Toradol

[Dwindlin]

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.

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.

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.

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.

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.

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.

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

 

[fma08]

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.

 

[fast65]

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...

 

[fma08]

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

 

[Veneficus]

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?

 

[Veneficus]

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.

 

[Aidey]

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.

 

[Aidey]

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.

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.

 

[Veneficus]

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.

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.

 

[Aidey]

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.

 

[epipusher]

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?

 

[Veneficus]

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.

 

[abckidsmom]

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.

 

[Veneficus]

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.

 

[FLdoc2011]

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.

 

[abckidsmom]

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.

 

[TheLocalMedic]

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.

 

[Veneficus]

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.

 

[bigbaldguy]

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.

 

[Doczilla]

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.