# ER Doc give his advice to drug seekers.



## 8'Duece (Nov 9, 2010)

Not like there's anyone here that drug seeks, but this was in our ACM (Advanced Clinical Medicine) in box this morning. :uhh: 

This is supposedly from an ER doc at University Of Louisville and he posted this on Craigs Lists.  

This is funny, so feel free to comment on your experiences if your in the Health Care field etc. 




> OK, I am not going to lecture you about the dangers of narcotic pain medicines. We both know how addictive they are: you because you know how it feels when you don't have your vicodin, me because I've seen many many many people just like you. However, there are a few things I can tell you that would make us both much happier. By following a few simple rules our little clinical transaction can go more smoothly and we'll both be happier because you get out of the ER quicker.
> 
> The first rule is be nice to the nurses. They are underpaid, overworked, and have a lot more influence over your stay in the ER than you think. When you are tempted to treat them like shit because they are not the ones who write the rx, remember: I might write for you to get a shot of 2mg of dilaudid, but your behavior toward the nurses determines what percent of that dilaudid is squirted onto the floor before you get your shot.
> 
> ...


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## Muppet (Nov 9, 2010)

Priceless. I love it.

F.M.


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## 8'Duece (Nov 9, 2010)

I can tell you from shadowing the ER docs at my school that this paragraph is the absolute truth !!

I'm not advocating this behavior.  This is for humor and humors sake only. 



> So if you keep these few simple rules in mind, our interaction will go much more smoothly. I don't really give a shit if I give 20 vicodins to a drug-seeker. Before I was burnt out in the ER I was a hippy and I would honestly rather give that to ten of you guys than make one person in real pain (unrelated to withdrawal) suffer. However, if you insist on waving a flourescent orange flag that says 'I am a drug seeker' and pissing me and the nurses off with your behavior, I am less likely to give you that rx. You don't want that. I don't want that. So lets keep this simple, easy, and we'll all be much happier


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## Dame (Nov 9, 2010)

Wow. That explains the Thorazine they gave me this weekend. Off label for migraine in a 9.5/10 pain situation (I was basically blind by the time I got in there) but the I.V. helped. I'm guessing it wouldn't have had that effect on my brain if I was addicted to pain meds. And it only helped my brain. My neck and shoulders still hurt like a sonofabitch.  Almost over now thank goodness.


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## 8'Duece (Nov 9, 2010)

Dame said:


> Wow. That explains the Thorazine they gave me this weekend. Off label for migraine in a 9.5/10 pain situation (I was basically blind by the time I got in there) but the I.V. helped. I'm guessing it wouldn't have had that effect on my brain if I was addicted to pain meds. And it only helped my brain. My neck and shoulders still hurt like a sonofabitch.  Almost over now thank goodness.



That's just silly !!

I'm surprised they didn't just go for 2mg's Stadol from the start with 25 mg's of Phenergan.  Some Docs practice what their tought through their rotations and others learn along the way that most migraines never respond fully to triptans and Thorazine.  I have yet to meet a person that suffers from true migraines that is given any relief from Sumatriptan or other cocktails that do not involve narco therapy.  If you have other experiences, please share them. 

Hell, screw the IV, just hit your ass with 3mg's of Stadol or 2mg's of Dilaudid with 25 mgs of Phenergan and your out the door and home comfortable without the IV wait. Following protocol for wait time and BP and O2 sats. 

The fact that you said "9.5" ont the pain scale is percieved pain.  If you've never experienced a compound fracture of the femur then you don't know the pain relative to the injury, just that your head is about to explode and you can't see or stomach anything.


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## 8'Duece (Nov 9, 2010)

ADD:

The IV helped due to probable dehydration.  I've seen migraine sufferers respond to IV therapy and pure O2.


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## Dame (Nov 10, 2010)

The 9.5 response was to the question, "Based on the worst migraine you've ever had..." not the worst pain. As far as the rest of the experience, you're right, it did not fully respond to the Thorazine and I had a minor reaction of throat and nasal cavity closing. I was able to vocalize it and it subsided quickly. Still on Percocet for pain and Prochlorper for the nausea/dizziness/balance issues. OK, I'll STFU now. I'm sure this is boring.


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## Muppet (Nov 10, 2010)

Dame said:


> The 9.5 response was to the question, "Based on the worst migraine you've ever had..." not the worst pain. As far as the rest of the experience, you're right, it did not fully respond to the Thorazine and I had a minor reaction of throat and nasal cavity closing. I was able to vocalize it and it subsided quickly. Still on Percocet for pain and Prochlorper for the nausea/dizziness/balance issues. OK, I'll STFU now. I'm sure this is boring.


 
I am not bored. I learned something.

F.M.


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## policemedic (Nov 10, 2010)

The muppet is right; you're not boring us. 

The truth is that migraines are fairly common (roughly 15% of the population experience them), so a decent knowledge of how to assess and treat one should be possessed by anyone in emergency medicine. Migraine is an interesting syndrome that is associated with a wide list of differential diagnoses, and as you can attest, the pharmacology involved in the treatment of migraine variant HA is fairly complex. 

The thing about migraine is that (with some notable exceptions, such as first-time presentations), the diagnosis is based on a careful history. Imaging and other studies tend to be overused.  It's one of the reasons migraines are interesting and not boring; proper assessment requires critical thinking instead of reliance on technological crutches. 

Have you had Thorazine before?  Reactions to meds that cause airway issues are worrisome. 

Duece is right. Triptans and Thorazine aren't the drugs of choice.  In fact, triptans are often contraindicated in several migraine variants, as are drugs containing ergot. Stadol may be effective, but can be addictive and can produce bothersome side effects in those persons who are not accustomed to narcs. 

Anyway, I'm sorry you were suffering. Migraines suck. Feel better!


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## Manolito (Nov 10, 2010)

I am sorry for laughing but the Thorazine shuffle is the greatest thing to watch. Some Dr. that have a low tolerance for people will light them up with Thorazine and they will shuffle out of the room like they have large slippers on and are trying to keep them on their feet. 
Sorry to hear about the migraine. 
Bill


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## Dame (Nov 10, 2010)

Bill, if I could remember walking out of there I'd confirm or deny the shuffle, LOL. I was hoping no one would start to hypothesize why a drug that acts like a chemical lobotomy might have worked. I'm flying to Reno/Carson again today for govt meetings and I'm hoping the travel doesn't trigger anything more.

Policemedic, I've never had anyone give me Thorazine before which is why (despite the difficulty is forming a coherent sentence) I made sure to vocalize the difficulty breathing.  They added more of the other stuff to the cocktail; triptans I guess.  Eventually they gave me a pain killer but I'm not even sure it was the same stuff they sent me home with a prescription for.

Muppet, glad to be of assistance, LOL.  Wish me luck today.  I hate it when they schedule more than one meeting in a day for me in two different cities up there.


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## Headshot (Nov 10, 2010)

Many docs DO NOT know what to do with a migraine as they are a bit of a mystery given most fail to do a proper social history anymore on their patients.  With that, many many docs will give a migraine sufferer something strong enough to put them out of their right mind long enough for the migraine to go away on it's own.  Symptomatic cures as usual when it comes to a migraine.  You will continue to have migraines until you find someone who is willing to do a proper social history workup on you and help you make the proper lifestyle changes that will bring about a cure rather than occasional relief.


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## 8'Duece (Nov 10, 2010)

policemedic said:


> The muppet is right; you're not boring us.
> 
> The truth is that migraines are fairly common (roughly 15% of the population experience them), so a decent knowledge of how to assess and treat one should be possessed by anyone in emergency medicine. Migraine is an interesting syndrome that is associated with a wide list of differential diagnoses, and as you can attest, the pharmacology involved in the treatment of migraine variant HA is fairly complex.
> 
> ...



Sever itching is the most commom side effect in just about all patients.  Stadol is also available in a Nasal Spray for home use.  This is what get's most people in trouble.  It works so damn well !!  

Headshot hit the nail on the head.  A differential diagnoses by a Neurologist is called for in most cases.  There are plenty of prophylactic drugs that can be taken on a daily basis to stave off migraines.  Topamax, Beta blockers and a couple others that come to mind.  Although these drugs seem to only prevent the number of migraines you may suffer over a given length of time.  You may still require ER treatment a couple times a year for relief.

Honestly, the highlighted portion regarding the use of Thorazine has me wondering why they even attempt it. :uhh:   It's totally off label for Migraine relief.


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## policemedic (Nov 10, 2010)

I don't mind off-label use (BTDT) but not without good evidence of safety and efficacy.


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## Marauder06 (Nov 10, 2010)

> And I firmly believe that if you manipulate your way to the back and make a 19 year old young woman with an ectopic pregnancy that might kill her in a few hours wait even a moment longer to be seen, I should be able to piss in a glass and make you drink it before you leave the ER.



lol :)


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## 8'Duece (Nov 10, 2010)

policemedic said:


> I don't mind off-label use (BTDT) but not without good evidence of safety and efficacy.



I'm gonna take an educated guess without looking up the class of drugs. 

Good for nausea, vomiting and relaxing the patient ?  It's usually a given for schizophrenia patients. 

Why use it ?  The ER doc here will give you 2-4mgs Stadol, 25mgs Phenergan and maybe 2mgs Ativan.   You'll be damned comfortable by then.


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## policemedic (Nov 10, 2010)

No argument with that. My comment about off-label drug use was intended generally.  Many drugs are used off-label to good effect. With that said, the clinician must have a solid understanding of the pathophysiology of the disease process they're attempting to correct and a good understanding of how the drug they've chosen will produce the beneficial effect they're seeking to achieve. 

Thorazine isn't a drug I'd choose for migraine HA, just for clarity's sake.


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## 8'Duece (Nov 10, 2010)

Some docs just are too damn skeered to use narco therapy first.  For good reason, but if the patient does not have any underlying conditions that restrict the use of narcotics then you can GOMER them out of the ER and both you and the patient have been served well.  Beds need to be open for more serious cases coming out of triage. Assuming this is a typical migraine with no underlying causes that would require a CAT workup, blood cultures, etc. 

It's ok to use lesser drugs, such as the triptans, but don't expect the patient to suddently say "Hey, feels better, I'm like new" when those have proven track records of poor perfomance for pain relief once the migraine has ventured passed the pain threshold, bell curve. 

Tell tale signs are high BP, intense photophobia, nausea, gagging and muscle weakness.  If my patient does not have any trauma related issues, respiratory distress etc or is on daily medications that are highly contraindicated to narco therapy then I'm going to get them the pain relief they need and get them home and out of the ER.  It's good business. This is also assuming I've completed a proper neuro exam with  expected results. If the patients eyes are not dilating properly I've got something entirely different and  serious on my hands.


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## Diamondback 2/2 (Nov 10, 2010)

I get headaches from taking the vicodin. :uhh: 

Of course I take more vicodin in a week than any drug addict crack head, but it’s due to actual severe pain…


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## Headshot (Nov 10, 2010)

J.A.B. said:


> I get headaches from taking the vicodin. :uhh:
> 
> Of course I take more vicodin in a week than any drug addict crack head, but it’s due to actual severe pain…



You're dehydrated.  Try hydrating till you piss clear (you know the drill); in the morning drink 2 tall glasses room temp water about 30 minutes before eating to get re-hydrated.  Vicodin saps water from your system as quick as alcohol does, and if you go to be dehydrated the problem is compounded by moisture loss from breathing while you sleep.  Also, if you find yourself hungry often then try drinking some water.  Most people are dehydrated and confuse it with the feeling of hunger when they actually need to drink water.  Stay away from the sports drinks for actual hydration (read the labels), nothing beats water.  You are made mostly from H2O, not Gatorade.  You can buy electrolytes to add to water without all sodium that most sports drinks have.  Try it for a couple of days and see if the headaches don't disappear.


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## 8'Duece (Nov 10, 2010)

Word to the wise, one of the side effects of Vicodin are headaches.


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## Headshot (Nov 11, 2010)

8'Duece said:


> Word to the wise, one of the side effects of Vicodin are headaches.


 
Yours are what the medical community refers to as a "hangover".


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## Wills (Nov 14, 2010)

I have gotten very good results with real migraines using Toredol 60mg,Reglan 10 mg ,Benadryl 25 mg IV and a liter of NS. When it doesnt work morphine or dilaudid are next line. The drug seekers you usually just have to give them their 2 mg of Dilaudid and an Rx for 12-15 Vicodin before they will go away.
Damn do I hate drug seekers . They prevent you from getting to the people who are in real need in a timely manner, they stress the whole staff and make everybody bitchy, their families sue you when they finally die and they are multiplying like freaking rabbits. The next category I hate are the ones who call an ambulance for a three day old paper cut to the finger or the pencil eraser sized rash on the arm that started yesterday.
Ask why they called an ambulance and they say "well if I didnt I would have to wait in the lobby for three hours, Duh?" I love the ones who come in and say they have a severe headache and when you ask if they took any tylenol or motrin they look at you as if they want to say; "Why would I do that when I can come in here and spend $800. of taxpeyer money and get 25 cents of tylenol for free ?"
Everybody wonders why healthcare cost are rising its because of what I call Malignant Entitlement Syndrome. They dont pay taxes, they get free gold plated healthcare even taxi vouchers to go see doctors.
What do they care if the working taxpayers are struggling and have to buy their own substandard insurance?
OK Im going to STFU now because a man with a scapel in his hand can be dangerous when his blood pressure goes up.


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## DoctorDoom (Nov 15, 2010)

Interesting... we laugh at the ER guys who use narcotics for headaches... because it doesn't work. The pain is not a mu-receptor based pain. Which is why they give Phenergan and Ativan and IVF: that knocks the person out. And it spares them from having to diagnose basilar or hemiplegic migraine. Avoiding Toradol and other NSAIDs avoids the embarassing complication of furthering bleeding if the "migraine" is a missed intracranial bleed.  Thorazine is a joke; the reason it's given is the same reason big narcs are used, it knocks you the fuck out and so you can't complain.  Thorazine doesn't really act as an analgesic at all.

It's shotgun CYA medicine. It shuts the patient up until they can get a CT scan done, or gets them out of the ER.  Since 90% of migraines will go away with hydration anyways, its a false efficacy and a waste of money.

Triptans work very well for true migraine, but that requires history and physical and diagnosis.  In short supply in a lot of ER's due to a variety of reasons.

By the way, easiest way to figure out a drug seeker?  10/10 pain with stone cold normal vitals.  You can't have that much pain and have a heart rate of 60 not on a beta blocker with BP 120/70.  Again, history, physical, diagnosis.  You know, that old school doctor stuff.


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## TLDR20 (Nov 15, 2010)

So I have had a grand total of 3 migraines. 1 was when I was 14 maybe, the other at 19 or 20 then one more at 21. All of them present the same way. I get an aura(spotty vision, difficulty formulating sentences, not really too much pain) then I get the headache.Weird thing is that the headache is never really that horrible. maybe 4/10. However the aura symptoms and assosciated symptoms of the headache are much worse(light sensitivity). I seriously am almost unable to speak.

Anyways back to the topic of pain seekers. I have seen lots of em, and the one thing that jumps out at me is when they freak out at the IV stick, if you are in 10/10 pain a lil needle stick in your arm is not gonna phase you. Granted this doesn't work on IV drug users, but it will work on guys that are pill poppers.

I have also had a pt that I coulda sworn was drug seeking. Came in screaming and hollering about all her back pain said it was 10/10, calling nurses bitches and all this stuff, then she flinches at the IV. I was an SFMS student at the time on the indian reservation, so I am thinking this lady is a classic case of a drug seeker. Until we find out she has kidney stones and is literally deathly afraid of needles. Gave her fluid therapy and some pain meds and the lady was prolly one of the sweetest lady's I had the pleasure of treating. Learned from that one for sure.


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## Manolito (Nov 15, 2010)

I was only a EMT-B that transported the frequent fliers to the ER. I can tell you thorazine shuffle was common on certain ER DRs shifts. Certain RN's saw nothing but GOMERs and others were very compassionate. Just like all walks of life there are good uns and not so good uns. Just an observation from the least qualified on the board.


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## 8'Duece (Nov 15, 2010)

DoctorDoom said:


> Interesting... we laugh at the ER guys who use narcotics for headaches... because it doesn't work. The pain is not a mu-receptor based pain. Which is why they give Phenergan and Ativan and IVF: that knocks the person out. And it spares them from having to diagnose basilar or hemiplegic migraine. Avoiding Toradol and other NSAIDs avoids the embarassing complication of furthering bleeding if the "migraine" is a missed intracranial bleed. Thorazine is a joke; the reason it's given is the same reason big narcs are used, it knocks you the fuck out and so you can't complain. Thorazine doesn't really act as an analgesic at all.
> 
> It's shotgun CYA medicine. It shuts the patient up until they can get a CT scan done, or gets them out of the ER. Since 90% of migraines will go away with hydration anyways, its a false efficacy and a waste of money.
> 
> ...



Now you start talking abou Mu, Delta and Kappa receptors and you get me all fooked up again. :confused:

Neuro Pathway's etc Agonists, opiod receptors.  We have to know this shit to treat a migraine ??


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## Muppet (Nov 16, 2010)

Ahhhhhhhhhhh! Neuro pathways! My head hurts now. Doc Doom: Do we get C.M.E.'s for that? :)

F.M.


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## Dame (Nov 16, 2010)

Hey, I'm complicated.


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## Centermass (Nov 16, 2010)

All I know is I hate the damn things (pain meds)

Having been prescribed a few over the years, after few, next thing I know is I'm backed up from here to Oshkosh. Turns my damn inards into a dust bowl..........:confused:


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## 8'Duece (Nov 16, 2010)

Centermass said:


> All I know is I hate the damn things (pain meds)
> 
> Having been prescribed a few over the years, after few, next thing I know is I'm backed up from here to Oshkosh. Turns my damn inards into a dust bowl..........:confused:



That's why they should tell you to use a laxative when taking them over a longer period of time.


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