Drug seeking patient signs?

[medichopeful]

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

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

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

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

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

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

 

[medichopeful]

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

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

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

 

[NomadicMedic]

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

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

 

[GMCmedic]

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

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

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[medichopeful]

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

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

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

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

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

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

 

[Hold My Beer]

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

 

[hometownmedic5]

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

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

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

 

[Hold My Beer]

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

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

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

 

[hometownmedic5]

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

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

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

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

 

[medichopeful]

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

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

 

[Hold My Beer]

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

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

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

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

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

 

[VentMonkey]

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

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

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

 

[GMCmedic]

I forget MS is still a thing in most places.

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

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[NomadicMedic]

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

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

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

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

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

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

 

[hometownmedic5]

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

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

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

 

[Carlos Danger]

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

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

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

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

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

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

 

[GMCmedic]

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

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[VentMonkey]

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

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

 

[hometownmedic5]

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

 

[medichopeful]

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

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