiction is any less deserving of a stigma than a disease like syphilis you pick up by making bad choices.  It's not the addiction that attracts the stigma anyhow.  It's the associated behavior that makes most people treat addicts the way they do.  You'll notice that most of the diseases with an associated stigma have a connection or transmission associated with poor hygiene or risky behavior.  The stigma is simply the natural response by a society to minimize and discourage persons from engaging in those activities.  In the case of leprosy, it actually serves a pretty important public health role by encouraging quarantine. 



> Until then, how about a little tolerance?


You mean, how about I feed their addiction or feel sorry for them?  No, not going to happen.  Feeling sorry for them does no good for them.  I offer to get them help, most of them tell me to do something anatomically impossible and the medical equivalent of a Mexican standoff ensues until they become someone elses' problem.



> Addicts are not bad people, they are not losers as many of you think, they are people in turmoil, they suffer and they hurt.


You could have described about 90% of people in EMS.  I know most addicts are not "bad" people but until they go into remission.



> one who is lacking intelligence.


No, just the ones with intelligence have better ways of getting their fix than scamming paramedics and emergency physicians so we get sort of the bottom of the barrel.


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## Sandog (Jan 19, 2011)

> So please, get off the high horse and let's not act like addiction is any less deserving of a stigma than a disease like syphilis you pick up by making bad choices.



 High horse? No, I am just attempting to clear up the misconceptions about addicts. My attempt here is that we are all worthy of redemption.

My drug of choice was alcohol, I had my first drink when I was in the Navy, I was 17 years old. Was this a bad choice, after all, how harmful could one drink be? For most, the one drink ended at that, one drink, for me it was just the beginning. At the time I had no idea that I had the propensity to abuse alcohol. Subsequently I went on a twenty year binge and a lot of regrets. At the time no one told me that I would become an addict so I did not think that first drink was a bad choice.

What I am trying to convey here is that most people do not make a decision to become an addict, one social smoke or drink and they will be done. For many that one social drink or smoke turns into a catastrophic outcome the likes of which the user never anticipated. 

Have you ever taken a drink of alcohol, was that a bad choice? Most likely you have and that was that, you are fine, not a drunk. For some that is not the case, the release of dopamine overwhelms the judgment center and indeed one does lose self control, but I must iterate that this loss of control was not a choice.

There is light at the end of the tunnel for those that seek help as I did. Through medications and therapy addicts can overcome the disease that propels so many into the darkness. 

As EMS providers I am sure many of you see the worst of the worst addicts. It is easy to understand that you develop a thick skin and intolerance to these people as they do not seem to want your help. Truth is they really do want your help, deep inside they do, they just do not know how to ask. Best thing you can do is talk to them, tell them about help programs, give them cards to help resources. If you can save just one, you have earned a pass to the afterlife...


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## Phlipper (Jan 20, 2011)

I've seen far too many seekers in my short career already who are obviously trying to scam us.  How can we be sure?  Because we pick them up every week, or more, for some crazy ailment.  One, a very overweight 30-ish lady, always has a new complaint and last time it was appendicitis.  She evidently researches these various diseases to get the symptoms down.  The ER has caught on and she gets nothing, but there we'll be ... dragging her fat butt off the porch next week cuz she won't give up.  

I have sympathy for folks who are in pain or lonely or whatever.  We've all had our moments, and I try to remember this when trying patients are trying my patience   We're here to help, so I help, regardless of my personal feelings.  Most all my pts get 110%.  But if we've picked you up six times just this month for a different disease each time and you're a known junkie you only get 100%, not 110%.  Our medics won't break out the fentanyl unless something's broken or bleeding or your bp is so high it's obvious you're really in pain.  And I see myself following suit next year.  

One last thing ... I'm sorry, and I don't mean this personally.  I'm speaking of the general public "you", not the poster above:  this "disease" excuse just doesn't add up.  There is no disease I am aware if that takes over your muscles like Linda Blair being possessed by Satan and forces you to take drugs.  It is a choice.  A conscious choice.  Telling yourself you have a "disease" releases you from responsibility when you ARE responsible for your actions.  It's a cop out.  Nothing more.


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## the_negro_puppy (Jan 20, 2011)

Regardless of how much we are here 'try help' and how much 'addiction is disease' i still feel used and cheated when I transport someone to hospital w/pain relief only to find **alerts** for drug seeker etc at hospital


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## medicRob (Jan 20, 2011)

the_negro_puppy said:


> Regardless of how much we are here 'try help' and how much 'addiction is disease' i still feel used and cheated when I transport someone to hospital w/pain relief only to find **alerts** for drug seeker etc at hospital



Just a question (Not picking or anything), but what is it that makes you and the others feel cheated when this happens? Is it the thought that someone pulled a fast one on you, is it a feeling that what you've done is unethical, or is it something else?


Every provider who has access to prescribe narcotics and administer them per their own discretion is going to end up scammed at one point or another. Here is the funny thing about it.. usually it is the little old lady coming in complaining of back pain that is seeking, because at her age docs have seen fit to pretty much prescribe her anything she wants, and even she wants more. 

When I give a patient morphine, fent, or any other pain med only to find out that they are 'seeking', I just see it as a learning opportunity. I don't get mad, I don't feel guilty, and I don't take it personally. We are all going to get tricked.. If I see that patient again, I am certainly going to be skeptical.. However, I will do my best not to let my clinical judgement get clouded over a previous experience. Now, if I see your *** twice in the same day and you haven't just been in a serious car accident or something of the like, then I will more than likely ask you to explain yourself, lol.. or at least take you to the medical center of your choice so you can tell the doc yourself that you are allergic to X even though it is in the same class as Y that you say works well on you without prob.


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## Veneficus (Jan 20, 2011)

Why make more work for yourself than you have to?

Since you cannot possibly help the seeker with their problem, give them the med and be done with it like every other EMS treatment.

I don't see many medics revascularizing an MI in the field. But you still do what you can for them right?

You don't have what it takes to treat an addict, so just give them what little you can.

One day I will figure out why any level of health provider who knows the resources don't exist to treat addiction except for the extremely wealthy somehow feel compelled to try and help by restricting access. 

So now instead of calling 911 and scamming some narcs they can go hold up a pharmacy with a gun (or similar) or finally go into DT and get what they wanted at death's door.

I keep telling people. Addiction is not and can not be solved by medicine. It is a social issue and requires a social address.


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## jjesusfreak01 (Jan 20, 2011)

Veneficus said:


> I don't see many medics revascularizing an MI in the field. But you still do what you can for them right?



I imagine if you could do cardiac caths in the field, medics would have more practice at that than intubation...just saying.


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## mycrofft (Jan 21, 2011)

*Drug seeking or Munchhuasen?*

 1983, young woman borrowed her absent roommate's work clothes (stewardess uniform) and nametag, driven to ER by taxi, said she was on layover and came down with horrible flank and back pain and had history of renal calcs. Left by herself to produce a UA specimen; of course it had a little occult blood. She actually underwent a KUB with contrast and received a Demerol shot, then eloped during a busy stretch before we could tell her the KUB was fine and hand her a pain medication Rx. 

I worked with addicts for over twenty years, including six overseeing subacute housing detox, in a jail. Before you generalize, examine your mental picture of an "ADDICT". Firetender got it, the smart ones and the rich/managed ones are not the ones you see on Skid Row. The best con is the one you never know was pulled on you.

What makes all addicts poor people to be around is the preeminent role their addiction takes in their lives. For people without resources (mental, fiscal or other) or with cumulative brain damage, that means they will do anything to get their addiction met...and "anything" can get really "out-there" as your choices narrow.

Why people like entertainment like "Weeds" or "Breaking Bad" is beyond me.


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## firetender (Jan 21, 2011)

the_negro_puppy said:


> Regardless of how much we are here 'try help' and how much 'addiction is disease' i still feel used and cheated when I transport someone to hospital w/pain relief only to find **alerts** for drug seeker etc at hospital



I will cop to having had this same experience in my time in the field. The system that formed me -- Florida in the 1970's -- was barely able to manage "true" emergencies. I didn't so much resent the drug usage, what bugged me was using an ambulance as a vehicle to get what they needed. Most could have walked to the ER on their own and pulled their scams there.

At times, the presence of passersby would prevent me from "discouraging" transport for someone very well known to the system, an obvious scammer and pitiful, yes, but, in my mind an obstruction. Stuff like this drove me nuts, and to be honest, at times I was less than kind!


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## jjesusfreak01 (Jan 22, 2011)

Had a patient rolling on the ground complaining of back pain. When told he was going to the hospital, promptly hopped up, walked into the ambulance without any apparent difficulty, and explained he was allergic to Toradol. He didn't get anything for the pain.


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## DCAP-BLS-TIC (Jan 23, 2011)

I had a patient complaining of the "worst headache" he's "ever had". So bad that he was "seeing squiggly lines". We get there and he literally has a book bag full of prescription bottles for various drugs, probably about 30-40 bottles, all of them being full/unopened except for his Oxycontin. Pain scale a 13 out of 10, of course.

We get to the ER only to find out that he had been to that same ER just the day before for the exact same complaint.


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## usafmedic45 (Jan 23, 2011)

> Have you ever taken a drink of alcohol, was that a bad choice? Most likely you have and that was that, you are fine, not a drunk. For some that is not the case, the release of dopamine overwhelms the judgment center and indeed one does lose self control, but I must iterate that this loss of control was not a choice.



Given the massive  history of alcoholism in my family?  Probably.  However, I've learned to moderate my drinking by simply associating it with food (a glass of wine with dinner, a beer with a steak, etc.) and also by finding a lot of humor at parties in watching other people act stupid while blitzed out of their gourds. 

BTW, I don't believe it's a "choice" to be come an addict, at least not in the case of alcohol.  However, the choice to abuse narcotics and illegal substances is somewhat different.  I know a lot of people who became addicted largely through no fault of their own to pain medication because of poor prescribing practices, but I know far more who simply seek them out as an "escape" because to quote the country song "the whiskey ain't working anymore".  That is a conscious choice.  Same with someone who becomes addicted to heroin, cocaine, meth, etc.  You can't plead ignorance on the fact that these are massively and nearly universally addictive substances.  Those folks are the ones I have little empathy for because of the bad choices in their life.


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## mycrofft (Jan 24, 2011)

*A little off line but contributive.*

Some (not all or most) people feel that analgesia means absolutely no pain, and even a little euphoria. Coupled with adaptive tolerance and possibly a worsening condition (because getting some Rx is cheaper than surgery and less boring than therapy), of course their frequency and doseage increase, and soon, beyond their means to supply legally.


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## spike91 (Jan 24, 2011)

Frankly find the idea of addiction being a 'disease' fully ridiculous. Its called irresponsibility and total lack of appreciation for life. Anyone who has so little respect for life that they feel the need to dull it away with any type of drugs, prescription narcotics or otherwise, disgust me and will never gain an ounce of sympathy. I've heard and seen plenty of sob stories from addicts; many of which are legitimately tragic. I've heard and seen even more cope with equally tragic life situations without the person having turned to such self pity and self induced misery. 

Again, no sympathy.


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## JPINFV (Jan 24, 2011)

What, exactly, is your background in medicine and/or addiction?


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## firetender (Jan 24, 2011)

spike91 said:


> Again, no sympathy.



Wrong business.


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## MediMike (Jan 24, 2011)

Very wrong business. 

If there are physiological tendencies towards a physical dependence to a substance I'm more than happy to qualify that as a disease.


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## usafmedic45 (Jan 24, 2011)

spike91 said:


> Frankly find the idea of addiction being a 'disease' fully ridiculous. Its called irresponsibility and total lack of appreciation for life. Anyone who has so little respect for life that they feel the need to dull it away with any type of drugs, prescription narcotics or otherwise, disgust me and will never gain an ounce of sympathy. I've heard and seen plenty of sob stories from addicts; many of which are legitimately tragic. I've heard and seen even more cope with equally tragic life situations without the person having turned to such self pity and self induced misery.
> 
> Again, no sympathy.


Jesus Christ....and I thought I was a bitter, harsh judge of my fellow man.  I may not have much sympathy for drug addicts, but I do at least manage empathy for most of them.


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## Tone (Jan 24, 2011)

spike91 said:


> Frankly find the idea of addiction being a 'disease' fully ridiculous. Its called irresponsibility and total lack of appreciation for life. Anyone who has so little respect for life that they feel the need to dull it away with any type of drugs, prescription narcotics or otherwise, disgust me and will never gain an ounce of sympathy. I've heard and seen plenty of sob stories from addicts; many of which are legitimately tragic. I've heard and seen even more cope with equally tragic life situations without the person having turned to such self pity and self induced misery.
> 
> Again, no sympathy.



You are obviously uneducated on the topic. What is legitimately tragic is that we have health care providers like you who are not intelligent enough to look past their own stereotypes.


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## ffemt8978 (Jan 24, 2011)

A reminder for everyone, just because you don't agree with a person's viewpoints does not mean that our "Be Polite" rule is not in effect.


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## Tone (Jan 24, 2011)

ffemt8978 said:


> A reminder for everyone, just because you don't agree with a person's viewpoints does not mean that our "Be Polite" rule is not in effect.



My threads always get like this! did you miss me?


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## platypus (Jan 24, 2011)

*why toradol?*



DCAP-BLS-TIC said:


> I had a patient complaining of the "worst headache" he's "ever had". So bad that he was "seeing squiggly lines". We get there and he literally has a book bag full of prescription bottles for various drugs, probably about 30-40 bottles, all of them being full/unopened except for his Oxycontin. Pain scale a 13 out of 10, of course.
> 
> We get to the ER only to find out that he had been to that same ER just the day before for the exact same complaint.




Why would an addict say they are allergic to Toradol? Im a new EMT so sry if this is a dumb question. :unsure:


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## Tone (Jan 25, 2011)

platypus said:


> Why would an addict say they are allergic to Toradol? Im a new EMT so sry if this is a dumb question. :unsure:



its not a narcotic but it is used for pain, so the seeker is trying to limit the choices of the health care provider to opiates.


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## platypus (Jan 25, 2011)

ahhhhh okay! thanks


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## Tone (Jan 25, 2011)

platypus said:


> ahhhhh okay! thanks



There's a few allergies that seekers use, another one is allergy to tylenol. tylenol one of the common drugs oxycodone is mixed with, in the form of Percocet (5mg oxycodone+ 325mg acetaminophen)

abusers don't like tylenol containing drugs like percocet due to the "bunk" which is the extra volume in the pill that is the acetaminophen, because they cannot crush and snort it.


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## platypus (Jan 25, 2011)

very interesting..thanks for the info


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## medicRob (Jan 25, 2011)

Tone said:


> There's a few allergies that seekers use, another one is allergy to tylenol. tylenol one of the common drugs oxycodone is mixed with, in the form of Percocet (5mg oxycodone+ 325mg acetaminophen)
> 
> abusers don't like tylenol containing drugs like percocet due to the "bunk" which is the extra volume in the pill that is the acetaminophen, because they cannot crush and snort it.



Actually, many people snort percocets. A Percocet 10 (10/325) contains 10 mg Oxycodone Hydrochloride and 325 mg Acetaminophen, both can be easily crushed down and then snorted by abusers. This is actually quite common. 

The only pharmaceuticals that you will find that have methods to impede using the drug by any other route than PO are the new Oxycontins and Xanax to the best of my knowledge. 

Hydrocodone contains Tylenol as well, as do many drugs.. this has never stopped anyone from "snorting" it.


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## Sandog (Jan 25, 2011)

spike91 said:


> Frankly find the idea of addiction being a 'disease' fully ridiculous. Its called irresponsibility and total lack of appreciation for life. Anyone who has so little respect for life that they feel the need to dull it away with any type of drugs, prescription narcotics or otherwise, disgust me and will never gain an ounce of sympathy. I've heard and seen plenty of sob stories from addicts; many of which are legitimately tragic. I've heard and seen even more cope with equally tragic life situations without the person having turned to such self pity and self induced misery.
> 
> Again, no sympathy.



Actually your sentiments are quite common, but surely a medical association with some 200,000 plus members can't be all wrong. 

According to the AMA (American Medical Association)



> When scientists first started to study drug abuse, people addicted to drugs were thought to be morally flawed and lacking in willpower. This view has shaped society’s response to drug abuse, treating it as a moral failing rather than a health problem, resulting in punitive rather than preventative and therapeutic actions. Due to groundbreaking scientific discoveries, we now recognize drug addiction as a brain disease that can be successfully prevented and treated.


quoted from:
http://www.ama-assn.org/ama1/pub/upload/mm/388/sci_drug_addiction.pdf

Indeed bad choices are often the moral door opened by some that lead them into the hall of misery we call addiction. Who here is without making a bad choice once in their lifetime? Surely one bad choice should not condemn a soul to forever suffer without chance of redemption. In these cases sympathy is not needed, but empathy is. All I ask here is that you take a look at some of the research into addiction and then you may be able to have a better understanding of what this problem is.


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## Veneficus (Jan 25, 2011)

medicRob said:


> Actually, many people snort percocets. A Percocet 10 (10/325) contains 10 mg Oxycodone Hydrochloride and 325 mg Acetaminophen, both can be easily crushed down and then snorted by abusers. This is actually quite common.
> 
> The only pharmaceuticals that you will find that have methods to impede using the drug by any other route than PO are the new Oxycontins and Xanax to the best of my knowledge.
> 
> Hydrocodone contains Tylenol as well, as do many drugs.. this has never stopped anyone from "snorting" it.



I like the PO methadone mix as a way to limit IV use.

It is mixed with narcan which is inactivated by gastric acid. So if you eat it, you get the PO dose and effect. If you crush it and try to take it IV or snort it, the narcan inhibits it. 

Absolutely brilliant. Chemistry at its finest.


As food for thought, many psych or recently recoined neuropsych issues including PTSD have a similar pathophysiology as addiction behaviors. Which would logically be concluded that if a person does not "believe" in addiction as a sickness, you couldn't "believe" in many neuropsych disorders. Which might I add by the way behave very similar to parkinson's disease. 

That is sort of limiting.

Having said that, I recognize that the life stressors that lead many to addiction cannot be solved by medication or surgery. The psych folks call it "extrinsic" factors. However, there is some convincing anthropology research (can't post a link I only have a paper copy) that people with high level of social support suffer less from psych illnesses and have lower remission rates. 

Like any disease, I conclude that the key to fighting addiction is prevention and then fighting the disease at the source. Which is largely extrinsic. Medicating people without such social support is little more than palliative therapy.

again, if you can't fix it, do what you can to make the person feel better is my opinion. If you had a person dying of a traumatic injury or chronic disease, we would not hesitate to palliate them with narcotics. What really is the difference between them and addicts who society is not willing to spend the money to help? They are all dying.


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## Tone (Jan 25, 2011)

medicRob said:


> Actually, many people snort percocets. A Percocet 10 (10/325) contains 10 mg Oxycodone Hydrochloride and 325 mg Acetaminophen, both can be easily crushed down and then snorted by abusers. This is actually quite common.
> 
> The only pharmaceuticals that you will find that have methods to impede using the drug by any other route than PO are the new Oxycontins and Xanax to the best of my knowledge.
> 
> Hydrocodone contains Tylenol as well, as do many drugs.. this has never stopped anyone from "snorting" it.



I have to re-correct you on this one. In theory you could crush and snort any pill, but percocet really are not the preferred choice. 

Common use for an addict would be to snort a 40mg oxycontin at one time, approximately. 

To get the same dose of oxycodone that would be 4 or 8 percocet pills, depending on whether they are 5 or 10mg. 

Try crushing even just 4 percocet pills and look at the amount of powder created, its a line the size of a pen. Won't work for the nasal route. 

That's why they say they have the allergy to tylenol. It's also why oxycontin is so highly pursued, due to its very high oxycodone density allowing for nasal use.


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## medicRob (Jan 25, 2011)

Tone said:


> I have to re-correct you on this one. In theory you could crush and snort any pill, but percocet really are not the preferred choice.
> 
> Common use for an addict would be to snort a 40mg oxycontin at one time, approximately.
> 
> ...



@Tone I work with junkies on a regular basis, your points are irrelevant. 

First off, 1 percocet 10 = $7.50 on the street, so 4 really isn't a problem, versus an oxycontin 40, whose price on the street is $40 a pill. These individuals are merely using a cellophane and a lighter to crush them down fine, constitute them into multiple lines, and snort them. 

Moreover, Oxycontin is not pursued due to it's low oxycontin density, it is pursued because of it's high oxycodone content. Furthermore, if this were the case, the individuals would just say they had liver problems to try to get straight oxycodone 5 mg or 10 mg. 

9 out of 10 addicts I encounter that are addicted to pills admit to having snorted: Percocet and Hydrocodone.. Fact.


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## Tone (Jan 27, 2011)

medicRob said:


> @Tone I work with junkies on a regular basis, your points are irrelevant.
> 
> First off, 1 percocet 10 = $7.50 on the street, so 4 really isn't a problem, versus an oxycontin 40, whose price on the street is $40 a pill. These individuals are merely using a cellophane and a lighter to crush them down fine, constitute them into multiple lines, and snort them.
> 
> ...



first off I don't know where you are getting your prices! 

I'll take the time to explain the nasal route to you because you obviously do not understand how these people are using pills. Yes, people do snort percocet, but they are primarily users who don't know what they are doing.

The nasal route is chosen by users because it is a faster route of administration. When users crush and snort pills containing higher amounts acetaminophen than oxycodone, the oxy absorption is reduced due to the surface area in the nares that is occupied by acetaminophen. 

Thus, slowing the absorption to a rate slower or equal than PO. It also causes nasal congestion. 

Point: educated users use pills with no "bunk".


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## usalsfyre (Jan 27, 2011)

Tone said:


> first off I don't know where you are getting your prices!
> 
> I'll take the time to explain the nasal route to you because you obviously do not understand how these people are using pills. Yes, people do snort percocet, but they are primarily users who don't know what they are doing.
> 
> ...



I'm not quite sure you grasp concentration. I can make 325mgs of APAP have a much smaller surface area than 5mgs of hydrocodone depending on how I manufacture it.

The reason oxycontin is preferred is because when you crush a time release pill, you end up with a much higher concentration of med than otherwise.

I can't imagine a scenario where nasal insulation would be similar to a PO onset time, APAP or no APAP. Snorting three lines vs one is rarely a deterrent to the user. MOST true addicts will snort whatever they can get their hands on. 

Some of the preference will be region dependent as well. The docs around here RARELY write for oxy, so we see more hydrocodone w/APAP than anything, followed closely by chewing fentanyl patches. Although, there seems to be a trend towards methadone for severe refractory pain.


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## usafmedic45 (Jan 27, 2011)

> Try crushing even just 4 percocet pills and look at the amount of powder created, its a line the size of a pen. Won't work for the nasal route.



You'd be surprised.  



> first off I don't know where you are getting your prices!



They sound accurate in most markets I've worked with the exception of DC.  Those prices are about average for most of the Midwest outside of Chicago.



> I'll take the time to explain the nasal route to you because you obviously do not understand how these people are using pills.



Actually I'm willing to bet money that MedicRob knows more than enough about the "nasal route" since he's one of the smartest people on this forum.


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## usafmedic45 (Jan 27, 2011)

> Although, there seems to be a trend towards methadone for severe refractory pain.



That explains the recent spike in methadone OD deaths around here.


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## medicRob (Jan 28, 2011)

Tone said:


> first off I don't know where you are getting your prices!



Well, my brother is in the penitentiary right now for prescription fraud and manufacture of schedule II substances (Methamphetamine).. His big thing was the trafficking of narcotics and proliferation of D-methamphetamine. $7.50 - $10 was his price and the price of every other junky he dealt with for an endocet 10. 

Not to mention this quote from the DEA:

" According to reports from DEA field offices, oxycodone products sell at an average price of $1 per milligram"

$1 x 10mg = $10
$1 x 5 mg = $5

Source: http://www.deadiversion.usdoj.gov/drugs_concern/oxycodone/summary.htm



> I'll take the time to explain the nasal route to you because you obviously do not understand how these people are using pills. Yes, people do snort percocet, but they are primarily users who don't know what they are doing.



Sure, go right ahead because obviously my BS of Chem didn't teach little ole me about the adsorption of 4,5-epoxy-14-hydroxy-3-methoxy-17-methyl-morphinan-6-one, dihydrohydroxycodeinone it's analogues or derivatives.. 

Perhaps next you can educate me on absorption in the gastric mucosa and the role pKa plays in the ionization of drug particles for diffusion.. Hell, perhaps you can tell me why Phenythalamines with methyls at the 3,4, and 5 positions are more readily absorbed as opposed to those with methyls at the 2,4, and 6 positions.. 




> The nasal route is chosen by users because it is a faster route of administration. When users crush and snort pills containing higher amounts acetaminophen than oxycodone, the oxy absorption is reduced due to the surface area in the nares that is occupied by acetaminophen.
> 
> Thus, slowing the absorption to a rate slower or equal than PO. It also causes nasal congestion.
> 
> Point: educated users use pills with no "bunk".



This explanation is limited at best.. How about explaining why the nasal route is a "faster route", the overall role surface area plays within the nasal mucosa in absorption, and cite me literature showing these compounds to be less effective than those containing no acetaminophen?

Do you even know what the acetaminophen is there for? If your thought is binder, you would be incorrect. It actually potentiates the effects of most derivatives of the papaver somniferum (Opium Poppy).

As far as the synthesis of this compound goes, the Rice Synthesis (The most common method with highest yields for the synthesis of Oxycodone) states that the carboxylation of isovanillin resultant in 3-hydroxy-4-methoxybenzoic acid, a chemical which is then reacted with 3-methoxyphenethylamine to yield a chemical whose properties are such that it can be regioselectively brominated  to form an analogue where the bromine acts as a blocking group (Preventing para-coupling in cyclization) .. Upon cleavage of the bromine, methylation of the amine occurs resulting in "dihydrocodeinone" which is then demethylated and hydrogenated to result in morphine. At this point, selective methylation of the 3-hydroxy group on the morphine ring is performed by way of trimethylphenylammonium ethoxide to form Codeine.. Once codeine is oxidized, it becomes codeinone, which now is hydroxylated to form 15-hydroxycodeinone aka Oxycodone, but no... I wouldn't know anything about chemistry or drug absorption...

Thanks so much for educating a simpleton like me on "Nasal Absorption" and it's relation to the surface area of a molecule. 

Also, why in the hell would someone snort 4 percocets at once? It only takes 1 to get the effect... Oxycodone hydrochloride (without the tylenol) is the same amt of mg.. 

Your logic is flawed.

1 Percocet 10 = 10 mg Oxycodone and 325 mg Tylenol
1. Oxycodone 10 = 10 mg Oxycodone

4 Percocet 10 = 40 mg Oxycodone (4 times the dose of 1 oxycodone 10) 

So it is more logical to say that:

Since 1 oxycodone 10 is 10mg oxycodone, a user would have to snort 1 percocet for the same effect.. Not 4.


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## nogie1717 (Dec 19, 2011)

"99.9% of drug addicts are not smart.  The remaining 0.1% have better established sources of the pain meds than pulling fast ones on the 

In 15+ years, I've never encountered one.  Then again, unless someone is burned or obviously have something broken, they get nitrous or Toradol"


You have undoubtedly encountered one, you were bamboozled.  I understand the authors thread, but you can't spot the best, because you don't think they are faking for pain meds or anti anxiety pills.

Just because someone has an addiction has nothing to do with their intelligence.


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## 18G (Dec 19, 2011)

Sandog said:


> Your attitude is typical of most health care providers. The addict is seen as a screw up, a loser, one with no self control, one who is lacking intelligence. As a former addict and now a speaker at addict meetings, I can tell you, addicts are not those things mentioned above.
> 
> The AMA has determined that addiction is a disease, yet addiction still carries a stigma and the accompanying disdain. You have cancer and everyone supports you, your an addict and screw you, it is your fault.
> 
> ...



I tend to agree. We don't know everyone's story. We don't know what may have led up to the addiction. It is never a right choice to use but perhaps it was the only choice a person felt they had and was their only escape. Not all addicts are party goers who just love to get high. Many would give anything to escape the addiction and lifestyle. 

A lot of addicts feel horrible about themselves and the fact they are the way they are. How would you feel to be bound by something that controls your life and destroys it and the people around you. Some addicts take their own life because of addiction and the emotional, social, and physical pain associated with it.

The same stigma holds true with suicidal patients. Unless you have been so severely depressed and hopeless to feel that the only end to your suffering is by taking your own life, than you have no room to comment on how someone is feeling or why a person made the life ending attempt or success. Again, you don't know your patient's story. Don't apply your own life experiences and upbringing to someone else because chances are you have no idea and can't even began to imagine what they've experienced. 

I personally hate the cracks and jokes directed towards suicidal patients. It just show a pure ignorance on part of the healthcare provider who thinks its amusing. The same holds true with the addict. Yes, many are low-life's that just enjoy the high... but not everyone fits that mold. 

Don't be condescending. Show these PEOPLE caring and respect. You may be the only person in their life to do that and you would be surprised at the impact it may have even if just for a moment.


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