PACPhD Posted February 21, 2006 Share Posted February 21, 2006 I was reading one of the threads and found PAs giving all kinds of pain medication and wonder the rational for what they give. I have an excellent article entitled "the 11 myths in pain management" or something like that which I give to all of my PA/med students & residents. It starts out citing how we as fail at giving the proper pain medication to our patients. Here is my take on some of the meds given: IV Morphine - Excellent, cheap, decent 1/2 life. Very appropriate 90% of the time in the ED. Fentanyl - Great for short procedures Dilaudid - The elexir of the gods for Sicklers. Great for any pts who MS just won't cut it. Demerol - Feed the bears, the bears will come. Seizures in high doses. PO Vicodin/Lortab - Excellent, low nausea, low cost. Percocet - Very good, higher nausea rates then the above. T3 - Average, lots of complaints about nausea/vomiting. Rarely give it. Darvocet- Poor narcotic, difficult to handle overdoses Narcotic antagonists/ Stadol - Does anyone actually still give this? Ultram - Poor analgesic, given to drug seekers when someone wants to pretend they are giving pain meds but doesn't really want to. Others Motrin - Very good analgesic, cheap Torodol IV/IM - Very good analgesic, very few indication over motrin, same efficacy, high cost (compared to Motrin), complications of iv/im compared to PO. Given way too often. Can knock out an elderly / diabetics kidneys. Torodol PO - Totally useless Tylenol - Good for preggos and fevers Did I miss any? 1 Quote Link to comment Share on other sites More sharing options...
rcdavis Posted February 21, 2006 Share Posted February 21, 2006 EXCELLANT posting. PO: Mepergam fortis (Demerol and Phenergan) good for immediate out of hospital post op period. no nausea - still demerol tho) Fiorocet/Fiorinal w, w/o codeine: Butalbitol is pretty addicting and tolerance grows quickly, creating withdrawal issues. agree with IV/IM demerol downplay: too "euphoric" and addicting.. toxic metabolites. No need for it over dilaudid. Fentanyl also good for surgical abdominal pain (not phenergan) control. Stadol and Nubain should probably never used Quote Link to comment Share on other sites More sharing options...
melcal Posted February 21, 2006 Share Posted February 21, 2006 VERY helpful, PACPhD. good stuff to know, especially as a soon-to-be graduating pa student. can that article be found online or pubmed? can we also make this thread a sticky? Quote Link to comment Share on other sites More sharing options...
andersenpa Posted February 21, 2006 Share Posted February 21, 2006 Did I miss any? Steroids for acute pain syndromes? Triptans/Ergots for migraine? I'm not an ED guy but these are used on an inpatient basis.... Quote Link to comment Share on other sites More sharing options...
BlocDoc Posted February 21, 2006 Share Posted February 21, 2006 Steroids for acute pain syndromes?Triptans/Ergots for migraine? I'm not an ED guy but these are used on an inpatient basis.... True, but the conditions for which these treatments are indicated are not specific to a particular environment (inpatient, outpatient, ED, out-patient clinic) -They work just as well as you might expect. Quote Link to comment Share on other sites More sharing options...
amanquee Posted February 21, 2006 Share Posted February 21, 2006 I worked in a peds unit with a lot of trauma, and Nubain was used pretty often. I know most providers for adults don't use this d/t lack of efficacy, but it seemed to work really well in the pediatric population. Amanda Quote Link to comment Share on other sites More sharing options...
Guest Slntwolf Posted February 21, 2006 Share Posted February 21, 2006 Narcotic antagonists/ Stadol - Does anyone actually still give this? I currently work in a pharmacy and only time I ever see Stadol is in nasal spray form and usually given to those with migraines and some are very addicted to it. I don't work in a hospital as of yet but think they use injectable form in ob/gyn for labor pain before an epi. This is a CE from a pharmacy times magazine but still interesting and related to opiod pain meds. https://secure.pharmacytimes.com/lessons/200507-01.asp Quote Link to comment Share on other sites More sharing options...
themadmedic Posted February 21, 2006 Share Posted February 21, 2006 I use Nubain somewhat regularly in the military side of practice and it seems to do well. The best aspect of this medication is that it is not controlled. I have better results that Ultram use in the outpatient population than you must, PhD. Toradol. Works for kidney stones. Works for post op pain control as a one time dose while closing. Quote Link to comment Share on other sites More sharing options...
rcdavis Posted February 21, 2006 Share Posted February 21, 2006 and toradol, along with voltaren, ophthalmic gtts for take home meds in corneal injuries/abrasions, works great. Quote Link to comment Share on other sites More sharing options...
BlocDoc Posted February 21, 2006 Share Posted February 21, 2006 This is a CE from a pharmacy times magazine but still interesting and related to opiod pain meds. https://secure.pharmacytimes.com/lessons/200507-01.asp This article is actually quite factual and very well done- I would recommend it ! I agree with many of the considerations illustrated. Thanks for posting it! Quote Link to comment Share on other sites More sharing options...
PACPhD Posted February 22, 2006 Author Share Posted February 22, 2006 I am not sure why my posting was moved. I hope whoever was responsible would move it back to the emergency medicine threads as it was meant solely in the context of acute pain management in the emergency department. This thread, I am assuming, is more geared towards long term pain management. Two totally different specialities. Thanks. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 18, 2007 Moderator Share Posted January 18, 2007 new one today- oral fentanyl...marketed as fentora in 100,200,400,600, and 800 microgram dissolving buccal tabs. this is really only for malignant pain folks. don't let someone convince you to write this for their acute back pain or you will be seeing lots of overdoses. I won't be writing for this in the e.d. and I would recommend that you guys don't either except by consultation with an oncologist. Quote Link to comment Share on other sites More sharing options...
Guest ER_PA Posted April 22, 2007 Share Posted April 22, 2007 Ever wonder why Motrin or Tylenol helps PEDS pt.s but not adults? They couldn't be drug seeking could they? I for one believe EVERY pain complaint (well at least for my first 2 or 3 shifts after graduation) Quote Link to comment Share on other sites More sharing options...
andersenpa Posted April 22, 2007 Share Posted April 22, 2007 They couldn't be drug seeking could they? Yes. I for one believe EVERY pain complaint (well at least for my first 2 or 3 shifts after graduation) You should, but keep the clinical setting in context- esp. for frequent flyers. Just my opinion, better to treat made up pain than ignore real pain.. Quote Link to comment Share on other sites More sharing options...
Guest ER_PA Posted May 14, 2007 Share Posted May 14, 2007 You should, but keep the clinical setting in context- esp. for frequent flyers. Just my opinion, better to treat made up pain than ignore real pain.. I was kidding.... I have a hard time believing any pt with pain that I can't physically see an injury. the "DSB" pt.s have ruined me. At least 50% of my time is spent weeding out these guys. something needs to be done and SOON! our heath care system supports the drug seekers with NO ID and NO insurance and those that do have insurance get stuck with $150 co-pays for getting their fracture or lac repaired while they where going to one of their 10 jobs to pay for the insurance premium. I would love to see a NATIONAL site that I can pull up someones name / DOB / SSN and see when, where, how many narcs or any med they have filled in the entire USA. If someone just had 120 Percocets filled yesterday then I would have a hard time believing that the "MOTRIN" just isn't helping his paper cut.:p Quote Link to comment Share on other sites More sharing options...
kittryn Posted May 14, 2007 Share Posted May 14, 2007 something I found very useful in pain management is lidocaine patches -- they come in patches ~ 5"X8", and you can cut them to fit various body parts. I've had pts w/ musculoskeletal pain who have found these very helpful, and it's totally topical. you can combine it with oral meds for stubborn MS pain. Quote Link to comment Share on other sites More sharing options...
goldenbodhi Posted May 15, 2007 Share Posted May 15, 2007 Our hospital removed Demerol from use on all patients due to complications. I very seldom give narcs for Migraine's as they cause as many headaches as they solve. Usually use tordol, imitrex, Compazine or decadron or combo of them. I used to use Roids for Sciatica and some back pain syndromes but this has very mixed and mostly low efficacy, per research. I think it helped me with a shoulder problem once. We actually have a Doc in our group that has received a commendation from the CO DEA for the number of arrests he has aided in for giving false information to a medical professional to obtain controlled substances. Pain management can be tough on the chronics but usually easy on the true acute problems. I LOVE MOTRIN 800mg for my self and for patients, It actually treats most of the problems we use it for and not just mask the pain. Quote Link to comment Share on other sites More sharing options...
Contrarian Posted May 15, 2007 Share Posted May 15, 2007 ... [brevity edit]...I would love to see a NATIONAL site that I can pull up someones name / DOB / SSN and see when, where, how many narcs or any med they have filled in the entire USA... [brevity edit]... The insurance companies are working on it... here Quote Link to comment Share on other sites More sharing options...
Guest ER_PA Posted May 16, 2007 Share Posted May 16, 2007 Our hospital removed Demerol from use on all patients due to complications. I very seldom give narcs for Migraine's as they cause as many headaches as they solve. Usually use tordol, imitrex, Compazine or decadron or combo of them. I used to use Roids for Sciatica and some back pain syndromes but this has very mixed and mostly low efficacy, per research. I think it helped me with a shoulder problem once. We actually have a Doc in our group that has received a commendation from the CO DEA for the number of arrests he has aided in for giving false information to a medical professional to obtain controlled substances. Pain management can be tough on the chronics but usually easy on the true acute problems. I LOVE MOTRIN 800mg for my self and for patients, It actually treats most of the problems we use it for and not just mask the pain. I love motrin too but you obviously don't work in my neck of the woods even Vicodin will get the DSB's screaming and threatening to kill you (serious) I have had so many threats on my life it's almost got me to the point of if they don't care about the addiction why should I? I am no longer listed in the phone book b/c of this. What has this would come too?......... :eek: Quote Link to comment Share on other sites More sharing options...
Guest ER_PA Posted May 16, 2007 Share Posted May 16, 2007 I try to do alot of Regional blocks for pain Dental, Digital, Hand, Foot blocks work great! Quote Link to comment Share on other sites More sharing options...
jmj11 Posted May 16, 2007 Share Posted May 16, 2007 My care plan for migraine patients in the ER. Remember the vast majority of migraine patients hate having migraines and hate even more coming to the ER. They are sick. They have a disease and are not "drug seeking" or malingering. A small percentage (whom you get to know very well) mis-manage their own headaches by seeking a quick fix of a narc rather than working hard on prevention. An even smaller percentage are making up their headaches to get narcs. They come in at other times for "back pain" "renal stones" "dental pain." But assume that they are the first type (nice people with a bad disease) until proven otherwise. Up to three times per month, give them whatever you want. I suggest reglan 10 mg followed by DHE 45 1 mg . . . then if no response in 30 minutes narc of choice (IV or IM) but never, ever take-home narcs. Another good option is IV Valproate (1 gram- Depacon). If headache more than three days (status migraine) add 100 mg hydrocortisone or solu medrol est. 50 mg. Other options are toradol, IV droperidol or IV compazine. Never, ever give narcs (IM, IV ) more than three times in a month. Send my patients back to me ASAP if they aren't doing well. If they are not my patients and they are in the ER too often, send them to me. And please do not call me in the middle of the night just to make sure I know that "Your patient is in my ER." Especially don't call me to tell me that "Your patient has gotten eight shots of Demerol or Dilaudid this month" . . . when my care plan always says to never give them more than three. If they get more they will come more. Mike Quote Link to comment Share on other sites More sharing options...
Guest canjosh Posted July 17, 2007 Share Posted July 17, 2007 Our hospital removed Demerol from use on all patients due to complications. I very seldom give narcs for Migraine's as they cause as many headaches as they solve. Usually use tordol, imitrex, Compazine or decadron or combo of them. Anybody giving Magnesium sulfate IV as part of their migraine cocktail? Quote Link to comment Share on other sites More sharing options...
medic25 Posted July 17, 2007 Share Posted July 17, 2007 Anybody giving Magnesium sulfate IV as part of their migraine cocktail? I tried it once a couple of years ago, with no real success. I'll usually start with Compazine or Reglan along with Toradol, and then move on to opiates. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 17, 2007 Moderator Share Posted July 17, 2007 I tried it once a couple of years ago, with no real success. I'll usually start with Compazine or Reglan along with Toradol, and then move on to opiates. I do something like this as well. round 1 : reglan 10/benadryl 50 + toradol 30 round 2 ativan 1 round 3 narcotics Quote Link to comment Share on other sites More sharing options...
Vandy Posted July 17, 2007 Share Posted July 17, 2007 new one today-oral fentanyl...marketed as fentora in 100,200,400,600, and 800 microgram dissolving buccal tabs. this is really only for malignant pain folks. don't let someone convince you to write this for their acute back pain or you will be seeing lots of overdoses. I won't be writing for this in the e.d. and I would recommend that you guys don't either except by consultation with an oncologist. I believe this replaced the Actiq lollipop - I've heard of kids dying after getting ahold of grandma's "lollipop," so I'm glad to see they now have the dissolvable tab. Also, remember not to give any of those opioid agonist/angatonist (Stadol, Nubain, etc) to someone on chronic opioid therapy...they'll go through withdrawal and they'll be cussing you like crazy! I see a lot of orthopods prescribing the old NSAID's Voltaren & Cataflam for pain and they appear to be quite effective. Just remember they have a Black Box Warning and require monitoring of LFT's. Quote Link to comment Share on other sites More sharing options...
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