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Headache - Morphine - No No

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I've seen two new consults lately managed by FP PAs who had the same story. I hope those here would know better. Both times a patient develops a new severe headache. The PA tries sumatriptan and it doesn't work. Has no clue what is causing the headaches so they put them on daily morphine as the next step, getting them up to 60-120 MG per day for a few months. Then the PA realizes that they have made a big mess and sends them to me with just enough morphine to get them to my front door and tells the patient that they are done prescribing it.

 

This is called dumping.

 

I've never prescribed morphine in 31 years of working in headache and I'm not about to start with your patient.

 

So, if you don't know what the kind of hell of headache it is, make the referral at that juncture. Don't fill them up with morphine, get them hooked, and then send them to me.

 

Just venting. Honestly haven't seen this with any MDs in a long time. I don't know why it is more common with PAs.

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IMO PAs don't get nearly enough pain prescribing pharmacology instruction and those who have gotten decent instruction are more likely recent grads since pain management was added to ARC-PA accreditation standards. The vast majority of PAs don't do residencies so unless they've learned from a good mentor who does pain management rationally and responsibly they are likely doing it badly.

Take this opportunity to reeducate them and suggest they get some specific opioid-prescribing instruction or don't do it at all.

I *****ed and moaned about having to so SC's Controlled Substance Prescribing course (16 hr CME and about $500 at the time, mandatory for DEA privileging in SC) especially as an experienced PA from Oregon where I had schedule II privileges (but had rarely used them). I learned a LOT I didn't know and I think there's benefit in this kind of continuing Ed for the privilege of prescribing potentially lethal therapies.

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Morphine for a headache? Wow. I'm no headache expert but at least start with figuring out whether they're already taking stuff that's causing rebound headaches and try to educate the patient that pain medications whether OTC are more often than not the cause of lots of headaches. Get them started on a prophylactic medication and if they're still not improving then refer.....

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Guest Paula

I do not understand how one can jump from sumatriptan to morphine for a headache? I just took a pain management course too and it was quite interesting. I still have lots to learn. I was taught to never use (or rarely use) opioids for HAs.

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Morphine? Seriously? WTH? I am sure there is more to this story... Tell me u called these guys and gave them more than an earful...i want details. We police our own comes to mind

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It is not just PAs with this issue

 

I worked in chronic pain and by far the greatest offenders is older doc's who have not stayed current, closely followed by FMG who don't understand the pharm

NPs are next with some crazy prescribing with out a clue on controlled subs

pa seemed to be a the bottom - likely due to smaller numbers in the local area

 

 

Honestly they need to have MANDATORY DEA training on this issue and FLAG over prescribing providers this is happening in RI and Florida is actually going after licenses for this.....

 

 

This is not a joke, this is REALLY BAD for the patients

 

 

 

So the lesson - DO NOT GIVE CHRONIC opiates if you don't know EXACTLY what you are doing......

 

 

The ER and UC folks - if there is not TANGIBLE PLACE YOUR HANDS ON THE SOURCE OF PAIN - DON'T give them narcotics!

 

Motrin for tooth pain

Flexeril or skelaxin for back pain

 

nasty ankle sprains size of grapefruit - yeah give some narc but for the "i twisted my ankle" that is totally normal in appearance - motrin and ICE

 

 

As for the chronic back pain - PCP's can and do sometimes write for small PRN scripts but NEVER give this in the ER enviro as you have ZERO ability to follow up and follow along with the patient - all you are doing is feeding the devil!

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Agree completely with Ventana- I see inappropriate prescribing more with physicians than midlevels, but I'm sure this is more of a selection bias.

 

Percocet and dilaudid are the bane of my existence. They are excellent pain relief medications....in the right setting. In the wrong hands and in the wrong situation they are truly evil.

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Migraineurs who visit the ER for headache are often given opiates simply due to time constraints as well as issues of laziness. Basically, the headaches get them hooked to the point where they end up returning either for the headache or craving/pain from withdrawal. I remember on my ER rotation, the PA gave Dilaudid to a patient who was swinging her legs in my testing of her "bad back" and smiling and laughing while she talked. The PA gave her Dilaudid. I asked her why she did that. "Oh, it's the holidays" (with a lighthearted laugh). Providers like that simply. Do. Not. Get. It. They have no idea of the potency of these medications or their dependency and abuse issues. I personally was given Dilaudid once in the ER for severe pain related to kidney stones (BP was 220/140, diaphoretic, vomiting, could barely make it into the rig) and so I know first-hand of the relief that is available from that drug. But for headache or smiling and laughing "back pain"? HELL. NO.

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I work in UC and nobody gets narcs for HA. NOBODY. We try NSAIDs in anyone who can tolerate them - read: anywhere near normal renal function, age <75. This is what I teach to my students as well. If it's an older person or someone with a true NSAID allergy, renal failure, or bleeding ulcer then we'll try vistaril or DHE. I personally really liked the results of 1mg of DHE with 10mg reglan for migraineurs with n/v. Works wonders, but it costs the practice $50 to give DHE (pharmacy charges us $80 and we can only charge the Pt $30) - so we no longer stock it at my request (if we have it, I'll use it and get in trouble with the bean counters).

 

On a side note, what is your opinion on Fioricet and Fiorinol for chronic HA?

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fioricet/fiorinal cause a lot of rebound effect.

in folks you have time to get an ekg on to r/o long qt droperidol/inapsine is still a great drug. yes, there is a "black box warning" but that's why you cover yourself with the screening ekg.

it's not many folks who still have a significant h/a after 2.5-5 mg of inapsine + 50 mg of benadryl IM. along the same lines as reglan/benadryl or compazine/benadryl but I think the inapsine tends to work better if you have the time to jump through the hoops to give it. if not(dept crazy, charge nurses screaming for d/c's asap) then reglan/benadryl/toradol.

I almost never give narcs for h/a. sometimes will use nubain in the narcotic naive pt who has failed everything else.

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This works in the PACU for me all the time when a migraine comes up:

1. Apply Nonrebreather at 12-15LMP

2. Place a butterfly and give a SLOW IV push of 2-3grams of IVMgSo4

3. If needed have the patient tilt their head over the side of the gurney nose pointed to the air and drip in a small amout of 2% lido drawn up in a syringe

4. Return a delighted patient to their Primary care or Neuro PA!

 

try it!!!

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Guest JMPA
This works in the PACU for me all the time when a migraine comes up:

1. Apply Nonrebreather at 12-15LMP

2. Place a butterfly and give a SLOW IV push of 2-3grams of IVMgSo4

3. If needed have the patient tilt their head over the side of the gurney nose pointed to the air and drip in a small amout of 2% lido drawn up in a syringe

4. Return a delighted patient to their Primary care or Neuro PA!

 

try it!!!

 

2-3 grams? really?

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2-3 grams? really?

 

I'll also periodically use mag sulfate for migraines; there is little risk and some patients will get real benefit. I used it this week on a patient who was still in significant pain after reglan, toradol, Benadryl and decadron. An hour later he was sleeping like a baby and woke up ready for discharge.

 

http://www.ncbi.nlm.nih.gov/m/pubmed/11251702/

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Wow... Shocked about the morphine! I would never. I had a patient come in today with a 13-year history of migraines (epidural gone wrong) and has been prescribed Demerol as a first line treatment. She never even trialed triptans or prophylaxis. My SP said that's an "older practice"....

 

 

Sent from my iPhone using Tapatalk - now Free

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Just to chime in as a person about to graduate... we were trained decently in opiod use and I can't imagine any on my classmates doing what op said happened.

 

Sent from my PC36100 using Tapatalk 2

 

 

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Guest jb555

It happens a LOT. I've had patients come in on Oxycontin because they failed one triptan from their primary care doctor. Then I have to explain that in our clinic we do not prescribe ANY opioids and that we are starting from scratch with medication trials. Many people are very happy about this because they want to avoid potentially becoming addicted, obviously some patients are not happy at all. I've started becoming somewhat of the headache provider in my area and doctors are finding out, so they're sending patients much earlier, thankfully. It's really only been doctors, although there's not many PAs in my organization. 

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Had a patient last night close to shift change; many many visits to the ER for "Migraine Headaches" Same presentation this time. States they always give her Dilaudid 1-2mg. States that she already tried Maxalt at home with no relief.

 

I refuse and gave her The benadryl, reglan, toradol, IVF, decadron. 

 

This fails, and I started her on Depacon 300mg IV over 1 hour.

 

Ofcourse....This doesn't work. 

 

At this point it signed the patient over, The provider who took over for me gave her dilaudid 1mg IM and was sent home.

 

It is a very very frustrating scenario we all face nearly every day.

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Had a patient last night close to shift change; many many visits to the ER for "Migraine Headaches" Same presentation this time. States they always give her Dilaudid 1-2mg. States that she already tried Maxalt at home with no relief.

 

I refuse and gave her The benadryl, reglan, toradol, IVF, decadron. 

 

This fails, and I started her on Depacon 300mg IV over 1 hour.

 

Ofcourse....This doesn't work. 

 

At this point it signed the patient over, The provider who took over for me gave her dilaudid 1mg IM and was sent home.

 

It is a very very frustrating scenario we all face nearly every day.

 

I gave up on withholding narcotics to most drug seekers in our ER. The problem is that most of the docs are more than happy to pull out the dilauded if it gets the patient out the door with quicker with minimal fuss. It's not worth the battle. What frustrates me the most are the patients who fake serious, life threatening emergencies to get narcs. There have been times when I have wanted to slap some of these patients across the face. I've had to sometimes excuse myself, walk out of the room and calm myself down before 

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I gave up on withholding narcotics to most drug seekers in our ER. The problem is that most of the docs are more than happy to pull out the dilauded if it gets the patient out the door with quicker with minimal fuss. It's not worth the battle. What frustrates me the most are the patients who fake serious, life threatening emergencies to get narcs. There have been times when I have wanted to slap some of these patients across the face. I've had to sometimes excuse myself, walk out of the room and calm myself down before 

You've seen http://www.craigslist.org/about/best/sfo/301345524.html, I hope?

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I gave up on withholding narcotics to most drug seekers in our ER. The problem is that most of the docs are more than happy to pull out the dilauded if it gets the patient out the door with quicker with minimal fuss. It's not worth the battle. What frustrates me the most are the patients who fake serious, life threatening emergencies to get narcs. There have been times when I have wanted to slap some of these patients across the face. I've had to sometimes excuse myself, walk out of the room and calm myself down before 

 

Based upon your post in another thread about a mistake you made and what you describe above, I think you have a poor practice environment to work in.

 

Providing narcotics to drug seekers is a violation of your DEA license. Ethically you are responsible for contributing to the social chaos in your community. If all the other providers in this ED are practicing this way, they are not practicing medicine. They are acting as predators on susceptible members of the community just like drug dealers do, there is just a more indirect payment process.

 

Eventually your state medical board and the DEA will catch on that your ED is an easy place to get controlled substances. The pendulum has swung the other way on opiates and these 2 entities will drop the hammer on overprescribing and unjustified prescribing. Just a matter of time. The local pharmacies and law enforcement already know, they just have to get someone to listen to them. Best not to get judged guilty by association. 

 

G Brothers PA-C

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Had a patient last night close to shift change; many many visits to the ER for "Migraine Headaches" Same presentation this time. States they always give her Dilaudid 1-2mg. States that she already tried Maxalt at home with no relief.

 

I refuse and gave her The benadryl, reglan, toradol, IVF, decadron. 

 

This fails, and I started her on Depacon 300mg IV over 1 hour.

 

Ofcourse....This doesn't work. 

 

At this point it signed the patient over, The provider who took over for me gave her dilaudid 1mg IM and was sent home.

 

It is a very very frustrating scenario we all face nearly every day.

Dont sign these patients out.

Give them the treatment you feel is justified and discharge them.

They can go to another ED or see their PCP.

You could also take a leap and ask them if they have an opiate problem and need treatment.

I do this several times a week to month. 

Funny how these patients will not return when they meet an a reasonable treatment plan vs getting what they demand.

G Brothers PA-C

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