# Toradol



## d_miracle36 (Apr 12, 2012)

Would the community give me some info on this drug? When do you prefer to use it prehospital? Is it generally safe for any musculoskeletal pain? I know I'm vague about it but just unfamiliar and looking for some veteran preference. Thanks.


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## Anjel (Apr 12, 2012)

d_miracle36 said:


> Would the community give me some info on this drug? When do you prefer to use it prehospital? Is it generally safe for any musculoskeletal pain? I know I'm vague about it but just unfamiliar and looking for some veteran preference. Thanks.



We don't have it pre hospital. The hospitals around here love it though. It is a mild NSAID used for strains, sprains and stuff like that, must drug seekers seem to be "allergic" to it. In the hospital it is usually given IM or IV.

It is more for mild to moderate pain. 

I can't speak for it's use pre hospital, because we just carry morphine, and fentanyl.


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## bigbaldguy (Apr 12, 2012)

It's a NSAID like Aleve or Tylenol but more effective. I've been told and read that it is as effective as some narcotic agents for certain types of pain. I've seen it used with good effect specifically on kidney stone pain that morphine didn't touch. I've also heard it is used in cases where people are former addicts and refuse narcotics. Some medics will give it to patients they suspect of drug seeking behavior.


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## Veneficus (Apr 12, 2012)

bigbaldguy said:


> It's a NSAID like Aleve or Tylenol but more effective. I've been told and read that it is as effective as some narcotic agents for certain types of pain.(musculoskeletal) I've seen it used with good effect specifically on kidney stone pain that morphine didn't touch..



This.




bigbaldguy said:


> Some medics will give it to patients they suspect of drug seeking behavior.



Not this.


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## bigbaldguy (Apr 12, 2012)

Veneficus said:


> This.
> 
> 
> 
> ...



I didn't say I agreed with it just that they do it.<_<


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## Veneficus (Apr 12, 2012)

bigbaldguy said:


> I didn't say I agreed with it just that they do it.<_<



But you typed it out so well, I figured I would just use your work and point out what I agreed with and what I didn't.


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## d_miracle36 (Apr 12, 2012)

Anyone use it for headaches, or able to treat headaches/migraines?


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## TheLocalMedic (Apr 13, 2012)

bigbaldguy said:


> I've also heard it is used in cases where people are former addicts and refuse narcotics. Some medics will give it to patients they suspect of drug seeking behavior.



We have a few well know drug seekers in our area, so some of the medics keep some small saline flushes in the narc cabinet and they make a big deal out of drawing it up into another syringe with a 3 way stopcock and _slowly_ delivering it IV.  They'll say, "This isn't morphine, you won't feel it right away, but you should feel better in a little while."  If they ask what the "drug" they're getting is, the medic replies that it's Nor-Malsaline Sodium Hydrochloride.  Most of the time it works, too.


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## usalsfyre (Apr 13, 2012)

TheLocalMedic said:


> We have a few well know drug seekers in our area, so some of the medics keep some small saline flushes in the narc cabinet and they make a big deal out of drawing it up into another syringe with a 3 way stopcock and _slowly_ delivering it IV.  They'll say, "This isn't morphine, you won't feel it right away, but you should feel better in a little while."  If they ask what the "drug" they're getting is, the medic replies that it's Nor-Malsaline Sodium Hydrochloride.  Most of the time it works, too.



Because who needs ethical behavior...


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## TheLocalMedic (Apr 13, 2012)

usalsfyre said:


> Because who needs ethical behavior...



 Well, like I said, _other_ medics pull this one, not me...  I'm actually a big believer in not withholding pain meds, but when you see the same guy three times a day for the same complaint for years and years, well...  let's just say that certain system abusers, like fish, begin to smell after a while...


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## RocketMedic (Apr 13, 2012)

d_miracle36 said:


> Anyone use it for headaches, or able to treat headaches/migraines?



For suspected tension headaches, new and acute exacerbations of muscular or skeletal injuries, and some soft-tissue pain, Toradol is awesome. I actually think its better than morphine for some things.


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## usalsfyre (Apr 13, 2012)

TheLocalMedic said:


> Well, like I said, _other_ medics pull this one, not me...  I'm actually a big believer in not withholding pain meds, but when you see the same guy three times a day for the same complaint for years and years, well...  let's just say that certain system abusers, like fish, begin to smell after a while...



Withholding pain meds is a wholly different, much more difficult issue. 

Misrepresenting something as therapeutic when it isn't however, is massively unethical and we should call these people on it.


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## Arovetli (Apr 13, 2012)

There are some issues that arise with Toradol. It can interact poorly with patients on long term NSAIDS, ACE inhibitors, with renal impairment, the pregnant or the elderly.

*It is not appropriate for a possible surgical patient.*

It is not to be thought of as a general prehospital alternative for narcotics, however it has its' uses and is highly effective in the right application.


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## Arovetli (Apr 13, 2012)

d_miracle36 said:


> Anyone use it for headaches, or able to treat headaches/migraines?



Due to the limited drug selection in the box, for truly sick migraine patients I find a cocktail of diphenhydramine/zofran effective.


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## d_miracle36 (Apr 13, 2012)

Arovetli said:


> Due to the limited drug selection in the box, for truly sick migraine patients I find a cocktail of diphenhydramine/zofran effective.



Do you not carry phenergran? Or is it not preferred?


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## TheLocalMedic (Apr 13, 2012)

usalsfyre said:


> Withholding pain meds is a wholly different, much more difficult issue.
> 
> Misrepresenting something as therapeutic when it isn't however, is massively unethical and we should call these people on it.



:wacko: okay Mr Grumpypants.  So what's your answer?  Just give everyone who asks for it a healthy dose of morphine?  Yeah, that sounds like it would go over real well.  Massively unethical...ha.... you know what's massively unethical?  Calling 911 at a minimum of three times a day, each time with a different complaint, for the rest of your life and demanding morphine and pooping on the gurney if your morphine demand isn't met.


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## d_miracle36 (Apr 13, 2012)

TheLocalMedic said:


> :wacko: okay Mr Grumpypants.  So what's your answer?  Just give everyone who asks for it a healthy dose of morphine?  Yeah, that sounds like it would go over real well.  Massively unethical...ha.... you know what's massively unethical?  Calling 911 at a minimum of three times a day, each time with a different complaint, for the rest of your life and demanding morphine and pooping on the gurney if your morphine demand isn't met.



I think I would give the morphine. It would be better than them pooping on my cot


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## usalsfyre (Apr 13, 2012)

TheLocalMedic said:


> :wacko: okay Mr Grumpypants.  So what's your answer?


Excuse me for getting a bit upset when I see jack@ssery such as this. Is it OK for your lawyer to engage in unethical practices? Your accountant? Physician? If not then what makes paramedics special?



TheLocalMedic said:


> Just give everyone who asks for it a healthy dose of morphine?  Yeah, that sounds like it would go over real well.


Why not? How in Hades do YOU know if the patient is in pain? What skin is it off off your nose? Are you qualified enough in addiction medicine to diagnose an addiction problem vs legit pain? If it's a system abuser, see below. 



TheLocalMedic said:


> Massively unethical...ha.... you know what's massively unethical?  Calling 911 at a minimum of three times a day, each time with a different complaint, for the rest of your life and demanding morphine and pooping on the gurney if your morphine demand isn't met.


Perhaps your system should look into ways of dealing with system abusers BEFORE this becomes a problem rather than at the site of the call. The appropriate time to make these decisions is NOT at bedside. Get a hold of MedStar in Fort Worth for a good program.


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## Arovetli (Apr 13, 2012)

d_miracle36 said:


> Do you not carry phenergran? Or is it not preferred?



Do not carry. Rough on veins, concerns over extravasation necrosis and case studies of accidental arterial administration resulting in limb loss. 

There were a couple local incidents a while back that resulted in area hospitals pulling it.

I do not agree with lying to a patient regarding medication administration vs. Saline placebo.


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## fast65 (Apr 13, 2012)

TheLocalMedic said:


> :wacko: okay Mr Grumpypants.  So what's your answer?  Just give everyone who asks for it a healthy dose of morphine?  Yeah, that sounds like it would go over real well.  Massively unethical...ha.... you know what's massively unethical?  Calling 911 at a minimum of three times a day, each time with a different complaint, for the rest of your life and demanding morphine and pooping on the gurney if your morphine demand isn't met.



Sorry, but I'm going to agree with usalsfyre on this one. It's HIGHLY unethical to engage in such behavior. The argument of whether or not it's ethical for the "system abuser" to engage in behavior you condemn is irrelevant, they're not expected to be ethical, we are. Be proactive and find a way to deal with system abusers in an ethical way or treat them like a first time patient, there's no middle ground for pseudo-treatments that compromise the integrity of our profession. I have never, and will never falsify my treatments...but I guess I value a good nights sleep more than some others.

As far as the original topic, we don't carry Toradol at my current agency, but during my clinicals I gave it quite frequently for patients with kidney stone pain, seemed to work rather well.


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## TheLocalMedic (Apr 13, 2012)

d_miracle36 said:


> I think I would give the morphine. It would be better than them pooping on my cot



No.  Just... No.  I'd rather them poop than hand out morphine just because they ask.  Any day.  



usalsfyre said:


> Excuse me for getting a bit upset when I see jack@ssery such as this. Is it OK for your lawyer to engage in unethical practices? Your accountant? Physician? If not then what makes paramedics special?


 
Bear in mind that what I was talking about wasn't an outright lie, it was more a sleight of hand.  These are "patients" that even the hospital refuses to deal with, they'll give them their free "screening exam" and boot 'em right back out the door.  These guys actively seek us out, they walk right up to us and ask flat out for morphine and then pitch a fit when you refuse and then play sick and demand a ride to the hospital.  The cops won't deal with them because they "aren't breaking any laws", and if you simply refuse to deal with them and walk away there are a few that are smart enough to try and lawyer up and sue you.  I won't go so far as to say they're just "bad people", but it'll be a cold day in hell when I give someone a narcotic just because they want one.  



usalsfyre said:


> Why not? How in Hades do YOU know if the patient is in pain? What skin is it off off your nose? Are you qualified enough in addiction medicine to diagnose an addiction problem vs legit pain? If it's a system abuser, see below.



See above.  I can tell you for an absolute fact that the people that I referenced are not in pain unless it's from withdrawl symptoms, for which I will give them a ride, but not morphine.  Also, the skin off my nose comes from the QI process where they start questioning your practice of giving narcs to known system abusers without a good reason.  And yes, I have taken courses about addiction problems and addiction treatment.  You aren't doing anyone any favors by being the "candy man".  



usalsfyre said:


> Perhaps your system should look into ways of dealing with system abusers BEFORE this becomes a problem rather than at the site of the call. The appropriate time to make these decisions is NOT at bedside. Get a hold of MedStar in Fort Worth for a good program.



Unfortunately, the best places for most of these "frequent flyers" is either an inpatient addiction treatment center or a psych hospital.  The nearest psych facility is about two hours away and only takes patients from the justice system who are criminal offenders, other than that I don't know of any place for them to be sent, it's not uncommon for people on a 5150 to ride out their entire 72 hour hold right in the ER.  And you can't "force" someone to seek treatment for their drug abuse problems, so good luck trying to talk these folks into going to a rehab center.  

Look, I think that you all are missing the point here. 

I never proposed actually lying to a patient, just making a big show out of drawing up and administering saline.  If a patient is in actual pain, far be it from me to say "hold the morphine", I think that pain is actually undertreated in EMS and believe that people shouldn't be so begrudging with their drugs.  But that's for patients who are really in pain.  I do not consider someone walking up to me (in no distress at all) and asking me for morphine to be a valid excuse for administering a narc.  Ask anyone and they'll tell you the same.  If they want a ride, I'll give 'em a ride.  I'll even check their vitals and ask a few questions just to confirm that there isn't anything they need.  But if there is no reason to give a drug, you _don't_ give the drug.  If someone walked up to you and asked for a dose of epi, would you give it?  According to your earlier response, is assume your answer would be, "Well, I guess I can give you some epi.  I don't know why I would, but since you asked, far be it from me to say no..."


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## TheLocalMedic (Apr 13, 2012)

fast65 said:


> Sorry, but I'm going to agree with usalsfyre on this one. It's HIGHLY unethical to engage in such behavior. The argument of whether or not it's ethical for the "system abuser" to engage in behavior you condemn is irrelevant, they're not expected to be ethical, we are. Be proactive and find a way to deal with system abusers in an ethical way or treat them like a first time patient, there's no middle ground for pseudo-treatments that compromise the integrity of our profession. I have never, and will never falsify my treatments...but I guess I value a good nights sleep more than some others.



Oh thou high and mighty.  Thou that knowest all.  How exactly dost thou propose I "deal with system abusers".  The reason why they're called "system abusers" is because they are incorrigible.  And would _you_ treat they guy you just brought in to the ER 30 minutes ago like a "fist time patient"?  Oh, now his vague "all over" pain is even _more_ all over and even more vague?  Well, I guess I should pretend that I don't know he's used this same line on me every shift I've worked for the last four years and give him some morphine.  

Look, all I'm saying is that it makes all the other medics look back when you keep giving malingering patients unnecessary treatments.  I get a good nights sleep by knowing that I am smart enough to treat my patients appropriately, even if that means withholding treatment.


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## fast65 (Apr 13, 2012)

TheLocalMedic said:


> Oh thou high and mighty.  Thou that knowest all.  How exactly dost thou propose I "deal with system abusers".  The reason why they're called "system abusers" is because they are incorrigible.  And would _you_ treat they guy you just brought in to the ER 30 minutes ago like a "fist time patient"?  Oh, now his vague "all over" pain is even _more_ all over and even more vague?  Well, I guess I should pretend that I don't know he's used this same line on me every shift I've worked for the last four years and give him some morphine.
> 
> Look, all I'm saying is that it makes all the other medics look back when you keep giving malingering patients unnecessary treatments.  I get a good nights sleep by knowing that I am smart enough to treat my patients appropriately, even if that means withholding treatment.



If voicing my opinion makes me a high and mighty know it all, then so be it. I'm no paragod, but if that's you're opinion of me then I'm alright with that. 

Yes, I would treat him as a first time patient, however, I don't give all my patients who complain of "all over body pain" narcotics. I'm selective of who gets narcotics from me, and if someone is able to pull one over on me to get narcotics, then I'm alright with that. If I have a "system abuser" who does it frequently then I guess I won't treat them as a first time patient, and I apologize for being hypocritical. However, I WILL NOT give them fake treatments, and I will accept the consequences of my actions, or lack there of; even if that involves the soiling of my gurney. 

Kudos to you, however, I also receive a good nights sleep in knowing that I wasn't unethical, deceiving, or demeaning to my patients. I sleep well in the fact that I did my best for every patient and made no attempt at forming some sort of amusement out of giving fake treatments.


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## abckidsmom (Apr 13, 2012)

TheLocalMedic said:


> Oh thou high and mighty.  Thou that knowest all.  How exactly dost thou propose I "deal with system abusers".  The reason why they're called "system abusers" is because they are incorrigible.  And would _you_ treat they guy you just brought in to the ER 30 minutes ago like a "fist time patient"?  Oh, now his vague "all over" pain is even _more_ all over and even more vague?  Well, I guess I should pretend that I don't know he's used this same line on me every shift I've worked for the last four years and give him some morphine.
> 
> Look, all I'm saying is that it makes all the other medics look back when you keep giving malingering patients unnecessary treatments.  I get a good nights sleep by knowing that I am smart enough to treat my patients appropriately, even if that means withholding treatment.



Ours is not to label malingerers. Or to be overly sarcastic in this forum. Be nice, OK?


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## mycrofft (Apr 13, 2012)

*Parsing.*

Despite any explaination to the forum, adminstering a medication not called for, or out of your protocols without exceptional life saving reasons, is anything from grounds to being fired, to poisoning (potentially a felony and certainly civily liable).

Using placebos without  order or protocol is likewise, even if they are "inert" or "harmless", especially if done so parenterally or IM/SubQ (assault and battery, unauthorized invasive procedure).

I have heard from a number of patients that they experienced sensations of relaxation, lightheadedness, and/or sleepiness post Toradol injection. A few inmates sought Toradol injections. Most patients reported ansd exhibited signs of pain relief.

PS: in anticipation, the phrase "Oh, Come on!..." is semantically null and guaranteed to rile up a judge or employer.


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## TheLocalMedic (Apr 14, 2012)

mycrofft said:


> Using placebos without  order or protocol is likewise, even if they are "inert" or "harmless", especially if done so parenterally or IM/SubQ (assault and battery, unauthorized invasive procedure).



Point taken.  But again, the patient wasn't outright lied to, he was never told he was getting a narc or even any kind of medication.  He was given an IV and then a saline flush that was pulled from the narc cabinet.  Granted, the medic made a big show of transferring the saline from one syringe to another with a stopcock, but never did anyone say it was anything other than a flush ("Nor-malsaline"  ).  All he said was that hopefully he would feel better.  And it calmed the addict down, so mission accomplished.  

I think it would be great if our system adopted Toradol though.  We are in the process of trying to get Fentanyl right now, but a non-narcotic option for pain relief would be well received.


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## usalsfyre (Apr 14, 2012)

This type of deception is unethical period. Would you like if it was done to someone you care about?


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## Medic Tim (Apr 14, 2012)

The pt should know what you are giving them and why. There also needs to be a legitimate reason for doing so. Misrepresenting what you are giving your pt is unethical and grounds to have your license pulled. If you are going to treat them then do it the way you are supposed to. 

Please tell me they never started the iv just to give the saline.


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## usalsfyre (Apr 14, 2012)

I really don't understand the desire to keep defending this practice.


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## TheLocalMedic (Apr 14, 2012)

Again, let me stress _very well known_ system abuser who calls multiple times a day to demand a ride into town and to be given morphine.  Each time he is given a full assessment (gotta CYA) and depending on his complaint du jour, is sometimes given an IV as part of the routine care provided, so no, no one is getting poked just for the heck of it.  But he is frequently very angry, yelling that he wants morphine.  Bear in mind as well that this area staffed with only a few ambulances, so when he calls multiple times a day, often the same crew sees him over and over again.  Would you shell out narcs every time you picked this guy up?  If someone were to walk up to you and ask, would you just open your narc box and let them have their pick?  

And if it was someone I cared about, I would like to think that the crew dealing with them would recognize that the last thing that person needs is someone encouraging their destructive drug seeking behavior.  Give them a ride, give them an assessment just like everyone deserves, but please don't give them drugs that aren't warranted.


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## usalsfyre (Apr 14, 2012)

No, I wouldn't "shell out narcs" every time, but I d@mn sure wouldn't perform misrepresent a treatment in a deceptive manner either, which is the crux of the matter.

As for dropping a deuce on the cot? That's why we get paid the big bucks.


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## TheLocalMedic (Apr 14, 2012)

LOL, right, the big bucks.  

Well, at this point I guess I don't have much more to add.  The saline flush apparently calms him down, so people will probably keep giving it to him, and I can't really argue with that.  He's been a frequent flier for years, and will continue to be a regular for years to come, so what can you do?  They tell him outright that they aren't giving him morphine, and that's generally where the discussion ends.  Occasionally a newbie who hasn't run into him yet will give him some morphine, and he tells us about it the very next time we see him and he openly admits that he "tricked 'em that time".  He won't be tricking me though.


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## RocketMedic (Apr 15, 2012)

I personally don't try and deceive my patients.


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## mycrofft (Apr 15, 2012)

So the treatment plan is either an intervention to break a destructive lifestyle, or keep from getting fooled? Not somethings addressed by many EMSA's.

OK, get a standing order from the medical officer either allowing placebos, or a standing order not to give that one person analgesia and truthfully tell the pt.

I almost blew off an admitted faker the one time he was right, and he died during CPR under my hands.


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## johnrsemt (Apr 15, 2012)

Talk to the medical director and the police;  get the Doctor to sign off on the person going to jail everytime he calls 911 and the medics clear him.   It will stop the patient from calling so often.

   I will not lie to a patient and tell them that a NS flush will make them feel better;  although I had a patient with a ED inserted heplock, that when I flushed it with NS prior to giving Fentanyl; the patient (who was moaning and yelling in 'pain' stated that he felt much better, and slept for the next 60 miles.   And that was just after 5mL of NS.   All I did was flush it to make sure it was still patent.    He thought he had been given the drug;  I never said a word beyond "relax I will give you something that will help the pain"


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## Veneficus (Apr 15, 2012)

johnrsemt said:


> I will not lie to a patient and tell them that a NS flush will make them feel better;  although I had a patient with a ED inserted heplock, that when I flushed it with NS prior to giving Fentanyl; the patient (who was moaning and yelling in 'pain' stated that he felt much better, and slept for the next 60 miles.   And that was just after 5mL of NS.   All I did was flush it to make sure it was still patent.    He thought he had been given the drug;  I never said a word beyond "relax I will give you something that will help the pain"



It is not a lie to say "this might make you feel better"

As you have seen, placebo effect counts. 

Really though, I am a big advocate of treating pain, there is no reason not to. There is definately a breakdown in the system when the only option you have is a narcotic.

I once heard somebody say "Never judge, always help" (I forgot who) but it is something that has served me well.


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## Dwindlin (Apr 15, 2012)

Veneficus said:


> I once heard somebody say "Never judge, always help" (I forgot who) but it is something that has served me well.



I agree with the sentiment but frankly giving a known abuser what they want isn't helping anyone.


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## Veneficus (Apr 15, 2012)

Dwindlin said:


> I agree with the sentiment but frankly giving a known abuser what they want isn't helping anyone.



I tried to stay away from this topic...

Does a substance abuser lose the right to have their pain treated?

Do we treat pain regardless of the cause or do we make a moral decision on who is worthy and why?

As food for thought, 

Anesthesia in surgery allows providers to inflict damage upon the body. (Under the intent that the damage inflicted is more beneficial than not inflicting)

Is it ok to inflict social/psych damage and not offer analgesia?

How many drug abusers will actually undergo reform and become productive members of society?

What drives the ones who do? Do you really think it is lack of access to thier substance?

If it is ok to palliate people with terminal illnesses, what makes it so reprehensible to palliate people with social/psychiatric affliction?


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## 18G (Apr 15, 2012)

Veneficus said:


> I tried to stay away from this topic...
> 
> Does a substance abuser lose the right to have their pain treated?
> 
> ...



Awesome points.


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## mycrofft (Apr 15, 2012)

Do a good exam, treat based on objective exam. Protocols based strictly upon subjective complaint are not only insulting, they can allow you to stray then you will be told your professional judgement is lacking when you overtreat or mistreat based upon complaints.

Know the diagnotic differentials for common complaints, especially those that watershed at lifethreatening versus no biggee. Ask open ended questions as much as you can. DO NOT, even as a rebuke, list for the pt the signs and complaints you look for. And when in doubt, treat safely with continued eval for effect.


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## Dwindlin (Apr 15, 2012)

Veneficus said:


> I tried to stay away from this topic...
> 
> Does a substance abuser lose the right to have their pain treated?
> *Yes, appropriately, which often times is not with narcotics.*
> ...



Medicine shouldn't be practiced in a manner where "the customer is always right."  Turns out people actually don't always know what's best for them.

Nice article illustrating that point from AIM this year: link to abstract
And nice commentary on the article on the blog KevinMD: link


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## fma08 (Apr 16, 2012)

bigbaldguy said:


> It's a NSAID like Aleve or Tylenol but more effective. I've been told and read that it is as effective as some narcotic agents for certain types of pain. I've seen it used with good effect specifically on kidney stone pain that morphine didn't touch. I've also heard it is used in cases where people are former addicts and refuse narcotics. Some medics will give it to patients they suspect of drug seeking behavior.



Curious... Last I knew Tylenol wasn't an NSAID, just an antipyretic and centrally acting analgesic.


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## fast65 (Apr 16, 2012)

fma08 said:


> Curious... Last I knew Tylenol wasn't an NSAID, just an antipyretic and centrally acting analgesic.



Perhaps, however, it does have some mile anti-inflammatory properties...


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## fma08 (Apr 16, 2012)

Yet is not classified as an NSAID. (Not trying to troll here, just trying to provide accurate information.) I have too many pharmacist friends...


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## Veneficus (Apr 16, 2012)

Dwindlin said:


> Medicine shouldn't be practiced in a manner where "the customer is always right."  Turns out people actually don't always know what's best for them.
> 
> Nice article illustrating that point from AIM this year: link to abstract
> And nice commentary on the article on the blog KevinMD: link



Does a substance abuser lose the right to have their pain treated?
*Yes, appropriately, which often times is not with narcotics.*

Do we treat pain regardless of the cause or do we make a moral decision on who is worthy and why?
*Yes, but you treat it appropriately. Narcotics are not the answer for everything.*

Do all ambulances have other alternatives between a narcotic and nothing?

As food for thought, 

Anesthesia in surgery allows providers to inflict damage upon the body. (Under the intent that the damage inflicted is more beneficial than not inflicting)

Is it ok to inflict social/psych damage and not offer analgesia?
*I'm not sure what you're getting at here. But I'll say yeah, but to me "analgesia" would be therapy, rehab, social services, etc, etc.* 

Excellent, can you write a prescription for inpatient rehab for people who have no money?
A prescription to give an unemployed person a job?
A prescription to solve family problems?
A prescription for a better education?
A prescription to seal a criminal/arrest record?
A prescription for affordable day care to a single parent?

Nobody can. For certain those would be good solutions to help people get away from using drugs to escape the pressures of social affliction. Whether it is alcohol, nicotine, or something more illicit, people predisposed to harmful coping mechanisms of any sort will usually succumb to them and when they do, as in the case of prescription drug abuse, vs. street drug abuse, I know that restricted access doesn’t stop people from abusing drugs, it just forces them to abuse what they have access to. So in order to maintain their individual coping mechanism, should they lose access to a prescription, then they are forced to go to the street. Which creates a new set of problems and can actually worsen the plight of “functional” abusers. 

How many drug abusers will actually undergo reform and become productive members of society?

*I don't know about Europe but here, very few, doesn't mean I should become thier dealer.*

It has very little to do with location, only the type of substances change. But the cheap home cooked stuff vs. the more refined substances are of little consequence to this discussion. Becoming a dealer, sounds to me like a moral stance. In my opinion, personal morals are tricky things to introduce in medicine.

After all, what is really the difference between using an opioid pain killer or a neuroleptic in order to deal with anxiety, depression, etc?

While it may seem like intent, or mechanism of the drug, it is the same outcome, in the US until most insurance and government programs will not pay for psychiatry and ongoing psychology treatments they will pay for opioids.

Of course I doubt the usefulness of this alone without social support to solve the underlying cause, which of course is practically nonexistent. I am not sure I agree with the moral compass of “Let them die,” as postulated by supporters of one political party.  

What drives the ones who do? Do you really think it is lack of access to thier substance?
*No. I would say it's unique for each person, but ultimately has to be an internal drive.*
My point exactly.

If it is ok to palliate people with terminal illnesses, what makes it so reprehensible to palliate people with social/psychiatric affliction?

*It's not reprehensible to "palliate" social/psych afflictions, but again, throwing narcotics at a known addict isn't the way to go about it.*

I am an operations type guy, I like to know how things are actually going to work. I agree there are better solutions than throwing narcs at an addict, but what are the practical things that can be done in the US today? Especially in Ohio, where I am from originally and worked many years?

What is your better way that you can implement today?

Outpatient methadone is beyond outrageous, let me tell everyone how it works. Addicts get their methadone in order to help control withdrawal symptoms until they can get a some menial job or until a government cheque comes in so they can score something that they want.

It is an observable mana economy right in the US midwest, you can actually predict the types of ER visits related to drugs and violence by the approximate date of the month.

There is a difference between customer satisfaction and taking care of drug abusers by maintaining what little quality of life they have.

While many physicians would like to think that giving people the optimum quality of life is the undisputed goal, it is out of the capabilities of medicine to do so.

Not everyone is going to lead a middle class or upper class life. Not everyone is going to be able to eat healthy. Not everyone is getting an education. Not everyone is going to live to be 100. Not everyone is going to be able to cope with their position in life and society in a positive manner. But imposing morals on them or refusing to help when they do not match your own, makes for a rather poor physician in my mind, or a poor provider at any level.

There are physicians I have met that believe they are only around to treat the more "upstanding" members of society, by doing next to nothing and complaining all the while when dealing with lower class people. One even pawns those patients off to her PAs, but I honestly don't think too highly of those physicians. 

As unpalatable as it may sound, giving somebody a narc script so they can go on abusing is a much more humane way to take care of somebody to the best level they can expect, as opposed to forcing them to turn to street drugs, prostitution (both men and women), and crime in order to get their fix.

Does forcing somebody into those predicaments count as looking out for their health or best interest? Perhaps there is a study or a blog with an opinion on it?


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## Veneficus (Apr 16, 2012)

*sorry, cut and paste mistake*

This should actually read:

While it may seem like intent, or mechanism of the drug, it is the same outcome, in the US most insurance and government programs will not pay for psychiatry and ongoing psychology treatments, they will pay for opioids.


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## Aidey (Apr 16, 2012)

Vene, effective last year insurances companies were required to provide psychiatric care at parity with medical care. I'm not sure if that extends to medication coverage, but at the very least it eliminated a lot of maximum office visit limits and the lower lifetime limits on psych care.

Edit - I am also not sure if that includes rehab coverage. I know my health insurance lists substance abuse care separate from psych care in the explanation of benefits. The coverage for both is very good, but I also have very good insurance in general.


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## Aidey (Apr 16, 2012)

Veneficus said:


> It is not a lie to say "this might make you feel better"
> 
> As you have seen, placebo effect counts.
> 
> ...



I HATE only having fentanyl for pain. So many of the sprain/strain/migraine/etc pts would benefit from some analgesia but fentanyl is overkill. The EDs here often give them oral pain meds, which is what they did for me when I had a broken rib. 

I will admit to being subversive on occasion when giving meds, but it is extremely rare. In one case an old lady became convinced her fentanyl patch was making her sick and removed it, causing full blown withdrawal a few hours later. When zofran and ativan didn't work I finally gave her fent, telling her that I was giving her more medication to help her anxiety, which was 100% true, I just didn't mention it wasn't more of the same medication I had already given her. 5 minutes later she decided I was a miracle worker who cured her.


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## Veneficus (Apr 16, 2012)

Aidey said:


> Vene, effective last year insurances companies were required to provide psychiatric care at parity with medical care. I'm not sure if that extends to medication coverage, but at the very least it eliminated a lot of maximum office visit limits and the lower lifetime limits on psych care.



Thanks, I was not aware of this.

It is not the medication that is really the most expensive. It is the ongoing psychological counceling. Medication alone without counseling usually fails. 



Aidey said:


> Edit - I am also not sure if that includes rehab coverage. I know my health insurance lists substance abuse care separate from psych care in the explanation of benefits. The coverage for both is very good, but I also have very good insurance in general.



I am not sure that even if it is covered, rehab, without social support is going to make much difference actually.

I am used to dealing with very poor populations in the US and my experience with it is that a lot of substance abuse problems come from circumstances that required social support which doesn't exist. 

Like I siad, you cannot simply prescribe an education or a job. 

My opinion on substance abuse is similar to any other disease, if you can't treat or cure it, in this case because of lack of resources not lack of knowledge, then palliation seems like a reasonable solution and may actually slow or prevent a downward spiral in both health, function, and social stability.


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## Aidey (Apr 16, 2012)

Yup, it was part of health care reform. It took effect during the first round of changes. 

I agree that addiction recovery takes much more than going to rehab and "getting clean". It is one of those multifaceted problems that takes more work to fix than is usually possible to put into it. As you pointed out rehab can't usually fix the socioeconomic factors that play into addiction.

Where I grew up there was a rehab ranch. Fully functional small farm, they sold their veggies, eggs and whatnot at the local farmers market. I don't know what their success rate was, but the concept has always interested me. Rather than sitting around talking for 30 or 90 days or whatever they learn something practical and functional.


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## epipusher (Apr 16, 2012)

Veneficus, when I am finished judging my patient and have deemed them to be a "substance abuser", and then have passed said judgement onto the patient by not wanting to treat their pain with narcotics, what would you suggest for treatment if I only have narcotic analgesics available?


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## Veneficus (Apr 16, 2012)

epipusher said:


> Veneficus, when I am finished judging my patient and have deemed them to be a "substance abuser", and then have passed said judgement onto the patient by not wanting to treat their pain with narcotics, what would you suggest for treatment if I only have narcotic analgesics available?



You are telling me that once you decide your patient is a substance abuser, that because you have only narcotics, you will leave them in pain?

I think the solution is obvious, if you have a patient in pain, and you have only narcotics, then your hand is forced unless you plan to neglect the treatment of your patient.

Not having anything else to treat pain with is a system failure, and not something the patient should be punished for.


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## abckidsmom (Apr 16, 2012)

epipusher said:


> Veneficus, when I am finished judging my patient and have deemed them to be a "substance abuser", and then have passed said judgement onto the patient by not wanting to treat their pain with narcotics, what would you suggest for treatment if I only have narcotic analgesics available?



We are talking about "pain" in the vaguest possible sense. What are these people going I be complaining of?  Headache?  Abdominal pain? Leg pain?  Sometimes the right answer, even in a JCAHO compliant, treat all pain to a 0/10 situation, is to provide a supportive environment and drive them to the hospital. 

As we have referred to before in other threads, talking with the patient is many times more therapeutic than 2 mg of morphine or 25 mcg of fentanyl in lots of cases.


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## Veneficus (Apr 16, 2012)

abckidsmom said:


> As we have referred to before in other threads, talking with the patient is many times more therapeutic than 2 mg of morphine or 25 mcg of fentanyl in lots of cases.



If you are using 2mg of morphine, you will probably have to do a lot of talking. 

Particularly if you are treating pain in a substance abuser with legitimate pain.


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## FLdoc2011 (Apr 16, 2012)

abckidsmom said:


> We are talking about "pain" in the vaguest possible sense. What are these people going I be complaining of?  Headache?  Abdominal pain? Leg pain?  Sometimes the right answer, even in a JCAHO compliant, treat all pain to a 0/10 situation, is to provide a supportive environment and drive them to the hospital.
> 
> As we have referred to before in other threads, talking with the patient is many times more therapeutic than 2 mg of morphine or 25 mcg of fentanyl in lots of cases.



I think this is an important point.  My environment is a little different being as far as inpatient treatment but I routinely deny narcotics to people I clinically judge to have no organic cause of pain, are not in distress, and most likely just trying to continue their high and chronic opioid use.  I do have the option of non-narcotics though.   Certainly harder for you guys where you don't have the tests/imaging data I can look at that's already ruled out that bad abdominal pathology for example.   Can only go on exam and if they sitting there talking with ya, with normal vitals then they are probably not having 10/10 pain. 

Especially with chronic pain or chronic pain exaccerbations I don't think it should be your job to treat chronic pain.


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## abckidsmom (Apr 16, 2012)

Veneficus said:


> If you are using 2mg of morphine, you will probably have to do a lot of talking.
> 
> Particularly if you are treating pain in a substance abuser with legitimate pain.



Just imagining a typical situation. I talked a girl out of her falling over abd pain in 10 minutes the other day. She snored all the way to the hospital, and started the drama again for the nurse. 

These are the only people I see in my current system. The substance abusers with legitimate pain are not presenting with any frequency in this rural system.


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## TheLocalMedic (Apr 17, 2012)

Veneficus said:


> You are telling me that once you decide your patient is a substance abuser, that because you have only narcotics, you will leave them in pain?
> 
> I think the solution is obvious, if you have a patient in pain, and you have only narcotics, then your hand is forced unless you plan to neglect the treatment of your patient.
> 
> Not having anything else to treat pain with is a system failure, and not something the patient should be punished for.



If I have a substance abuser who is complaining of legitimate pain (trauma or from an other identifiable cause) I really don't have a problem giving narcs.  Granted, it probably won't do much considering their existing tolerances, but whatever.  

But if Joe Crackhead calls in for his "all over" pain that he calls 20/10 and is writhing in "agony" begging me for narcs, I'm not going to be fooled into giving him meds just because he's a junkie.  My hand is _not_ forced to give narcs just because someone cries wolf.  

Just because I can't give someone all the social support they really need doesn't mean I need to placate them with drugs.


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## Veneficus (Apr 17, 2012)

TheLocalMedic said:


> Just because I can't give someone all the social support they really need doesn't mean I need to placate them with drugs.



This is an interesting choice of words.


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## bigbaldguy (Apr 17, 2012)

fma08 said:


> Yet is not classified as an NSAID. (Not trying to troll here, just trying to provide accurate information.) I have too many pharmacist friends...



Yup your right it is not classed as a NSAID. I honestly thought it was. It does have some of the properties of NSAID's but a weak ant-inflammatory effect. Good catch.


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## Doczilla (Apr 17, 2012)

Havent seen this mentioned yet (forgive me if it has), but toradol is particularly effective with kidney stones... Almost a wonder drug. Does a great job of relieving the spasms and inflammation in the ureter, helps pass the stone. 
Oh, and like any NSAID, avoid in fractures. Inhibits osteoblastosis.


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## Hemostatic (Apr 17, 2012)

Would I be correct in thinking that Toradol is contra-indicated for unknown/suspected TBI? Specifically referring to blast/explosion victims with no other life threatening injuries.


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## shfd739 (Apr 17, 2012)

Doczilla said:


> Havent seen this mentioned yet (forgive me if it has), but toradol is particularly effective with kidney stones... Almost a wonder drug. Does a great job of relieving the spasms and inflammation in the ureter, helps pass the stone.
> Oh, and like any NSAID, avoid in fractures. Inhibits osteoblastosis.



I know of at least a dozen friends that have been given Toradol for kidney stones and it didnt do anything for the pain. 

It doesnt seem to be the wonder drug it's been made out to be.


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## DrankTheKoolaid (Apr 17, 2012)

shfd739 said:


> I know of at least a dozen friends that have been given Toradol for kidney stones and it didnt do anything for the pain.
> 
> It doesnt seem to be the wonder drug it's been made out to be.



Thas unfortunate as I have seen it work wonders with these patients when used in conjunction with Reglan


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## Doczilla (Apr 17, 2012)

I think its a given that it won't work on everyone. No telling what cocominant conditions they might have, or how big the stone is, or presence of complications. (Like secondary infection )


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## Hemostatic (Apr 17, 2012)

Hemostatic said:


> Would I be correct in thinking that Toradol is contra-indicated for unknown/suspected TBI? Specifically referring to blast/explosion victims with no other life threatening injuries.



After re-reading this, I realized I did not do a very good job of wording my question (and I can't figure out how to edit my post), so let me try again.

Would I be correct in thinking that Toradol is contra-indicated for pain management of non-life threatening injuries if the patient has a suspected TBI? 

Again referring to blast/explosion victims with no other life threatening injuries.


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## mycrofft (Apr 17, 2012)

*NIH article about Toradol*

http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=9090

It IS considered a NSAID, a COX-2 inhibitor, not for use for over five days, active metabolites produced hepatically an a side effect is renal failure (it is excreted renally).

Note: may decrease efficiency of uterine contractions in childbirth (not indicated for childbirth); maybe a smilar action makes ureteral contraction less pronounced, thus helping ith analgesia of liths?

No mention I saw of the relaxation or sedation I have seen or heard reported by pts.


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## Veneficus (Apr 17, 2012)

mycrofft said:


> Note: may decrease efficiency of uterine contractions in childbirth (not indicated for childbirth)



Fortunately it doesn't always 

Anyway, stopping a muscle spasm will certainly make things better.

Apparently there was once a study and it has been passed down like gospel that NSAIDs work equal or better narcotics on ortho pain, including fractures.

*note* Not always the best idea to take aspirin for the worst headache of your life


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## mycrofft (Apr 17, 2012)

Make that "LAST" headache of your life.


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## Farmer2DO (Apr 17, 2012)

d_miracle36 said:


> Anyone use it for headaches, or able to treat headaches/migraines?



I've taken the PO form for migraines.  It's fantastic.


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## Farmer2DO (Apr 17, 2012)

d_miracle36 said:


> I think I would give the morphine. It would be better than them pooping on my cot



Do what you do for your dog:  rub their nose in it.


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## Veneficus (Apr 17, 2012)

Farmer2DO said:


> I've taken the PO form for migraines.  It's fantastic.



Do you think it works better prior to full onset or does it work equally for you even after you have reached "as bad as it gets'?


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## Farmer2DO (Apr 17, 2012)

Veneficus said:


> Do you think it works better prior to full onset or does it work equally for you even after you have reached "as bad as it gets'?



I don't get auras or much warning.  I get sudden onset, and within half an hour, it's as bad as it gets.  Usually, ASA/APAP/caffeine helps, so I don't use it much (usually less than half a dozen times a year).  But, I've tried it both ways, and it seems to work best when the headache is worst.

ER Felodipine is a lifesaver.  I was started on it for HTN and noticed a dramatic decrease in frequency and severity of headaches.  But it's expensive without insurance.  $10 a month under my current plan.

My PMD is actually on the fence about migraine vs. cluster.  They seem to be "migranous in quality" (his words) but cluster like in pattern.  I can go months without one.  Last year, I had an entire month where I had one EVERY EFFING DAY.  (Actually, I think it was all the same, month long headache.)


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## Farmer2DO (Apr 17, 2012)

TheLocalMedic said:


> If I have a substance abuser who is complaining of legitimate pain (trauma or from an other identifiable cause) I really don't have a problem giving narcs.  Granted, it probably won't do much considering their existing tolerances, but whatever.
> 
> But if Joe Crackhead calls in for his "all over" pain that he calls 20/10 and is writhing in "agony" begging me for narcs, I'm not going to be fooled into giving him meds just because he's a junkie.  My hand is _not_ forced to give narcs just because someone cries wolf.
> 
> Just because I can't give someone all the social support they really need doesn't mean I need to placate them with drugs.



I think some people may be blurring the line of substance abuser vs. system abuser.  They're not the same thing.  (You've hit the nail on the head in your post.)

Just this week, I had a heroin abuser from the local shelter.  IV track marks, abcess growing on his AC.  Walked (limped) up to the local firehouse asking for an ambulance.  Said he gets kidney stones, and had a sudden onset of right flank pain.  He was a little pale and diaphoretic, and wincing with walking.  I tapped his flank, and had to catch him, because his knees buckled.  He wins.  Got 10 mg of IV morphine.  And he was honest:  said it didn't remove the pain, but made it more bearable and him more comfortable.  He also helped his situation by being polite and pointing out his good veins.

Contrast that with the system abuser who is discharged from the ED and walks to the pay phone to call 911.  He's banned from one ED by a court order b/c he's assaulted their staff.  He racks up about 80-100 visits a month to 2 hospitals.  He's abusive, he's obnoxious, and he does nothing but give our crews a hard time.  He demands narcotics by name (although he never gets them).  He's trying to get high.  He's the epitome of what's wrong in our system.  

I work in an urban system where his type is not that uncommon.  I call people out for being system abusers all the time.  And I consistantly give out a LOT of controlled substances.  I'm usually #1 or #2 for the company (for close to a hundred paramedics), and one year I was 70% of the controlled substance administrations company wide.  

So I think I do just fine telling the difference.


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## Veneficus (Apr 17, 2012)

Farmer2DO said:


> I think some people may be blurring the line of substance abuser vs. system abuser.  They're not the same thing.  (You've hit the nail on the head in your post.).



I did this on purpose, I wanted to get people to think philosophically and recognize that a paramedic is not the arbitrator or enforcer of the morals of part of society.

While I think that most providers actually want to help people, it is important to consider what actually "helps" people in different social and economic classes and the limits of the help medicine can provide.


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## epipusher (Apr 17, 2012)

My post was extremely sarcastic. I believe it is not our job, duty, obligation, or whatever word you think fits best, to judge whether someone is an addict or an abuser or a frequent flier. It is my job to treat the patient, not judge them. If my patient has pain, any kind of pain, they get pain meds. 

I am also curious as to what my fellow medics are writing in their run reports regarding why they chose not to treat their patient's complaining of pain. What is being written, if anything, to justify withholding pain medication for someone complaining of pain. Thank you for your time. 

As always, this is my opinion.

Edit: Another question to those withholding pain meds because they are an addict. If someone has been addicted to smoking for decades and is now experiencing some sort of respiratory distress, are you withholding oxygen, albuterol or whatever med would help them? Or do you berate them on how they are a detriment to themselves and society due to them making the choice to be a smoker?


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## Aidey (Apr 17, 2012)

Depends on their pain level, presentation and history. For example, allergies are listed twice in our reports, and if they have a fent allergy I honestly won't bother explaining why I didn't give them fentanyl since it should be pretty obvious. Same thing if their vitals or presentation are outside the protocol for giving fent. For example, no fent in headache pts with cva symptoms. 

For the 10/10 leg pain that walked down 3 flights of stairs to meet us the report will include that info along with something like "pt presented in no acute distress". I feel it is better to include objective info about the pts actions/behavior than just give a subjective opinion. And the level of pt distress is something that makes it into the vast majority of my reports, so I don't really see it as a negative judgemental thing. 

For the more inbetween cases it depends. I've had pts flat out refuse pain meds or refuse to be stuck with a needle, so that is what I put. 

Frankly, most of my pts who aren't in the aforementioned categories get fentanyl when indicated, so I'm not often documenting why I didn't give it.


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## Veneficus (Apr 17, 2012)

Aidey said:


> For the 10/10 leg pain that walked down 3 flights of stairs to meet us the report will include that info along with something like "pt presented in no acute distress". I feel it is better to include objective info about the pts actions/behavior than just give a subjective opinion. And the level of pt distress is something that makes it into the vast majority of my reports, so I don't really see it as a negative judgemental thing..



I would just offer a word about this when dealing with certain cultures or some older patients.

Some need permission to complain of pain and some will try "to tough out" rather grevious pain.

While I am not doubting your abilities or assessments, it takes a very astute eye to observe they are actually in more distress than they show or report. 

I once saw a renal failure patient who had a death grip on the hand rails of her bed, who was from a culture I know are extraordinarily embarassed by pain, and with the most stoic look I ever saw, she explained to the PA her pain was 0/10. (who felt that was enough to withold pain meds)

Later that night we heard her in her room begging god to let her die the pain was so bad.

When I asked her why she didn't want pain meds earlier, she replied, "those are for addicts who cannot cope with life."

Long and short, she ended up with a respectable dose of dilauded, and was extremely appreciative.


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## Aidey (Apr 17, 2012)

I look at 4 main things. How they react while being moved, what their hands are doing, the muscles around the eyes and mouth and how they respond to questions. Short and curt vs long and rambling. 

I also like to use the roads as a way to give people an 'out' and not feel like a wuss. "ok sir, i know you said your pain wasn't that bad but you've driven on the roads around here and you know how bad they are. The roads are even worse in the back of the ambulance, especially around St. Acme hospital. I can give you some pain medication now and that should make up for the ambulance and the roads. "

Works pretty well honestly. I've also asked the more "americanized" children of pts if the pt would tell me if they are in pain, and then go from there.


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## Farmer2DO (Apr 17, 2012)

epipusher said:


> My post was extremely sarcastic. I believe it is not our job, duty, obligation, or whatever word you think fits best, to judge whether someone is an addict or an abuser or a frequent flier. It is my job to treat the patient, not judge them. If my patient has pain, any kind of pain, they get pain meds.
> 
> I am also curious as to what my fellow medics are writing in their run reports regarding why they chose not to treat their patient's complaining of pain. What is being written, if anything, to justify withholding pain medication for someone complaining of pain. Thank you for your time.
> 
> ...



You guys have got to be kidding me.  If a patient has ANY kind of pain, they get pain meds?  Good lord, we must work in vastly different systems. 

So if I call 911 and tell you I stubbed my toe and it's "10/10", I'm getting a narcotic?  That's like swatting a fly with a buick.

I'm a paramedic:  an experienced, educated medical provider.  I use my JUDGEMENT every day on the job, and it includes when someone needs morphine (morphine and midazolam are the only controlled substances we carry).  My protocols are just a guideline; they say that in the opening remarks.  We finally got morphine standing order for whatever we deem necessary.  No more calling for orders, unless we want to exceed 10 mg.  (0.1 mg/kg for peds X2.)

Know what?  I'm giving more morphine and versed than ever!  Now I don't have to call the hospital, wait for the nurse to get a physician, and explain the whole story, and have someone say "Gee, 5 mg is a lot.  Why don't you start with 2 and call me if you need more."  Did I mention my patient is 200 kg?!?  Yes, mam, that's over 400 lbs.  Nope.  2 mg, call for more.  By that time, I'm there.

The notion that we have to give narcotics to everyone who says they're in pain is just ridiculous.  I mean, why not just set up machines at the store like a pop machine, drop in $20, put your rear end up and get your injection of vitamin D.  That's all many of these people want.  WE are the medical provider.  Oftentimes, the patient doesn't know what's best for them.  

I still give out a lot of medication.  A LOT.  More than most all of my co-workders.  I also call a lot of bull$hit.  Your chronic backpain isn't getting morphine.


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## Veneficus (Apr 17, 2012)

Farmer2DO said:


> You guys have got to be kidding me.  If a patient has ANY kind of pain, they get pain meds?  Good lord, we must work in vastly different systems.
> 
> So if I call 911 and tell you I stubbed my toe and it's "10/10", I'm getting a narcotic?  That's like swatting a fly with a buick.
> 
> ...



I think only having narcotics to treat pain is ridiculous. Even chronic back pain should be treated. "Suck it up" and "you can wait" doesn't seem like a treatment plan to me.

Perhaps not by a narcotic, but if you have nothing else, it seems a bit inhumane to just watch the person suffer. Just my opinion.

I think medical direction that only permits the use of narcotics might be a bit lacking.


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## Dwindlin (Apr 17, 2012)

Veneficus said:


> I think only having narcotics to treat pain is ridiculous. Even chronic back pain should be treated. "Suck it up" and "you can wait" doesn't seem like a treatment plan to me.
> 
> Perhaps not by a narcotic, but if you have nothing else, it seems a bit inhumane to just watch the person suffer. Just my opinion.
> 
> I think medical direction that only permits the use of narcotics might be a bit lacking.



Well that is the reality for a large number of departments/services.  And I am in total agreement with Farmer2DO, not everyone with "10/10" pain is getting a narc, which is my only option pre-hospital, they will get assessed and treated based on both subjective and objective findings.


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## Veneficus (Apr 17, 2012)

Dwindlin said:


> Well that is the reality for a large number of departments/services.  And I am in total agreement with Farmer2DO, not everyone with "10/10" pain is getting a narc, which is my only option pre-hospital, they will get assessed and treated based on both subjective and objective findings.



So are there are times when in your assessment you find the patient has pain, but you do not treat it?


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## DrankTheKoolaid (Apr 17, 2012)

Dwindlin said:


> Well that is the reality for a large number of departments/services.  And I am in total agreement with Farmer2DO, not everyone with "10/10" pain is getting a narc, which is my only option pre-hospital, they will get assessed and treated based on both subjective and objective findings.



And what objective findings would those be?


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## RocketMedic (Apr 17, 2012)

Veneficus said:


> So are there are times when in your assessment you find the patient has pain, but you do not treat it?



Yes, but it depends on the patient presentation.


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## Veneficus (Apr 17, 2012)

Rocketmedic40 said:


> Yes, but it depends on the patient presentation.



like what?


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## mycrofft (Apr 17, 2012)

*metacommunication*

Thread's getting tangled, people are restating each other, repeating themselves, and way off base answering about toradol.
How about anther thread or go PM? Chat?


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## Farmer2DO (Apr 18, 2012)

mycrofft said:


> Thread's getting tangled, people are restating each other, repeating themselves, and way off base answering about toradol.
> How about anther thread or go PM? Chat?



You're right.  Before going back to the original topic, I will tell a story that one of my favorite ED nurses uses:

"Sir, what is your pain, on a 1-10 scale?  Bear in mind, 5 is being hit by a car."

What would be some other reasonable choices?  PO agents, like acetaminophen, aspirin, ibuprofen, or narcotic combinations like vicodin or percocet?  Or an IV agent like toradol?


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## Scott33 (Apr 18, 2012)

IV acetaminophen is being used to good effect in parts of Europe.


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## Doczilla (Apr 18, 2012)

I've seen the local docs in D-bagistan give I.V NSAIDS like duflunisal, seemed fairly effective... though by the time they got to us, they had deteriorated to the point where the only viable non-opiate path was to put them in a K-hole.

But back to Toradol, I can speak from experience that it works pretty well. I got my calf crushed in a 800lb. MRAP door, and I was continuing the mission 60mg of toradol later.


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## bigbaldguy (Apr 18, 2012)

Doczilla said:


> I've seen the local docs in D-bagistan give I.V NSAIDS like duflunisal, seemed fairly effective... though by the time they got to us, they had deteriorated to the point where the only viable non-opiate path was to put them in a K-hole.
> 
> But back to Toradol, I can speak from experience that it works pretty well. I got my calf crushed in a 800lb. MRAP door, and I was continuing the mission 60mg of toradol later.



And doczilla grabs the wheel and wrestles the train back onto the tracks for a last minute save. Nicely done. 

Try to keep it on track guys  remember the topic is toradol.


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## epipusher (Apr 18, 2012)

Speaking of Toradol, I treat all physical pain with some sort of medication. Be it oral Tylenol, oral or IV Toradol, or IV Fentanyl. I assess the level of the pain, not the sincerity of their story or how many times they have called.


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## Farmer2DO (Apr 18, 2012)

mycrofft said:


> Thread's getting tangled





Farmer2DO said:


> You're right.





Doczilla said:


> But back to Toradol, I can speak from experience that it works pretty well. I got my calf crushed in a 800lb. MRAP door, and I was continuing the mission 60mg of toradol later.





bigbaldguy said:


> Try to keep it on track guys  remember the topic is toradol.



Isn't that what we were doing all on our own?


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## TheLocalMedic (Apr 21, 2012)

Dwindlin, Farmer2DO, you are both after my own heart.  Pragmatism and critical thinking are some of the most important things for a medic to learn, and often they are learned over time.  Sometimes the mark of a decent paramedic is knowing when or what _not_ to treat, i.e. the "stubbed toe complaining of 10/10 pn"... ahem...  

Narcotics are obviously a touchy subject, but being that those are all that many systems have to deal with, I can understand why some might say that narcs are their go-to treatment the minute a pt says "boo".  I don't agree with that, but I can see it from their viewpoint...  dimly...  

As for Toradol, frankly I can understand why many systems do not allow their paramedics to administer it.  Clearly if medics think it's okay to give a narc for any old thing, then why should they hold back from giving Toradol to a pt with a trauma complaint or any other complaint involving hemorrhage?  Okay, I know that there are a lot of smart medics out there who know better, but there are also clearly medics out there who do not critically examine their patients and may not be able to differentiate who is or is not a good candidate for Toradol as opposed to a narcotic.


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## Veneficus (Apr 21, 2012)

TheLocalMedic said:


> As for Toradol, frankly I can understand why many systems do not allow their paramedics to administer it.  Clearly if medics think it's okay to give a narc for any old thing, then why should they hold back from giving Toradol to a pt with a trauma complaint or any other complaint involving hemorrhage?  Okay, I know that there are a lot of smart medics out there who know better, but there are also clearly medics out there who do not critically examine their patients and may not be able to differentiate who is or is not a good candidate for Toradol as opposed to a narcotic.



I am not sure I agree with this fully.

It is just my speculation, but I think the reason most systems have only narcs is becuase there is this crazy idea that people only call ambulances for emergencies. 

So if an ambulance and pain are involved somebody must think the patient must be serious enough to warrent narcotics.

This could be be propagated by "what is everyone else doing" medical direction or systems where the medical director buys a premade set of protocols and signs them off as his own without any more effort or thought.

Since most trauma is muscle/skeletal it should respond rather well to toradol. Even a fracture.

If a medic is giving somebody with a serious bleed toradol because they don't know better, I would think they are just as likely to givethe narc in the same instance.

As long as the patient in't complianing of head pain, vomiting blood, or chest/abd pain raidiating to the back with signs of shock, the risk of improper toradol use is rather insignificant.

I guess I just think that the prolem isn't aggressive pain treatment, the problem is not treating pain, but anyone who only has narcs is going to have to choose between doing something and doing nothing.

EMS needs to have treatments available to deal with the patient population they actually see. Not just the perception of who they should be seeing.

I have it quite unacceptable a teenager can walk into a store and buy all kinds of crap off the shelf from everything from sore throat to menstrual relief (that has both asa and tylenol usually in the mix) But the people working on the ambulance have only the option of a narc or an injected NSAID.

I think it much more appropriate to treat the 10/10 toe pain etc with an oral nsaid than with a needle of anything.

I just find it more detestable to leave somebody who is obviously struggling in pain. 

I am not suggesting giving narcs to seekers with a BS story. I a suggesting that if the patient is an abuser and has pain, then if that means narcs, treat the pain. 

I attempted to start a philosophical argument on whether or not palliating seekers was a reasonable medical therapy, but it didn't get anywhere other than to have a bunch of chest pounding about assessment.


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## Aidey (Apr 21, 2012)

Veneficus said:


> I am not sure I agree with this fully.
> 
> It is just my speculation, but I think the reason most systems have only narcs is because there is this crazy idea that people only call ambulances for emergencies.




For ages we didn't have saline locks, because the prevailing opinion was that if the pt was bad enough to need an IV, they needed fluids.


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## Doczilla (Apr 21, 2012)

Toradol isn't even that bad for bleeds. The effect is reversible, and only lasts about half as long as ASA, if it DOES affect anything.


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## TYMEDIC (Apr 29, 2012)

usalsfyre said:


> Because who needs ethical behavior...



hahaha


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## ah2388 (Apr 29, 2012)

The take home point from this thread for me is that we should not be writing patients off because they are "system abusers as, these individuals do sometimes have legitimate complaints including pain.  

While it may be difficult, we should be approaching these patients as "first time patients" while keeping in mind that these patients often have glaring holes in the story which we (hopefully) have gathered in a diligent manner.

I have found in my limited experience that these patients often times benefit from hot/cold or positional adjustment.  

I have administered toradol with good results, especially in conjunction with other agents.


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## RocketMedic (Apr 29, 2012)

With the current shortages, I personally try and use toradol to compensate for musculoskeletal pain where I would consider morphine in some patients (ie isolated fracture).


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## EMSpursuit (May 2, 2012)

Yea the drug seekers like the stronger stuff...i have noticed they all say they are allergic as well to negate the Doc prescribing them it.


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## EMSpursuit (May 2, 2012)

Agree, many Migraine Patients this seems to provide relief...


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