Drug seeking patient signs?

[Carlos Danger]

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

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

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

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

 

[NomadicMedic]

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

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

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

Posts like this is really why I love this group

 

[medichopeful]

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

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

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

That's good to know. Thanks Remi!

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

 

[EpiEMS]

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

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

(Probably a silly question, sorry.)

 

[Carlos Danger]

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

(Probably a silly question, sorry.)

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

 

[VentMonkey]

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

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

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

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

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

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

 

[Carlos Danger]

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

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

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

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

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

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

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

 

[medichopeful]

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

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

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

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

 

[johnrsemt]

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

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

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

 

[VentMonkey]

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

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

 

[Handsome Robb]

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

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

@Remi @etank


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[RocketMedic]

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

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

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

 

[RocketMedic]

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

Honestly, even 0.1mg/kg is pretty effective.

 

[Carlos Danger]

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

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

 

[NomadicMedic]

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

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

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

 

[NPO]

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

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[Jim37F]

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

 

[NomadicMedic]

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

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

 

[NPO]

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

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

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[CoraElizabeth]

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

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

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