Question about an inpatient on narcotics

Buprenorphine Post
Posts: 1404

Postby drpasser » Tue Mar 18, 2014 4:34 am

Let's agree to call narcotics -"OPIATES." Full vs Partial Mu agonists is probably more descriptive.
Using the word Narcotics can at times be confusing...


Posts: 180

Postby entjwb » Tue Mar 18, 2014 4:34 am

First anyone on that daily dose for that long is addicted. The addiction is a physical property of opiates. To me it is malpractice to not give them opiates. I might suspect her symptoms might be withdrawal as a possibility. I would talk with them about decreasing dosages but realize you probably would be successful unless the patient has decided that is the best course for them. In my practice of opiate addiction, 80% of the patients on Heroin started on Rx opiates and after 10-12 months or longer the physician wouldn't give any more. By that time the patient is addicted. Heroin is cheaper than other opiates so that becomes their drug of choice. Many of these patients could be sent on a different course of action with common sense. The physician should begin to slowly wean and have the patient seen by a drug councillor. Better would try to get them to a Medically****isted Opiate Addiction Center.

Posts: 104

Postby jmosby1469 » Tue Mar 18, 2014 4:34 am

"Fantastic"! and a big bravo to my fellow FP. Bucking the trend in overprescribing and misprescribing narcotics and other drugs takes a courage and determination sometimes so difficult to maintain.

Jeremy K
Posts: 109

Postby Jeremy K » Tue Mar 18, 2014 4:34 am

I greatly appreciate the responses here, thanks so much!

FWIW, the pt symptomatically improved today, went home. The GI found nothing other than either viral GI'itis or w/drawals; he favors the latter dx as do I. She did receive a dose or 2 of parenteral narc's but no po; this a.m. when I saw her I told her the GI thought she should go home and I found no reason to dispute this; she averred that she 'still didn't feel completely well' and requested to stay a few more hours; her K+ was a bit low so this gave me an opportunity to give her some replacement and repeat it.

IMO she has a narcotics problem. Does she have a 'chronic pain' problem too? I can't say; I can't read her mind. Do I strongly suspect that she is misusing narc's and selling some of what she's dispensed? Yes, but have no way of confirming that. So this a.m. I told her if she stayed in house to receive some more IV fluids and K+ I'd give her no more narc's, no IV phenergan. I told her I suspected she has a prob w narc's and recommended she seek tx (unfortunately there's nothing available for said tx in this area except my Suboxone program and I'm, of course, full...). She actually expressed some gratitude at my expression of concern for this possibility and agreed to stay in-pt under these conditions, although later in the afternoon, after receiving some but not all of the K+ I planned to give her, she left before I could recheck her 'lytes. But since I had offered to D/C her this a.m. (w p.o. K+ and outpt re-check of 'lytes) this didn't bother me.

This to me is the crux of the problem in my area. I have no pain specialist I can rely on. IMO COT for non-CA pain is so problematic that I'm rarely comfortable with it, yet it is endemic in my area. I strongly suspect that many who are supposedly being treated with COT for chronic non-CA pain are actively diverting and selling, but there's no practical way to identify which are and which aren't. And the physician and ancillary staff generally would prefer to 'not rock the boat'. I'll freely admit I wish that the 'ethos' at the hospital was: if a patient presents to the facility claiming COT, not prescribed by an active staff member, it is ordinarily NOT continued unless the attending who 'picks up' the patient has some special reason to consider it appropriate.

As an example of the latter: I had an elderly man, unclaimed, admitted to me on 'backup' with AECB recently. He claimed COT for severe arthritis, especially R shoulder, Rx'd by a physician in a nearby town. When I examined him his R shoulder had severe LOM and gross palpable crepitus. We negotiated, and I put him on scheduled narcotics with extra for break-through pain, also put him on continuous pulse-ox and telemetry in case he had resp depression, my biggest fear in his case. He did well, slept well that night, went home the next day apparently pleased.

But the 40-somethings who claim narc's for 'bulging discs' prescribed by some way out-of-town physician with no hosp affiliation, with no obvious disease on PE? Not so much.

Posts: 1404

Postby drpasser » Tue Mar 18, 2014 4:34 am

Just in case you did not know this, it isn't illegal to tx any pt who is in the hospital with any opiate, even if they are an addict. This is based on the Controlled Substance Act of 1970. That includes tx for both pain as well as for Opiate WDRL Sxs.

Good to know?


Posts: 571

Postby kcairns » Tue Mar 18, 2014 4:34 am

Hi, Jeremy...well of course it IS a bup question. How many people have we all seen who have kept going down that COT road (though this patient is apparently not yet at the end), pain never really relieved in spite of dose escalations, then gradually finding themselves unable to stop taking more than prescribed in spite of sensing the pills making them more dysphoric, less alert and less able to function well in life (and the older they have become the harder this is for them, until it is finally just too late for help ) either saying, "I have to get off these" or being fired by their pain clinics/docs who get nervous/frustrated re situation getting stickier, or, doc suddenly sacked by the DEA and patient left in pain/jonesing/scrambling for other docs, but, by then meeting addiction criteria and no longer seen as cot-desirable, patient ending up, if unable to find a bupdoc w openings, being saved only by OTP methadone maintenance. What happy people those i have turned around on bup, for the , by then, dx of addiction, and how i wish more could be picked up and helped earlier for pain dx and that such wasn't so dea-discouraged. Though you are within standards by continuing documented primary care doc opioid doses, and surely your life easier by so doing than than fighting each pt to lower doses, you are the GOOD doc, as (even if only by educating patients and docs) you stand your ground for a better approach to the world epidemic of chronic pain/chronic opioid harm. We must NOT under treat chronic pain. But it is our responsibility as up to date docs to know that COT is unsafe (over 15,000 US deaths per year and countless addictions from opioid analgesics) , and that there is no high quality evidence to support it as effective for the majority of people, and for us then to go on to develop our understanding of the mental mechanisms of chronic pain and what these call for in re relieving the very real suffering of chronic pain patients.In U of Washington area, they have named this whole issue cod2cp, (complex opioid dependency secondary to chronic pain). In my experience and study, best is no new opioid starts for chronic pain, much work on mental mechanisms, and if provider still feels forced to go to agonists, then the partial agonist is going to lead to a long term more well patient.

Posts: 267

Postby peterorrin » Tue Mar 18, 2014 4:34 am

If your inpatient's doses are reduced before there is a full understanding of what's going on, she and the nursing staff will become a management problems. Its better to make these patients comfortable as you aggregate information. And I suggest that explain your rationale to nursing staff, whose negative attitudes are often uncovered when a patient is seen as 'addicted'. Just what you need when every professional aims for 'non-judgemental' care.

For more data, give the family a try, they are often the 'truth serum' of what's going on at home. And maybe an orthopedic consult.

You have a great opportunity to reach a deeper understanding, and thereby do greater good, when a patient is in the hospital.

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