# Fentanyl overdoses with street drugs



## Red Flag 1 (Aug 25, 2016)

The


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## TLDR20 (Aug 25, 2016)

It is scary. The opioid epidemic is something that worries me going forward. It is a self (healthcare)induced problem. scary shit.


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## Brill (Aug 25, 2016)

Why and how did it get so bad? Is this because of cheap heroin from Mexico?


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## Red Flag 1 (Aug 25, 2016)

TLDR20 said:


> It is scary. The opioid epidemic is something that worries me going forward. It is a self (healthcare)induced problem. scary shit.



It


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## RackMaster (Aug 25, 2016)

There's been some big busts up here, one just last month and they show it's not only being diverted from the health care system.  These were drums from China.


Seized chemical could have produced 38 million deadly fentanyl pills, police say


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## Red Flag 1 (Aug 25, 2016)

lindy said:


> Why and how did it get so bad? Is this because of cheap heroin from Mexico?



D


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## TLDR20 (Aug 25, 2016)

lindy said:


> Why and how did it get so bad? Is this because of cheap heroin from Mexico?



No it got bad because healthcare providers give out hard drugs like Vicodin for rolled ankles and "back pain".


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## Ooh-Rah (Aug 25, 2016)

TLDR20 said:


> No it got bad because healthcare providers give out hard drugs like Vicodin for rolled ankles and "back pain".



THAT is the truest statement I have seen on this board today.  I've got shit ankles, and at some point in the future I know I will need surgery, but the last couple of times I really f'ed one up, I went to Urgent Care and they gave me enough Vicodin to pay for my upcoming vacation.


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## R.Caerbannog (Aug 25, 2016)

I don't mean to sound callous. By treating overdose cases, I get the feeling we are awarding self-destructive behavior. Not only that, but we are essentially prolonging the lifespan of the drug markets customer base.


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## Red Flag 1 (Aug 25, 2016)

R.Caerbannog said:


> I don't mean to sound callous. By treating overdose cases, I get the feeling we are awarding self-destructive behavior. Not only that, but we are essentially prolonging the lifespan of the drug markets customer base.



Oh


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## policemedic (Aug 25, 2016)

Throw carfentanil in the mix and now you've really got a party.

Physicians do own some of the problem, but it's an oversimplification to lay all the blame on healthcare providers.  While some people become addicted through irresponsible prescribing habits, many more go down that path voluntarily.  I liken the problem of over-prescribing narcs to the same issue with ABX because many times the motivation is the same.  That is to say, the physician is afraid he'll lose the patient (and their insurance payments) if he prescribes a NSAID or refuses to write for ABX.  The problem is compounded by the number of people who exhibit drug seeking behavior, which is not seen with ABX (people just want ABX because they mistakenly think they need them, not because they're addicted).

My fear is that physicians, dentists, and midlevels now become afraid to write for narcs when they are appropriate, or to write for a sufficient course.  I'm a big pain management advocate and have no problem administering MS, fentanyl or another appropriate drug (to include things like Toradol) to relieve my patient's pain.  I'm concerned that with increasing oversight and awareness of the addiction problem, necessary and legitimate opioid prescriptions will decrease resulting in unnecessary suffering.


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## policemedic (Aug 25, 2016)

Red Flag 1 said:


> Oh they pay for it when the EMT's give them some Narcan to reverse the effects of the narcotic. It is akin to injecting instant narcotic withdrawl.
> 
> Looking at the problem at hand, when you do rescue someone, you have saved a life, and I'd do that every time, all day long. You never know what will get someone to turn the corner and make a flight into sobriety. Of those who do that, first time patients see about a 30% chance at staying clean.
> 
> I can see your point about saving the life until next time, but you really don't know what the out come will be.



The noxious effect of naloxone is really dose and administration dependent.  A milligram or two IN is generally 'gentle', as is 0.4mg IV pushed slowly.  IM administration is also less jarring than IVP.  The opposite side of the spectrum is 2 or 4 mg rapid IVP.  That's guaranteed to result in a negative reaction (puke, screaming, violence, need for both a young and old priest, etc.). 

I understand being frustrated with junkies; I see the same ones dipping on the street daily.  But that doesn't give us license to make them suffer.  I'm of the school of thought that we should titrate naloxone administration to adequate respiratory effort and sats.  I'm OK with it if they don't wake up, just so long as they're not blue.

All that said, the synthetic opioids are much harder to reverse than heroine.  Higher and more frequent dosing may be required.  Even then, it can come down to simple airway management.

I know you know all this, sir.  I'm just throwing it out there for discussion.


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## AWP (Aug 26, 2016)

I had some pretty severe pain with diverticulitis; I was utterly miserable. When the docs put me in the hospital the first thing they pushed after starting an IV was morphine.

If I were a junkie, I promise you 100% it would be morphine. I'm not even remotely surprised about this epidemic.


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## Muppet (Aug 26, 2016)

@policemedic and I went to paramedic school in 1999, as some of you know. Since then, I have been a paramedic in busy urban/suburban areas very close to Philly, where some of the "best heroin" is sold. I can say this. In my 16 years as a paramedic, this is the worst I have seen in heroin drops. In a 24 hour tour of mine, I have seen 7 O.D.'s with 3 being cardiac arrests / no R.O.S.C. (getting pulses back). People think it is in the hood that this is occurring, they are right AND wrong. It is everywhere. Kids from the burbs (affluent areas) are going to the badlands of Philly (that best heroin), picking up a bundle, going back to burbs, selling it for twice the profit AND ODing in moms bathroom, found an hour later, blue with no pulses. I have worked 14 year olds dipping on dope, a 71 male, unconscious on highway, presuming something different, assessing and finding a toxidrome (signs and symptoms) of OD, giving Narcan and waking him up. 

It is a God damned scourge that will not end. I carry Narcan in my pocket at work. Nearly every third call for 911 is an O.D. E.R.'s are full of junkies, many on ventilators. Many, many of these people double dip. They get heroin, many times mixed with a drug like crack or a medication used for other issues which resulting in the pt. dipping. Once the high is gone (in my care), they get monkey retarded crazy (I will leave the medical terms out) and start kicking/spitting and punching. The last one I had, Kenny (my bro that took his life) and I had it and had to go "hands on" with this junkie. With bloodbourne pathogens and fighting, it makes for bad times. 

So. Every O.D. that gets dispatched now as a "non breather" gets 2, yes, 2 paramedic units (each unit as a paramedic and EMT or 2 medic) plus a cop or 2 ad a fire engine. For a dipped junkie. While a father of 5 a mile away has a massive heart attack in front of his wife and 3 kids, by the time a medic from 5 miles gets there, he is no longer in a shockable rhythm, and dies on the floor. I am busy giving Narcan to the same junkie dipped 7 times in 3 weeks. Yeah, I am jaded. Yeah, I am cynical but when will this stop? 

I'm tired.

M.


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## policemedic (Aug 26, 2016)

Freefalling said:


> I had some pretty severe pain with diverticulitis; I was utterly miserable. When the docs put me in the hospital the first thing they pushed after starting an IV was morphine.
> 
> If I were a junkie, I promise you 100% it would be morphine. I'm not even remotely surprised about this epidemic.



I was very resistant to it when I had a gall bladder issue years ago.  Didn't want narcs, didn't want to explain it to work (yeah, that's a thing), other meds are available and effective...coming from a guy who literally fell on his face when he tried to get out of bed.  The doc shook his head, called me a stubborn asshole (he knew me; he was right) and gave me IV Toradol.  Problem solved; pain will go away soon....but of course it didn't.  2mg of MSO4 slow IVP and the pain was instantly gone.  No high, no buzz, no whatever (save for a very transient period of dizziness when it was pushed, lasted two seconds or less).

The lesson I learned was that what I was doing clinically was absolutely the right thing for my patients.  Oh yeah, and gall bladders are the devil.


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## policemedic (Aug 26, 2016)

Muppet said:


> I'm tired.
> 
> M.


Apropos of nothing whatsoever, because Muppet...


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## Muppet (Aug 26, 2016)

policemedic said:


> I was very resistant to it when I had a gall bladder issue years ago.  Didn't want narcs, didn't want to explain it to work (yeah, that's a thing), other meds are available and effective...coming from a guy who literally fell on his face when he tried to get out of bed.  The doc shook his head, called me a stubborn asshole (he knew me; he was right) and gave me IV Toradol.  Problem solved; pain will go away soon....but of course it didn't.  2mg of MSO4 slow IVP and the pain was instantly gone.  No high, no buzz, no whatever (save for a very transient period of dizziness when it was pushed, lasted two seconds or less).
> 
> The lesson I learned was that what I was doing clinically was absolutely the right thing for my patients.  Oh yeah, and gall bladders are the devil.



Ditto. My gastritis attack in 2013, Doc Dubeil @ L.B.H. E.D. wanted to give me Fentanyl. I declined and requested I.D. Toradol also. I do, however, offer pain meds to people in true and honest pain. Not the 10/10 pain while they are on their phone, laughing. The 210/103 pain, crying and sweating pain. I will smoke you with Fent AND Zofran.

M.


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## policemedic (Aug 26, 2016)

Opioids and anti-emetics are a great pair.  No puking and the narcotic is potentiated.


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## AWP (Aug 26, 2016)

policemedic said:


> Oh yeah, and gall bladders are the devil.



Mine was snatched yet the pain leading up to the surgery was "stiff" but manageable. My bilateral inguinal hernia with "parts descending into parts" was one notch better than diverticulitis. For lasting, miserable, "can't sleep, eat, or shit" pain, diverticulitis won hands down and I was oh so happy for the morphine. I'll sound crazy for this (nothing new), but that was the first time in my life where my brain shut down and relaxed. It was frightening how I felt after the injection, but it handled the pain and I slept for the first time in almost two days.


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## Marauder06 (Aug 26, 2016)

There was an article about this in the local paper this morning.  Interesting reading in this thread.


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## RackMaster (Aug 26, 2016)

Marauder06 said:


> There was an article about this in the local paper this morning.  Interesting reading in this thread.



It doesn't matter the size of the community, it seems to have reached all of North America.  Even our most remote First Nations communities are dealing with this epidemic.


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## Devildoc (Aug 26, 2016)

TLDR20 said:


> No it got bad because healthcare providers give out hard drugs like Vicodin for rolled ankles and "back pain".



Some EDs and healthcare systems are wising up...patients can only get "n" number of a script, and pharmacies aren't filling more than "n" number of scripts or pill #.   Many EDs and pharmacies are "linked" (I don't know how, I never bothered investigating the technology) so they can see if a patient is "doctor shopping" or if they are getting multiple prescriptions.  Most providers in our ED won't do narcs for "soft" diagnosis (headaches, back pain).

For me all it took was the massive, horrible, and life-threatening (so I say) constipation from my one time on PO narcs.  Never again.  Never.


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## TLDR20 (Aug 26, 2016)

policemedic said:


> Throw carfentanil in the mix and now you've really got a party.
> 
> Physicians do own some of the problem, but it's an oversimplification to lay all the blame on healthcare providers.  While some people become addicted through irresponsible prescribing habits, many more go down that path voluntarily.  I liken the problem of over-prescribing narcs to the same issue with ABX because many times the motivation is the same.  That is to say, the physician is afraid he'll lose the patient (and their insurance payments) if he prescribes a NSAID or refuses to write for ABX.  The problem is compounded by the number of people who exhibit drug seeking behavior, which is not seen with ABX (people just want ABX because they mistakenly think they need them, not because they're addicted).
> 
> My fear is that physicians, dentists, and midlevels now become afraid to write for narcs when they are appropriate, or to write for a sufficient course.  I'm a big pain management advocate and have no problem administering MS, fentanyl or another appropriate drug (to include things like Toradol) to relieve my patient's pain.  I'm concerned that with increasing oversight and awareness of the addiction problem, necessary and legitimate opioid prescriptions will decrease resulting in unnecessary suffering.



I get what you are saying. There are just too many pill mill doctors scattered around that pretty much only give out pills. My BIL is a pharmacist, he knows the docs that are pill mills. He can refuse scripts, but they will just go somewhere else.


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## Devildoc (Aug 26, 2016)

policemedic said:


> The noxious effect of naloxone is really dose and administration dependent.  A milligram or two IN is generally 'gentle', as is 0.4mg IV pushed slowly.  IM administration is also less jarring than IVP.  The opposite side of the spectrum is 2 or 4 mg rapid IVP.  That's guaranteed to result in a negative reaction (puke, screaming, violence, need for both a young and old priest, etc.).
> 
> I understand being frustrated with junkies; I see the same ones dipping on the street daily.  But that doesn't give us license to make them suffer.  I'm of the school of thought that we should titrate naloxone administration to adequate respiratory effort and sats.  I'm OK with it if they don't wake up, just so long as they're not blue.
> 
> ...



Back in my paramedic days we would intubate (because, you know, we had to have a certain number every year), give narcan, and extubate.

As for rapid narcan push, one local ED had an absolute asshat of a doc.  On one OD I pushed 2 mg rapidly about two blocks out after getting a ration of shit and dissertation on the radio, and let him deal with the consequences.  I have grown a lot since then.


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## BuckysBadger24 (Aug 26, 2016)

Wasn't too long ago that I was in high school, small town Wisconsin.  We were like the majority, or what I thought was the majority, of hs kids.  We had our drinking parties after football games, tested and tried to figure out our limits, went too far and puked and had to be carried to bed and placed face down to sleep it off.  Occasionally we would smoke a joint or whatever, but that was always the worst thing I saw at a party.

  My brother is now a Sophomore in hs at a bigger school than I attended (D1 over D3, which here is a difference of about 500-600 kids).  He's afraid to go to parties anymore.  Kids are selling and shooting heroin at the parties he says.  He heard some of his football buddies talking about doing coke before games, or popping oxys and percs.  When the hell did this shit start?  Because the last thing on our minds was where we can get harder and better drugs.  Hell it was hard enough finding that occasional joint, and someone of age for the beer.  I can't speak intelligibly for other states, despite how obvious the problem is everywhere, but heroin especially, is sweeping through this state.  Comes in through Milwaukee, up to Madison where god knows what's done to it when stepped on, and on it branches to the Northern cities and suburban kids who don't know a fuckin thing about what they're shooting, snorting, or smoking.  It's an epidemic on an ugly level.


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## RackMaster (Aug 26, 2016)

My wife works in addictions.  It's not an easy job and there's no lack of work. The wide array of demographics isn't a new thing; it's the sheer number of patients.   Wait lists are getting longer.  And no sign of it getting better anytime soon.

The only good thing I can see up here is the changes being done to address treatment.  Recognizing it as a disease in itself, comorbidity with mental illness and untreated/ill treated chronic pain.  You can't treat the addiction without treating the aggravating illnesses.  But at the same time, it's hard to work on anything else until the addiction is under control.


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## Muppet (Aug 26, 2016)

Devildoc said:


> Back in my paramedic days we would intubate (because, you know, we had to have a certain number every year), give narcan, and extubate.
> 
> As for rapid narcan push, one local ED had an absolute asshat of a doc.  On one OD I pushed 2 mg rapidly about two blocks out after getting a ration of shit and dissertation on the radio, and let him deal with the consequences.  I have grown a lot since then.



Done that once or twice. Rapid Narcan push as we are walking through the E.D. doors. Fuck you very much for treating us like shit. Have not done that in forever though.

M.


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## Muppet (Aug 26, 2016)

I recall a story from a Philly Fire medic on an O.D. one day on the El in the badlands years ago.

Dipped on the bench. Medic gets there. Takes junkies shoes and throws em on the tracks, kicks junkie in the asshole really hard and Narcan's him. Medic wakes him up, junkie says his ass hurts and medic tells him that he believes he was raped. Takes him to closest E.D. which happened to be next to SVU. Totally fucked up and unprofessional but the amount of burn out is absurd. I don't condone it but I get it. I have been known to give tough love.
"Hey dummy. Do you you see what the fuck you have here? You have 2 paramedic units, a fire truck and cops PLUS your parents all freaking out because you were dead. How about you stop being a fucking retard and straighten up. We are offering help" is what I would say. Most don't listen, a few have. Of course, I know it's not that easy, they have to want it but again, day after day, the giving Narcan over and over gets tiring, especially when they are abusing themselves. I was called a fucking asshole last weekend for giving it because he was with drawing and I was gentle with it, even game him Zofran for vomiting. He said "let me die". I said "well, go dip where people can't find you then wise ass, you're welcome".

M.


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## Diamondback 2/2 (Aug 26, 2016)

I used to pop a lot of pills, about 240perc every 3 weeks. All legal, legit, doctor ordered, blah, blah, blah. When I transitioned to the VA, the doctors freaked out and cold turkey'ed my ass off everything I was taking. I could have walked into any doctors office and got a prescription but I honestly felt like a junkie pill head after the VA doc talked to me like one. So I figured fuck it...Now when the pain gets too bad, I drown myself with a bottle of vodka, and actually it works better than the pills ever did. Now my new VA doc thinks I have a drinking problem, and this is probably the least amount of alchole I have drank since age 15. Hell I'm pretty damn conservative with my drinking compared to 2 years ago. But when I fuck up and irritate my back, about the only way to relax it and crash out is too get drunk off my ass (or at least that's what I tell the wife lol).

With today's culture and the social insanity coupled with the political bullshit and fucking active terrorist cells attacking us at home. I think everyone is looking for an escape, and as long as they are not hurt anyone else, fuck it, let them. No special service's, not going to pay for your bambo ride and stay in the ER. Just check their ID and if their over 18 years old, let them sit their and choke on their own vomit.

Too be honest, if we quit protecting everyone from their own damn selves, natural selection would clear up a shit load of the problems we are having today.

No Berry, you actually have to find a political solution,  because I'm not going to go fight your playground bully for you anymore.

No black community, we don't care anymore if Kr8tel just shot $1.50 for his new Jordans. Y'all wanted to police it, we'll get it...oh and your SNAP just got shut off, get a job or starve.

No little juanneto, you can not get free medical care here. Get insurance and pay in like the rest of us. Have a hot iron behind the building for bleeding wounds.

No Susan, you have to get a fucking job and pay your way through school and you can't take student loans out to party on all next semester.

No Johnny dope head, you chose to be a dick head and get high and escape reality and now you found a new reality,  it's called the next life, because we ain't stopping you dumb ass fuckers from killing yourselves no more.

I think I just heard @Deathy McDeath head explode.:-"


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## AR Paramedic (Aug 26, 2016)

policemedic said:


> Opioids and anti-emetics are a great pair.  No puking and the narcotic is potentiated.



Going a little bit off topic here.
I was told by an ER doc buddy of mine that the N/V and itchiness associated with the "more natural" of opioids (ie morphine) is caused by a histamine reaction so he'll give morphine with 50mg of diphenhydramine (Benadryl) instead of 4mg of Zofran.

This is great for your hypotension patients in pain because the Benadryl will potentially mitigate any further hypotension caused by the morphine.

I would however stick to Zofran in chest pain/STEMI patients because a lot of the desired effects (reduction of preload and resultant decrease in myocardial O2 demand) are caused by the histamine response to morphine. That is unless your patient has a prolonged QT-interval. Little known fact, Zofran prolongs QT and should be avoided in patients with an already prolonged QT to avoid causing Torsades.


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## Red Flag 1 (Aug 26, 2016)

TLDR20 said:


> I get what you are saying. There are just too many pill mill doctors scattered around that pretty much only give out pills. My BIL is a pharmacist, he knows the docs that are pill mills. He can refuse scripts, but they will just go somewhere else.



Th


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## TLDR20 (Aug 26, 2016)

AR Paramedic said:


> Going a little bit off topic here.
> I was told by an ER doc buddy of mine that the N/V and itchiness associated with the "more natural" of opioids (ie morphine) is caused by a histamine reaction so he'll give morphine with 50mg of diphenhydramine (Benadryl) instead of 4mg of Zofran.
> 
> This is great for your hypotension patients in pain because the Benadryl will potentially mitigate any further hypotension caused by the morphine.
> ...


How does Benadryl counter the hypotension effects of opioids? I have never heard that before, and would be interested in the physiology behind it.


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## Red Flag 1 (Aug 26, 2016)

TLDR20 said:


> How does Benadryl counter the hypotension effects of opioids? I have never heard that before, and would be interested in the physiology behind it.





As for itching, i


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## TLDR20 (Aug 26, 2016)

Red Flag 1 said:


> As for itching, it is a pretty common side effect from all narcotics. It is somewhat dose related, but if  you give enough of any narcotic, the patient will itch. The itching is generally from histamine release.
> 
> With patients that I had on epidural narcotics for post-op pain relief, I left standing orders for either Benadryl, or low dose Narcan to reduce the itching.
> 
> In the face of hypotension, I would reach for either Ephedrine, or Epi. There are other vasoactive agents but Benadryl has not been on any of my lists.



Yeah I get that, hence my question. The histamine response to opioids and the hypotension are unrelated. @AR Paramedic stated that utilizing diphenhydramine could reduce the hypotensive effects of opioids. I don't think that has any basis in physiology.


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## AR Paramedic (Aug 26, 2016)

TLDR20 said:


> How does Benadryl counter the hypotension effects of opioids? I have never heard that before, and would be interested in the physiology behind it.



The hypotension is caused by a histamine reaction just as it is in anaphylaxis. Benadryl reportedly prevents morphine induced hypotension by blunting the histamine reaction.

Definitely not calling Benadryl a vasoactive drug, but it has been shown to blunt the vasoaction of  morphine.


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## TLDR20 (Aug 26, 2016)

AR Paramedic said:


> The hypotension is caused by a histamine reaction just as it is in anaphylaxis. Benadryl reportedly prevents morphine induced hypotension by blunting the histamine reaction.
> 
> Definitely not calling Benadryl a vasoactive drug, but it has been shown to blunt the vasoaction of  morphine.



If you give anyone morphine they will have a reduction in BP. Let's be clear Benadryl is not vasoactive. Even in the case of a histamine response, Benadryl should be given with Epi, so as to get effects on hemodynamics.


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## TLDR20 (Aug 26, 2016)

AR Paramedic said:


> The hypotension is caused by a histamine reaction just as it is in anaphylaxis. Benadryl reportedly prevents morphine induced hypotension by blunting the histamine reaction.
> 
> Definitely not calling Benadryl a vasoactive drug, but it has been shown to blunt the vasoaction of  morphine.



Looking more into it I see where you are coming from. 

This article talks about local, rather than systemic histamine response as the mediator for vasodilation.

Morphine is an arteriolar vasodilator in man


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## AR Paramedic (Aug 26, 2016)

TLDR20 said:


> If you give anyone morphine they will have a reduction in BP. Let's be clear Benadryl is not vasoactive. Even in the case of a histamine response, Benadryl should be given with Epi, so as to get effects on hemodynamics.



I completely agree. I'm definitely not advocating administering Benadryl in response to vasodilation, but administering it up front with morphine in the normotensive patient to prevent vasodilation or further hypotension in the already hypotensive patient. Not speaking toward treating hypotension, just optimizing analgesia administration. Epi is my first line of treatment for any igE caused hypotension of course.


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## Red Flag 1 (Aug 26, 2016)

AR Paramedic said:


> I completely agree. I'm definitely not advocating administering Benadryl in response to vasodilation, but administering it up front with morphine in the normotensive patient to prevent vasodilation or further hypotension in the already hypotensive patient. Not speaking toward treating hypotension, just optimizing analgesia administration. Epi is my first line of treatment for any igE caused hypotension of course.



This is an interesting topic.


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## Devildoc (Aug 26, 2016)

Red Flag 1 said:


> As for itching, it is a pretty common side effect from all narcotics. It is somewhat dose related, but if  you give enough of any narcotic, the patient will itch. The itching is generally from histamine release.
> 
> With patients that I had on epidural narcotics for post-op pain relief, I left standing orders for either Benadryl, or low dose Narcan to reduce the itching.
> 
> In the face of hypotension, I would reach for either Ephedrine, or Epi. There are other vasoactive agents but Benadryl has not been on any of my lists.



Or a low-dose narcan drip to go along with a PCA.

And for hypotension, would you grab the epi first or try some neo first?  In two institution in which I have worked one was 1, 2; the other, the opposite.  I think the neo is safer.


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## policemedic (Aug 26, 2016)

AR Paramedic said:


> Going a little bit off topic here.
> I was told by an ER doc buddy of mine that the N/V and itchiness associated with the "more natural" of opioids (ie morphine) is caused by a histamine reaction so he'll give morphine with 50mg of diphenhydramine (Benadryl) instead of 4mg of Zofran.
> 
> This is great for your hypotension patients in pain because the Benadryl will potentially mitigate any further hypotension caused by the morphine.
> ...



MS in NSTEMI/ACS?  Bad mojo, in my view.   Even in STEMI where the patient is bound for the cath lab MS inhibits oral anti platelet agents, and that's no bueno.


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## AR Paramedic (Aug 26, 2016)

policemedic said:


> MS in NSTEMI/ACS?  Bad mojo, in my view.   Even in STEMI where the patient is bound for the cath lab MS inhibits oral anti platelet agents, and that's no bueno.



Yeah that makes sense. Our interventional cardiologists want IV heparin so it's no problem here at my shop.


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## Muppet (Aug 26, 2016)

@Red Flag 1. Can we get C.M.E.'s for this thread doc?

M.


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## DocIllinois (Aug 26, 2016)

Muppet said:


> @Red Flag 1. Can we get C.M.E.'s for this thread doc?
> 
> M.



@Red Flag 1 's lessons give me a fuzzy feeling in my belly.

If there's no conflict of interest and any instruction is put into a 'death by Powerpoint' format, a state board would be silly for not accepting this as CME.  :-"


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## Muppet (Aug 26, 2016)

DocIllinois said:


> @Red Flag 1 's lessons give me a fuzzy feeling in my belly.
> 
> If there's no conflict of interest and any instruction is put into a 'death by Powerpoint' format, a state board would be silly for not accepting this as CME.  :-"



Almost gets me motivated to love medicine again. LMAO.

M.


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## RackMaster (Aug 27, 2016)

I'm always in awe of how many SMRT Fuckers we have here.


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