# Drug seeking patient signs?



## Ahertens21 (Mar 15, 2017)

I have a question for some of the more seasoned EMTs and medics out there. How can you tell someone is drug seeking? 

For example: patient has been vomiting and says they pulled their back whilst vomiting. Immediately upon getting into the rig, they ask for pain meds. Same thing the minute they hit the hospital bed: pain meds.


----------



## DesertMedic66 (Mar 15, 2017)

Every patient is different and everyone's pain tolerance is different. Sometimes you aren't going to be able to tell. 

We have some frequent flyer that every time they call as soon as we make patient contact they ask for an IV and pain meds. 

If they state 10/10 pain but are resting comfortably on the gurney and are talking on their cell phone will no distress then I am probably not going to give any meds. 

In the case where you can not tell I would rather give pain meds to a seeker than withhold pain meds from a patient who is in true pain.


----------



## zzyzx (Mar 15, 2017)

"For example: patient has been vomiting and says they pulled their back whilst vomiting. Immediately upon getting into the rig, they ask for pain meds. Same thing the minute they hit the hospital bed: pain meds."

LOL. That would be one sign.

You shouldn't really be trying too hard to figure out who is faking and who isn't. That said, you shouldn't give narcotics inappropriately, and giving narcotics to someone who is very obviously drug seeking is inappropriate. 

Do you carry non-narcotic pain meds? Hot packs? If it is appropriate (i.e., lower back pain, not a bone sticking out), consider giving those and telling the patient that you are going to give them something nonnarcotic because that is the safer choice.


----------



## VentMonkey (Mar 15, 2017)

How I know:

"I'm seeking drugs."- drug seeking patient.

Seriously though, OP. I look at the bigger picture. Are they tachycardic, hypertensive, tearing (applies to sedated, and intubated patients as well) for reasons not matching their chief? Does it hurt _me _to look at them, or their injury? Are my spidey senses saying "this poor schlub needs pain relief?"

Those are some of my big ones, but if all else fails if they're in pain and I can treat it, I do. I could care less what Nurse Ratchet tells me at the ED. They had pain, I provided relief, done.

Times are changing, and the almighty judgmental paragod is going the way of the dino (thankfully). The more you do it, the easier it gets, that's all.


----------



## GMCmedic (Mar 15, 2017)

It comes with experience. I consider myself to be fairly liberal with pain meds. That said I've been burned. If you truly listen to the patients story, you'll learn to pick up on the subtle BS. 

If you are not 100% sure they are seeking, give the meds. No matter how experienced you are, you will get burned again. 





Sent from my SAMSUNG-SM-G920A using Tapatalk


----------



## hometownmedic5 (Mar 15, 2017)

Visual signs of distress and vital signs are a really good start. People in real pain don't hide it well for the most part. Grimacing, grunting, labored breathing, perspiration, elevated bp, hr and so on are all good indicators of real pain.

Calm, minimal or no distress, flat vitals and directly asking for pain management for a vague, chronic pain complaint are all indicators of a bs call. Not absolutely bs of course. I took a guy yesterday who slipped on the ice and broke his ankle. His foot flopped around like a wet lasagna noodle. Multiple fractures confirmed on X-ray later at the hospital. He was the chillest dude ever. A bit hypertensive but nothing crazy. All other signs unremarkable. So there are people out there who are undercover sick. 

All that being said, when I wrecked my motorcycle and wound up in an ambulance, i was grossly undermedicated. It was ultimatley hours of ineffective small doses of pain medicine before one of the trauma surgeons at the hospital decided to nut up and get to it. Consequently, having lived through the side of the patient who's pain is being under treated or worse, ignored, i will give drugs to almost anybody. I truly believe a patient experiencing real pain deserves relief from that pain regardless of whether or not their injury or pain impresses me.

The only people I dont medicate are the obvious drug seekers. Beyond them, if I believe your pain is real and you want relief, I'm on it. I too have been burned. We cant put peoples pictures on the station house wall labeled "med seeker", so inevitably we're each going to encounter these people without knowing their game. I dont care. I'd rather unwittingly give a hundred junkies a free pop than let one patient with real pain slip past me. This causes me some grief when I'm working with a VOMIT medic, but I'm past caring about what lazy hacks think about my practice.


----------



## EpiEMS (Mar 15, 2017)

hometownmedic5 said:


> I'd rather unwittingly give a hundred junkies a free pop than let one patient with real pain slip past me.



I wish more medics had this attitude.


----------



## hometownmedic5 (Mar 15, 2017)

EpiEMS said:


> I wish more medics had this attitude.



So do I.


----------



## VentMonkey (Mar 15, 2017)

hometownmedic5 said:


> So do I.


Hacks.


----------



## Ahertens21 (Mar 15, 2017)

Thanks for all the input guys. As a BLS agent, we can't do any lines or anything for a patient. But I am going into medic school so I really wanted to know. I guess, as always, air on the side of safety. 

Hospitals in my area are cracking down hard on opiates. The one big hospital in my area will no longer be giving anyone any type of pain relief besides NSAIDs, unless necessary patients. Times are changing.


----------



## VentMonkey (Mar 15, 2017)

Ahertens21 said:


> Thanks for all the input guys. As a BLS agent, we can't do any lines or anything for a patient. But I am going into medic school so I really wanted to know. I guess, as always, air on the side of safety.
> 
> Hospitals in my area are cracking down hard on opiates.* The one big hospital in my area will no longer be giving anyone any type of pain relief besides NSAIDs, unless necessary patients. Times are changing*.


No problem, OP. I find this interesting, and it appears quite the opposite in my neck of the woods, good luck going from B to P.


----------



## EpiEMS (Mar 15, 2017)

Ahertens21 said:


> Thanks for all the input guys. As a BLS agent, we can't do any lines or anything for a patient. But I am going into medic school so I really wanted to know. I guess, as always, air on the side of safety.



I'd disagree - we can do more than nothing:
 1) distraction (plus, in some places, a little sugar water for infants)
 2) positioning, splinting, and padding
 3) cryotherapy (good old ice packs!)
 4) call for an ALS intercept



Sent from my iPhone using Tapatalk


----------



## hometownmedic5 (Mar 15, 2017)

Ahertens21 said:


> Thanks for all the input guys. As a BLS agent, we can't do any lines or anything for a patient. But I am going into medic school so I really wanted to know. I guess, as always, air on the side of safety.
> 
> Hospitals in my area are cracking down hard on opiates. The one big hospital in my area will no longer be giving anyone any type of pain relief besides NSAIDs, unless necessary patients. Times are changing.




Good for them. I'm glad their taking this stance. As a corollary, I'm I'm ever a patient there, and require analgesia, they will be intubating me as I am deathly allergic to all NSAIDS(or at least the few that have landed me in the hospital so far).


----------



## agregularguy (Mar 15, 2017)

hometownmedic5 said:


> Visual signs of distress and vital signs are a really good start. People in real pain don't hide it well for the most part. Grimacing, grunting, labored breathing, perspiration, elevated bp, hr and so on are all good indicators of real pain.
> 
> Calm, minimal or no distress, flat vitals and directly asking for pain management for a vague, chronic pain complaint are all indicators of a bs call. Not absolutely bs of course. I took a guy yesterday who slipped on the ice and broke his ankle. His foot flopped around like a wet lasagna noodle. Multiple fractures confirmed on X-ray later at the hospital. He was the chillest dude ever. A bit hypertensive but nothing crazy. All other signs unremarkable. So there are people out there who are undercover sick.
> 
> ...




I agree 100% with this. I previously while not unwilling, was more hesitant to give meds to abdominal pain patients of unknown etiology. However, after going through the pain of a very large gallstone back in November and being originally undertreated, I've become a much more willing medic. We (generally) aren't the ones causing the addictions to opiates. Like you, I'd much rather give a small dose of meds to a seeker than let someone in actual pain slip by.


----------



## Bullets (Mar 16, 2017)

EpiEMS said:


> I'd disagree - we can do more than nothing:
> 1) distraction (plus, in some places, a little sugar water for infants)
> 2) positioning, splinting, and padding
> 3) cryotherapy (good old ice packs!)
> ...


When  was a BLS provider, i had a woman who broke her femur in her basement. Getting her our was going to require a carry up narrow basement stairs and a turn that put her at almost vertical to negotiate. I requested an ALS intercept to give her pain meds prior to this move. 

The ALS providers laughed at me when they arrived and gave report, left, then filed a formal complaint that i was "wasting ALS resources"


----------



## hometownmedic5 (Mar 16, 2017)

I would have filed right back at them for abandonment, negligence, malpractice, and being an AH. 

Most likely none of it would have gone anywhere, but I really would like to have seen them squirm in the chair trying to explain how pain management in a long bone fracture with extrication is a waste of ALS.


----------



## EpiEMS (Mar 16, 2017)

Bullets said:


> When was a BLS provider, i had a woman who broke her femur in her basement. Getting her our was going to require a carry up narrow basement stairs and a turn that put her at almost vertical to negotiate. I requested an ALS intercept to give her pain meds prior to this move.
> 
> The ALS providers laughed at me when they arrived and gave report, left, then filed a formal complaint that i was "wasting ALS resources"



That's really substandard care on their part. 



hometownmedic5 said:


> I would have filed right back at them for abandonment, negligence, malpractice, and being an AH.
> 
> Most likely none of it would have gone anywhere, but I really would like to have seen them squirm in the chair trying to explain how pain management in a long bone fracture with extrication is a waste of ALS.



Agreed.

ALS pain management is so totally indicated for long-bone fractures that are acutely painful or may become so due to movement. I'd go as far as to say that anything where we might cause pain, ALS should be at least considered. I've never hesitated to call ALS for pain management - and I wouldn't want anybody taking care of me to demean my pain.


----------



## Old Tracker (Mar 16, 2017)

Ahertens21 said:


> air on the side of safety.



air or err? On the side of safety?  I will do what I can for patients, but if their O2sat is above 94%, no O2.


----------



## Bullets (Mar 16, 2017)

@EpiEMS @hometownmedic5 This was a few years ago, they claimed that they would never get orders for this. In the ensuing investigation it did turn around on them once they read my chart and the hospitals follow up. They both faced internal discipline


----------



## hometownmedic5 (Mar 16, 2017)

Good. People like that shouldn't be paramedics.


----------



## medichopeful (Mar 17, 2017)

hometownmedic5 said:


> Visual signs of distress and *vital signs* are a really good start. People in real pain don't hide it well for the most part. Grimacing, grunting, labored breathing, perspiration, elevated bp, hr and so on are all good indicators of real pain.



I'm glad you brought this up, and I absolutely don't mean to call you out on this but rather bring up an interesting point that many people are not aware of.

There is no reliable correlation between presence of pain and vital signs.  A patient can be in (legitimately) 10/10 pain and have no change in their vitals.  Of course, there MAY be other signs that one is in pain, but vital signs are not a reliable indicator of the presence or absence of pain unfortunately. 

I strongly advocate pain relief in many patients who may not "appear" to be in pain, including chemically paralyzed patients (these patients should all get prophylactic pain relief, preferably continuously), unresponsive patients with injuries (if appropriate), intubated patients (if there's even the slightest possibility that they are in pain), and others.  On a related note, just because someone is sedated or unresponsive does not mean they are not in pain.  In addition, many of the medications that have sedative properties have no analgesic properties (I'm looking at you, Propofol).

With all that being said, one must put together a clinical picture to determine if a patient is seeking meds.  If there's any doubt, give the meds.  One dose isn't going to do anything regarding their addiction, but if they are truly in pain it can do a lot for that.

As someone once said, it's better to give 9 seekers meds than withhold meds from someone who needs them.


----------



## medichopeful (Mar 17, 2017)

Bullets said:


> When  was a BLS provider, i had a woman who broke her femur in her basement. Getting her our was going to require a carry up narrow basement stairs and a turn that put her at almost vertical to negotiate. I requested an ALS intercept to give her pain meds prior to this move.
> 
> The ALS providers laughed at me when they arrived and gave report, left, then filed a formal complaint that i was "wasting ALS resources"



Sounds like a perfect indication for Ketamine (and, maybe, an opiate on top of that)


----------



## NomadicMedic (Mar 17, 2017)

medichopeful said:


> Sounds like a perfect indication for Ketamine (and, maybe, an opiate on top of that)



Or, in my case, Morphine and phenergan. Thats my "little old lady with a fracture" cocktail. You can create a fair amount of analgesia and sedation. Word is Ketamine is coming this spring, but I believe the dose will be small. They're talking about 0.1mg/kg. Seems low to me. I've read the usual analgesic dose is 0.2 - 0.3mg/kg or a straight bolus of 20mg... and that it's not particularly long lasting. Any thoughts?


----------



## GMCmedic (Mar 17, 2017)

NomadicMedic said:


> Or, in my case, Morphine and phenergan. Thats my "little old lady with a fracture" cocktail. You can create a fair amount of analgesia and sedation. Word is Ketamine is coming this spring, but I believe the dose will be small. They're talking about 0.1mg/kg. Seems low to me. I've read the usual analgesic dose is 0.2 - 0.3mg/kg or a straight bolus of 20mg... and that it's not particularly long lasting. Any thoughts?


We use 0.25mg/kg for pain/anxiety and 2mg/kg in the RSI protocol

Sent from my SAMSUNG-SM-G920A using Tapatalk


----------



## medichopeful (Mar 17, 2017)

NomadicMedic said:


> Or, in my case, Morphine and phenergan. Thats my "little old lady with a fracture" cocktail. You can create a fair amount of analgesia and sedation. Word is Ketamine is coming this spring, but I believe the dose will be small. They're talking about 0.1mg/kg. Seems low to me. I've read the usual analgesic dose is 0.2 - 0.3mg/kg or a straight bolus of 20mg... and that it's not particularly long lasting. Any thoughts?



I'm jealous that you guys carry phenergan.  Great medication for a variety of different things.

I agree with you that 0.1mg/kg is small, 0.1-0.5mg/kg (subdissociative) is the dose I usually hear for analgesia, or a bolus (and 20mg doesn't sound unreasonable).  I'm wondering if maybe the plans are to use Ketamine in addition to an opiate?  Or be able to repeat it?  That wouldn't be awful, but I'm a big fan of having dosing ranges, and if you guys are getting Ketamine I don't see any reason why you should only have a fixed dose, especially one that low.  Do you do RSI as well by any chance?

The duration of action for the bolus is relatively short (somewhere in the 15 minute range I read), but that should be enough for many painful procedures (extrication from a basement, for example).  Other medications added to the bolus (versed, fentanyl, etc) might lengthen the amount of time, but I'm not sure about that.  For long transports though or extenuating circumstances, repeat doses or a drip would be useful.

Either way, it's good to see that Ketamine is coming for you.  Massachusetts has it in the protocols, but I'm yet to know of a single agency that carries it.  It's also only IM for behavioral emergencies 

Here's a few links on it:
http://www.medscape.com/viewarticle/781463
http://www.emdocs.net/ketamine-analgesia-ed/
https://emcrit.org/wp-content/uploa...ative-Dose-Ketamine-versus-Morphine-Print.pdf


----------



## Hold My Beer (Mar 17, 2017)

At the end of the day their not my medications.  If I think the patient is seeking ill toss them a hot or cold pack and maybe an NSAID just to cover my ***.  If their a bit more convincing I will give them a small dose of fentanyl.  Fentanyl wont last long and will not provide them the "fix" they are seeking.  Like I said if i have never seen the patient before I'll give them the benefit of the doubt.  Like others have already said, take the big picture and treat appropriately.  Do not assume everyone is seeking and if you end up giving a seeker some meds not really the end of the world.


----------



## hometownmedic5 (Mar 17, 2017)

Hold My Beer said:


> At the end of the day their not my medications.  If I think the patient is seeking ill toss them a hot or cold pack and maybe an NSAID just to cover my ***.  If their a bit more convincing I will give them a small dose of fentanyl.  Fentanyl wont last long and will not provide them the "fix" they are seeking.  Like I said if i have never seen the patient before I'll give them the benefit of the doubt.  Like others have already said, take the big picture and treat appropriately.  Do not assume everyone is seeking and if you end up giving a seeker some meds not really the end of the world.



This is the problem, right here. Either do what's right or don't, but don't ride the fence. Sub dosing is the same thing as refusing to give the meds. 

You either believe the patient is having legitimate pain and treat them for it, or you believe they are seeking and they get nothing; but saying that you'd give a patient you believe to be in pain a "small dose of fentanyl"(which I interpret to mean more than nothing but less than the correct amount based on your protocols) is not a significant improvement over the medic who refuses to crack the narc seal for any reason.


----------



## Hold My Beer (Mar 17, 2017)

hometownmedic5 said:


> This is the problem, right here. Either do what's right or don't, but don't ride the fence. Sub dosing is the same thing as refusing to give the meds.
> 
> You either believe the patient is having legitimate pain and treat them for it, or you believe they are seeking and they get nothing; but saying that you'd give a patient you believe to be in pain a "small dose of fentanyl"(which I interpret to mean more than nothing but less than the correct amount based on your protocols) is not a significant improvement over the medic who refuses to crack the narc seal for any reason.



How is providing someone in pain a dose of fentanyl not a significant improvement over not treating it at all? What if you're wrong?  Yes, "small" is a relative term so let me specify as 50 mcg.  Which to me is small when compared to my allotted max cumulative dose of 500 mcg.  Pain is defiantly subjective.


----------



## hometownmedic5 (Mar 17, 2017)

You're either adequately treating the pain you feel to be real, or you're not. 

That "not" can either be no dose, or a sub dose. Either way, if you're going to do it then do it. A whiff of fent to make the paperwork look good that doesn't adequately manage the patient pain isn't a significant improvement over no analgesia. 

My pain is an 8. You give my nearly 300lb carcass your paltry 50mcg of fent because you aren't sure you believe me. My pain is now a 7.  Whoopdeedoo. You haven't adequately treated my pain and you still have to do the paperwork for the narcs. You're literally in the worst of both positions. 

Either keep the lock on the box or get to work. Riding the fence only causes splinters that are hard to get too....


----------



## medichopeful (Mar 17, 2017)

Hold My Beer said:


> How is providing someone in pain a dose of fentanyl not a significant improvement over not treating it at all? What if you're wrong?  Yes, "small" is a relative term so let me specify as 50 mcg.  Which to me is small when compared to my allotted max cumulative dose of 500 mcg.  Pain is defiantly subjective.



I can understand titrating pain meds, so if you're starting with 50mcg and moving up from there until you reach an adequate level of pain control I have no problem with that (though I personally would start higher than 50mcg unless they're a small person).  If you're wrong, and they're seeking pain meds, in all honesty who cares?


----------



## Hold My Beer (Mar 17, 2017)

hometownmedic5 said:


> You're either adequately treating the pain you feel to be real, or you're not.
> 
> That "not" can either be no dose, or a sub dose. Either way, if you're going to do it then do it. A whiff of fent to make the paperwork look good that doesn't adequately manage the patient pain isn't a significant improvement over no analgesia.
> 
> ...


I get what you're saying and I think we can both agree that every situation is going to be different.  Hashing out the generalizations I made in my first post defiantly do not stand up to individual cases.  If i give someone pain meds I have a stronger belief that the pain is real vs they are just really annoying seekers.  The all or nothing approach you suggest is what I don't agree with.  50 mcg makes your pain a 7, 50 more makes it a 6, 50 more makes it a 5... vs slamming a larger dose upfront which might make it harder to control.  Your right giving someone a measly dose just to make your chart look nice is not good medicine.  Also I can't say that in every situation I am 100% sure the pain is legit so why not start with a smaller dose?


----------



## VentMonkey (Mar 17, 2017)

I give all (hemodynamically) stable adult patients in pain 100 mcg off the bat, and our transport times more often than not are enough for that to hold them over.

Most paramedics, especially newer ones, tend to be driven by the book. I've even seen paramedics who are still in love with MS. While MS certainly still has its place, if we had Ketamine, Fent would most likely become second fiddle, and MS third if at all, respectively.

@medichopeful is right though, at the end of the day as long as you're providing pain relief specific your patient at hand who cares what you're using.


----------



## GMCmedic (Mar 17, 2017)

I forget MS is still a thing in most places. 

Speaking of protocol driven......you dont have to slow push Narcs over 2 minutes. (Our protocol actually says that) 

Sent from my SAMSUNG-SM-G920A using Tapatalk


----------



## NomadicMedic (Mar 17, 2017)

medichopeful said:


> I'm jealous that you guys carry phenergan.  Great medication for a variety of different things.
> 
> I agree with you that 0.1mg/kg is small, 0.1-0.5mg/kg (subdissociative) is the dose I usually hear for analgesia, or a bolus (and 20mg doesn't sound unreasonable).  I'm wondering if maybe the plans are to use Ketamine in addition to an opiate?  Or be able to repeat it?  That wouldn't be awful, but I'm a big fan of having dosing ranges, and if you guys are getting Ketamine I don't see any reason why you should only have a fixed dose, especially one that low.  Do you do RSI as well by any chance?
> 
> ...




Thanks for the links. No RSI at any ground service in Georgia. And we're not planning on pairing Ketamine with an opitate. I understand we'll still be carrying Morphine, but adding Fent and finally getting rid of Demerol. We're also not allowed to add benzodiazepines to opiates unless you call and ask. I don't think anyone but me has been granted orders for a benzo with pain meds, and that was for bilateral femurs after I used all of my morphine.


----------



## hometownmedic5 (Mar 17, 2017)

Forgive me if I misunderstood. I took your "small amount" post to me a one time bolus, not a titrate to effect. Naturally aliquot doses are acceptable by just about anyone's standards I should think. 

I also am a fan of the VentMonkey strategy. I haven't yet seen an adult that couldn't handle 100mcg of fent. Sure, that might be a harder hit than was absolutely necessary, but I don't get any complaints from my patients that I have them too much. 

Anyway, I think we've wandered away from the original topic. Obvious drug seekers get an ice pack. Everybody else gets appropriately aggressive analgesia. My medical director and my services clinical coordinator approve of my practice, so for me it works. Other systems where narcs are seen as totally unreasonable can do without my services.


----------



## Carlos Danger (Mar 17, 2017)

The general consensus here seems to be to err on the side of the patient having pain, because it's better to give opioids to someone who doesn't need it than to deny adequate analgesia to someone who does. I agree with this line of thinking 100%. Denying a little fent or MS is not going to do thing to cure an addict, and providing it isn't going to do a thing to hurt them. So it's really a silly thing to even worry about.

I honestly don't get the fascination among prehospital folks with ketamine. Unless someone is already on high doses of opioids, there's no way that small doses of ketamine are better than a standard dose of fent. Large doses of ketamine may be, but large doses of ketamine are undesirable for other reasons. And it's a poor substitute for opioids if your intention to prevent providing fix. I think ketamine is a great tool to have in your box, but like I said, I don't get the fascination with it.



Hold My Beer said:


> How is providing someone in pain a dose of fentanyl not a significant improvement over not treating it at all? What if you're wrong?  Yes, "small" is a relative term so let me specify as 50 mcg.  Which to me is small when compared to my allotted max cumulative dose of 500 mcg.  Pain is defiantly subjective.



Pain is subjective, yes, but that has nothing to do with what you are describing. Giving a smaller dose of analgesia than is otherwise indicated just because you think they "might be faking" borders on unethical, because you are either giving a drug that isn't indicated (if you are convinced that they are faking), or you are withholding adequate analgesia, if you think there's a lesser chance that they are faking. If someone is in pain, treat it right. If you think they aren't in pain, then withhold the drugs if you must. But whatever you do, own your decision and stand by it. Don't be a coward and do something to a patient "just to cover your a**". 



medichopeful said:


> I strongly advocate pain relief in many patients who may not "appear" to be in pain, including chemically paralyzed patients (these patients should all get prophylactic pain relief, preferably continuously), unresponsive patients with injuries (if appropriate), intubated patients (if there's even the slightest possibility that they are in pain), and others.  On a related note, just because someone is sedated or unresponsive does not mean they are not in pain.  In addition, many of the medications that have sedative properties have no analgesic properties (I'm looking at you, Propofol).



Not to drag this thread off topic, but the idea that a truly unresponsive or well-sedated patient experiences pain is a myth. There are reasons to add fentanyl or another analgesic to your sedation, or even to use it as your primary means of sedation, but those reasons have little or nothing to do with the patient experiencing pain.


----------



## GMCmedic (Mar 18, 2017)

Im just curious what everyones thoughts are on treating chronic pain? 

Sent from my SAMSUNG-SM-G920A using Tapatalk


----------



## VentMonkey (Mar 18, 2017)

GMCmedic said:


> Im just curious what everyones thoughts are on treating chronic pain?


To me it's situational just like most any call. Oftentime they're on analgesic doses that supercede anything I could prevent in our short encounter, so I treat accordingly.


----------



## hometownmedic5 (Mar 18, 2017)

If, in my estimation, their pain is real and needs to be addressed, I address it appropriately. As Vent said, if they're taking 100mg of po MS daily with oxycodone sprinkled in(and they have their meds and they took them), my 100mcg of Fent probably isn't fixing this problem.


----------



## medichopeful (Mar 18, 2017)

Remi said:


> Not to drag this thread off topic, but the idea that a truly unresponsive or well-sedated patient experiences pain is a myth. There are reasons to add fentanyl or another analgesic to your sedation, or even to use it as your primary means of sedation, but those reasons have little or nothing to do with the patient experiencing pain.



Not to continue dragging this off topic, but that's not something that I was aware of.  Do you have any links or can you point me in the right direction to read more about this?  When I have patients who are sedated/unresponsive I don't want them to be in pain (hence, the prophylactic pain management), but I also don't want to be giving them pain meds if the science states that it's not necessary.  Pain management is a pretty important topic to me, so any info you have or any direction you can point me in I'd be interested in!


----------



## Carlos Danger (Mar 18, 2017)

medichopeful said:


> Not to continue dragging this off topic, but that's not something that I was aware of.  Do you have any links or can you point me in the right direction to read more about this?  When I have patients who are sedated/unresponsive I don't want them to be in pain (hence, the prophylactic pain management), but I also don't want to be giving them pain meds if the science states that it's not necessary.  Pain management is a pretty important topic to me, so any info you have or any direction you can point me in I'd be interested in!


It comes down to awareness. If someone is on 100 mcg/kg/min of propofol, their higher CNS is essentially shut off, so they aren't _experiencing_ anything. Of course they may show objective signs of sympathetic discharge as a result of a noxious physiologic stimulus such as an injury or a ETT moving around in their trachea, but that is not the same as _feeling_ pain.

What happens though, is that we give some fentanyl or morphine to these folks and their HR and BP drop and we think "his tachycardia went away because he's feeling less pain now", when in reality his tachycardia went away because we just increased his depth of sedation by adding another GABA agonist, and also interrupted the reflex loop that was causing the sympathetic stimulation. Opioids act on receptors in the ascending spinal cord tracts to interrupt the afterrent side (as well as the efferent side, esp when you use large doses) of the reflex loop, which propofol and benzodiazepines don't do.

Again, there are good reasons to use opioids for sedation, but not really to make someone more "comfortable".


----------



## NomadicMedic (Mar 18, 2017)

Remi said:


> It comes down to awareness. If someone is on 100 mcg/kg/min of propofol, their higher CNS is essentially shut off, so they aren't _experiencing_ anything. Of course they may show objective signs of sympathetic discharge as a result of a noxious physiologic stimulus such as an injury or a ETT moving around in their trachea, but that is not the same as _feeling_ pain.
> 
> What happens though, is that we give some fentanyl or morphine to these folks and their HR and BP drop and we think "his tachycardia went away because he's feeling less pain now", when in reality his tachycardia went away because we just increased his depth of sedation by adding another GABA agonist, and also interrupted the reflex loop that was causing the the sympathetic stimulation. Opioids act on receptors in the ascending spinal cord tracts to interrupt the afterrent side (as well as the efferent side, esp when you use large doses) of the reflex loop, which propofol and benzodiazepines don't do.
> 
> Again, there are good reasons to use opioids for sedation, but not really to make someone more "comfortable".



Posts like this is really why I love this group


----------



## medichopeful (Mar 19, 2017)

Remi said:


> It comes down to awareness. If someone is on 100 mcg/kg/min of propofol, their higher CNS is essentially shut off, so they aren't _experiencing_ anything. Of course they may show objective signs of sympathetic discharge as a result of a noxious physiologic stimulus such as an injury or a ETT moving around in their trachea, but that is not the same as _feeling_ pain.
> 
> What happens though, is that we give some fentanyl or morphine to these folks and their HR and BP drop and we think "his tachycardia went away because he's feeling less pain now", when in reality his tachycardia went away because we just increased his depth of sedation by adding another GABA agonist, and also interrupted the reflex loop that was causing the sympathetic stimulation. Opioids act on receptors in the ascending spinal cord tracts to interrupt the afterrent side (as well as the efferent side, esp when you use large doses) of the reflex loop, which propofol and benzodiazepines don't do.
> 
> Again, there are good reasons to use opioids for sedation, but not really to make someone more "comfortable".



That's good to know.  Thanks Remi!

I'm gonna echo @NomadicMedic and agree that these sorts of posts are the ones that make this site worthwhile.


----------



## EpiEMS (Mar 19, 2017)

Remi said:


> If someone is on 100 mcg/kg/min of propofol, their higher CNS is essentially shut off, so they aren't _experiencing_ anything.



When you say "higher" CNS, are you talking primarily about cortical function of a particular (frontal?) lobe?

(Probably a silly question, sorry.)


----------



## Carlos Danger (Mar 19, 2017)

EpiEMS said:


> When you say "higher" CNS, are you talking primarily about cortical function of a particular (frontal?) lobe?
> 
> (Probably a silly question, sorry.)



Not a sillly question. General anesthesia affects almost all parts of the brain, with the parts that contribute to awareness being the most clinically important, for the purposes of comfort.


----------



## VentMonkey (Mar 19, 2017)

Agreed, excellent insight, @Remi. Are there any alterations that you're, or anyone, is aware of in the pathways with patients that have higher thresholds for pain/ sedation tolerance?

I'm not just referring to drug seekers specifically here, but let's face it, today's society is more often than not over medicated with pain management, and sedatives for almost every disease under the sun, then given the latest med to reverse their "opiod-induced constipation".

I'm just curious if there's anything that shows, says, or indicates that these patients not only may (?) require higher levels of sedation in-hospital, but would also be harder to wean from said medications once they're discharged. It's just some food for thought that's on my mind. 

I also wonder if there are any studies related to length of hospital stays, and addiction itself. The reason I mention this is because, while we joke about it now, my wife and I recall clear as day our oldest daughter having her tonsils out. 

She was discharged after the routine 2-3 day stay, but was kept comfortable, and sent home with a bottle of liquid opiates. Lo and behold 2 weeks post-op when we were trying to easy her off of it, and transition to tylenol she was having fits; a five year old with withdrawals, so I can't imagine it doesn't have some affect on patients in general, especially after _lengthy_, heavily-medicated hospital stays.

I'd love to hear from any RN, or hospital folk regarding weaning patients from their pain, and sedation meds; if that's such a thing...


----------



## Carlos Danger (Mar 19, 2017)

VentMonkey said:


> Agreed, excellent insight, @Remi. Are there any alterations that you're, or anyone, is aware of in the pathways with patients that have higher thresholds for pain/ sedation tolerance?



Opioid tolerance and its consequences is a really broad topic that touches on lots of aspects of patient care. There's a heck of a lot to talk about here.

There are some fairly well understood and some still poorly understood physiologic changes that take place as a result of exposure to opioids, especially high doses of opioids. Opioid-induced hyperalgesia and acute opioid tolerance are distinct mechanisms but can be difficult to recognize and differentiate clinically. As with anything, some patients are more susceptible than others - many or most don't seem to develop problems at all - but it does seem to be a growing issue, and it dovetails well with the opioid abuse epidemic. On the whole, many would agree that opioid analgesia probably causes nearly as many problems as it solves.

Because of that, there's a rapidly growing movement in anesthesia towards minimizing opioid administration. Where I work we've been doing a lot recently with ketamine, lidocaine, acetaminophen, and clonidine, along with the adjuncts that we've already been using for some time, like magnesium and esmolol and ketorolac and decadron, and of course, regional nerve blocks. The difference in a patient who wakes up pain-free after receiving no opioid during a painful surgery vs. one who got the traditional gallon of fentanyl topped off with a couple mg's of dilaudid is quite dramatic, in terms of how they feel in general, how much nausea they have, how much post-op analgesia they need, and how soon they are ready to go home.

In the prehospital setting, implementing the multi-modal approach that is required to replace opioids for pain management is much less practical and probably less important, since we are generally talking about smaller doses. So I'm not at all suggesting that we pull fentanyl and morphine off the ambulances and replace them with clonidine and acetaminophen.

Still, I cringe a little when I hear so many paramedics brag about the large doses of fentanyl they give, and also when they talk about the importance of using opioid analgesia in unresponsive patients who we have no reason to believe are experiencing pain. Are there times when those are appropriate? Of course. I would just like to see us strive more for "appropriate" analgesia than for "aggressive" analgesia, just like in airway management.

Edit: I also understand the affection in the FOAMed community for "analgo-sedation" or "fentanyl-based sedation" for intubated patients. I know the idea is largely a response to the problems that result from long-term benzo (and even propofol) sedation in ICU patients. I think it's probably a good strategy to combine low doses of opioids with propofol or even better, an alpha-agonist like dexmetomidine for intubation sedation. But at the same time I really think we should be moving away from giving opioids just for the sake of giving opioids.


----------



## medichopeful (Mar 20, 2017)

Remi said:


> Still, I cringe a little when I hear so many paramedics brag about the large doses of fentanyl they give, and also when they talk about the importance of using opioid analgesia in unresponsive patients who we have no reason to believe are experiencing pain. Are there times when those are appropriate? Of course. I would just like to see us strive more for "appropriate" analgesia than for "aggressive" analgesia, just like in airway management.



I'm not a fan of bragging in general, but I think I would rather here someone brag about the pain meds they gave than bragging about the pain medications they didn't (we've all heard someone in EMS at some point say something along the lines of "I don't give pain medications unless I can see bone"). 

There does, of course, need to be a reason for giving pain medications to unresponsive patients besides just the fact that they are unresponsive, and I think I alluded to that in one of my previous posts.  With that being said, there are many reasons why unresponsive or intubated patients may be in pain, and I think in these cases it's better to err on the side of caution and give the meds.  Pain management is a very tricky topic, and there definitely isn't a "one-size-fits-all" approach unfortunately.

That being said, I'd love to see other pain medication come to the prehospital environment besides just opiates.  Ketamine, toradol and other NSAIDS, inhaled agents, etc. would be great so that we can begin to treat pain in a different manor than we currently are.  For example, kidney stones?  I'd rather be able to give toradol instead of fentanyl for that.  Sickle cell crisis?  Different story.


----------



## johnrsemt (Mar 21, 2017)

I have worked with medics who brag they have NEVER given pain meds.  Who gave me grief for giving pain meds.  But then they say if they ever get hurt they want me to treat them because they know I will fix the pain.

I agree with above posters you are doing better to give a seeker pain meds than not give them to someone who needs them.

For the short time we have the patients we are not going to get a patient addicted to pain meds:   and where I work FT we have patient care for 1-3 hours for transport and PT 2-4 hours for transport.


----------



## VentMonkey (Mar 21, 2017)

Eh, I'm with @medichopeful here, not much into bragging one way or another. When I have to lug our narc log in with us on a call where we've administered a narcotic some crews like to pry and ask, or elude to a "good call".

Personally I find it extremely annoying, not to mention not their business. And yes, you do what you do. Right, wrong, or indifferent _you_ have to live with it, so what's it matter what _other_ providers think?


----------



## Handsome Robb (Mar 21, 2017)

So another question I have and if it's already been answered indirectly I apologize but what are your strategies with patients on partial mu agonists like buprenorphine in the realm of anesthesia? 

Recently I had a patient with a significant traumatic injury who was on suboxone films, albeit a "low" dose at 2mg/day for pain management. I ultimately used ketamine to manage their pain however I'm mandated to attempt to use opiates prior to moving to ketamine. They did experience slight relief from IV fentanyl, albeit high dosing at 2mcg/kg. Are you using alternate medications such as ketamine and nsaids? 

@Remi @etank


Sent from my iPhone using Tapatalk


----------



## RocketMedic (Mar 21, 2017)

Ahertens21 said:


> Thanks for all the input guys. As a BLS agent, we can't do any lines or anything for a patient. But I am going into medic school so I really wanted to know. I guess, as always, air on the side of safety.
> 
> Hospitals in my area are cracking down hard on opiates. The one big hospital in my area will no longer be giving anyone any type of pain relief besides NSAIDs, unless necessary patients. Times are changing.


Those are going to be some pretty terrible Press-Ganey scores, reimbursements and potentially lawsuits.


----------



## RocketMedic (Mar 21, 2017)

NomadicMedic said:


> Or, in my case, Morphine and phenergan. Thats my "little old lady with a fracture" cocktail. You can create a fair amount of analgesia and sedation. Word is Ketamine is coming this spring, but I believe the dose will be small. They're talking about 0.1mg/kg. Seems low to me. I've read the usual analgesic dose is 0.2 - 0.3mg/kg or a straight bolus of 20mg... and that it's not particularly long lasting. Any thoughts?


Honestly, even 0.1mg/kg is pretty effective.


----------



## Carlos Danger (Mar 21, 2017)

Rob, ketamine is the perfect analgesic for someone who already takes high doses of opioids, or an opioid antagonist. If ketamine isn't an option, larger doses of opioid often work.

I already use a multimodal approach in the OR, with minimal opioids. So my anesthetic practice is not affected much by someone who is non-responsive to opioids.


----------



## NomadicMedic (Mar 21, 2017)

Remi said:


> Rob, ketamine is the perfect analgesic for someone who already takes high doses of opioids, or an opioid antagonist. If ketamine isn't an option, larger doses of opioid often work.
> 
> I already use a multimodal approach in the OR, with minimal opioids. So my anesthetic practice is not affected much by someone who is non-responsive to opioids.



@Handsome Robb, here's a question I have for you. If you decided to *not* try opiates first and move directly to ketamine but justified the reasoning in your narrative, would you still get a QI flag?


----------



## NPO (Mar 21, 2017)

When the patient tells you "well soon you won't have to call the doctor to ask to give morphine" referring to an upcoming protocol change. That's usually a good sign. 

Sent from my Pixel XL using Tapatalk


----------



## Jim37F (Mar 21, 2017)

We had a patient yesterday demand we start an IV and give him pain meds, but he was allergic to Morphine, Acetomeniphan, Norco, etc etc, and that the only thing that worked was Dilaudid (yes he specifically demanded, not asked mind you, but demanded we give him Dilaudid by name), he was requesting a specific hospital because the two closer ones quote "kicked him out last time and called the Sheriff's Dept on him" last time he was there, the fire company knew his name on site, and so did the charge nurse of the requested facility....


----------



## NomadicMedic (Mar 21, 2017)

I had a patient not too long ago that presented with flank pain and said he had seen his doctor and that he had a kidney stone and 10 out of 10 pain ... yada yada yada. I gave him some Toradol and a ride to the hospital.

 When I got back to the station, one of the other medics said, "hey, you went to Jimmy's house." I said yup. He's got a kidney stone.
The other medic snorted. "He's had that kidney stone for 4 years. But he's a nice guy, isn't he?"


----------



## NPO (Mar 21, 2017)

Jim37F said:


> We had a patient yesterday demand we start an IV and give him pain meds, but he was allergic to Morphine, Acetomeniphan, Norco, etc etc, and that the only thing that worked was Dilaudid (yes he specifically demanded, not asked mind you, but demanded we give him Dilaudid by name), he was requesting a specific hospital because the two closer ones quote "kicked him out last time and called the Sheriff's Dept on him" last time he was there, the fire company knew his name on site, and so did the charge nurse of the requested facility....


It's amazing how people can be allergic to one phenanthrene but not another. 

Sent from my Pixel XL using Tapatalk


----------



## CoraElizabeth (Mar 30, 2017)

So, my question is...Why does it matter? 
Honestly, I don't really care about that, and figuring out who's faking, and who's not; Even drug seekers end up with medical problems. 
We don't give big doses...at least not in my state we don't. Typically, our doses aren't enough to appease an addiction, but it is enough to ease up some pain a patient might be in. So who cares? Just give them the meds, until there's a device to definitively prove if a patient's lying, which there never will be. 
Some people get massive hardons to be able to feel like they can prove someone's lying. Well, screw them. No one likes those "hard *** medics". 



Ahertens21 said:


> I have a question for some of the more seasoned EMTs and medics out there. How can you tell someone is drug seeking?
> 
> For example: patient has been vomiting and says they pulled their back whilst vomiting. Immediately upon getting into the rig, they ask for pain meds. Same thing the minute they hit the hospital bed: pain meds.


----------



## Handsome Robb (Mar 31, 2017)

NomadicMedic said:


> @Handsome Robb, here's a question I have for you. If you decided to *not* try opiates first and move directly to ketamine but justified the reasoning in your narrative, would you still get a QI flag?



The process would basically be to do it, justify it in your chart then after the call you're obligated to self report for a protocol deviation. That entails calling a specific phone number and speaking with the shift's Senior Medical Officer who would then take a report, file their own report so it's documented then that's usually the end of it unless you did something grossly negligent or incompetent then you may have some sort of a conversation with our clinical staff or potentially a conversation with our MD. 

Either way you wouldn't be in trouble, provided you followed the proper channels and self-reported. 

I've had to call more than a few times and beyond the conversation I had with the SMO, which usually goes something like "well that seems reasonable, ok thanks for reporting it have a good day", I've never heard anything else from anyone else in our clinical department. 


Sent from my iPhone using Tapatalk


----------



## EpiEMS (Mar 31, 2017)

@Handsome Robb, is the SMO a physician or another medic?


Sent from my iPhone using Tapatalk


----------



## Giant81 (Mar 31, 2017)

NPO said:


> It's amazing how people can be allergic to one phenanthrene but not another.



This is going to be off topic, but I'm looking for information on why someone would be receptive to one opiate and not another.  I can move to it's own topic if preferred.  

I've found that morphine and hydrocodone do little for me, but oxycodone and dilaudid work wonderfully, and in rather small doses.  When I burned my arm, they kept hitting me with morphine in the hospital, and it did nothing.  Eventually they moved to dilaudid, and in one small dose, my pain had come down from an 8-9 to like a 5, and another small dose in the ambulance during an IFT to the burn center, brought it down to a 4 or so.  

While at the burn center the Dr looked over my chart and even asked me "have you done drugs recreationally"  which I have not.  I then asked the nurse what that was about, and he peeked at my chart and mentioned that the amount I'd been given would probably be enough to knock him out for 24hrs.  I suspect the fact I was not only consious but also coherent was worrying.

I've also found that when given hydrocodone for pain, it did little more than the tylenol alone did.  When given oxycodone for pain, it was normally perscribed 5-10mg as needed.  And it only took one dose at 10mg to realize 5 was plenty.  

So I've been up and down the internet looking for an idea why.  Why does one have no effect on me and another a rather strong effect.  This thread seems to be full of people that could help point me to a reason.

It's left me in a couple uncomfortable positions where a Dr wanted to Rx me hydrocodone for something and I requested oxycodone, only to see them taken back a bit.  Contemplating if I'm drug seeking.  It would be much easier to be able to place something in my chart or have an idea of what it is so I can tell the Dr instead of getting looks of concern.

tldr; don't seek pain meds, don't take drugs recreationally, trying to figure out how to explain to a Dr why oxycodone and dilaudid works great, but morphine and hydrocodone don't do anything without getting the look of "do I need to call the sherif"


----------



## EMT9396 (Apr 1, 2017)

Giant81 said:


> This is going to be off topic, but I'm looking for information on why someone would be receptive to one opiate and not another.  I can move to it's own topic if preferred.
> 
> I've found that morphine and hydrocodone do little for me, but oxycodone and dilaudid work wonderfully, and in rather small doses.  When I burned my arm, they kept hitting me with morphine in the hospital, and it did nothing.  Eventually they moved to dilaudid, and in one small dose, my pain had come down from an 8-9 to like a 5, and another small dose in the ambulance during an IFT to the burn center, brought it down to a 4 or so.
> 
> ...




I have wondered the exact same thing. I was prescribed hydrocodone for my broken arm when I was 13 or so and it helped tremendously. about 6 months ago (I'm now 20) I was prescribed hydrocodone again after I had a hernia surgery and it did literally nothing for me. and about a month or so ago I had my wisdom teeth pulled and I was prescribed 600mg ibuprofen and that got rid of most of the pain in my mouth. the ibuprofen helped much more then the hydrocodone did.


----------



## Carlos Danger (Apr 1, 2017)

Giant81 said:


> This is going to be off topic, but I'm looking for information on why someone would be receptive to one opiate and not another.  I can move to it's own topic if preferred.
> 
> I've found that morphine and hydrocodone do little for me, but oxycodone and dilaudid work wonderfully, and in rather small doses.  When I burned my arm, they kept hitting me with morphine in the hospital, and it did nothing.  Eventually they moved to dilaudid, and in one small dose, my pain had come down from an 8-9 to like a 5, and another small dose in the ambulance during an IFT to the burn center, brought it down to a 4 or so.
> 
> ...



There are lots of individual physiologic factors that might explain why one opioid works better for you than another. It's actually not at all uncommon for people to say that.

But the simplest and most likely explanation is that oxy and dilaudid are simply more potent drugs than hydrocodone and morphine. 

It also sounds like you might have gotten an additive effect when the second drug was given. In other words, give someone a few doses of morphine, they still have pain, give them dilaudid, they feel better. It isn't just that dilaudid is more potent, it's that you are giving it on top of the morphine that you already gave them.

You are right; you will always run the risk of sounding like a drug seeker when you state up front that "the one with the D" is the only drug that works for you.


----------



## Handsome Robb (Apr 1, 2017)

EpiEMS said:


> @Handsome Robb, is the SMO a physician or another medic?
> 
> 
> Sent from my iPhone using Tapatalk



Another Paramedic. They're basically the equivalent to a Lieutenant but on the clinical side instead of operational. Still work a normal Paramedic shift but do training, chart reviews on certain types of calls, things of that nature. 

We have 100% peer review of our charts. 


Sent from my iPhone using Tapatalk


----------



## EpiEMS (Apr 1, 2017)

Handsome Robb said:


> Another Paramedic. They're basically the equivalent to a Lieutenant but on the clinical side instead of operational. Still work a normal Paramedic shift but do training, chart reviews on certain types of calls, things of that nature.
> 
> We have 100% peer review of our charts.
> 
> ...



Ok, gotcha - sounds pretty reasonable to me. 


Sent from my iPhone using Tapatalk


----------



## jaeems (Apr 11, 2017)

hometownmedic5 said:


> I would have filed right back at them for abandonment, negligence, malpractice, and being an AH.
> 
> Most likely none of it would have gone anywhere, but I really would like to have seen them squirm in the chair trying to explain how pain management in a long bone fracture with extrication is a waste of ALS.




Now the ALS people were not performing their care standards. Yes, and I do agree with you, I would file right back at them.


----------

