Parenteral Opioids in Migraine . . . What Does it Mean?

[jmj11]

The post about ER treatment of Migraine, which floated back to the surface today from the depts, reminded me of another question. I had two phone calls this week about patients 1) coming into the ER for a pain shot and 2) a patient coming into her PCP's office for the same.

 

In both cases, the views of the providers were quite . . . I thought . . . skewed.

 

So here is a question for you (and a survey I hope). Of course we all know the frequent fliers who have very poor care for their migraines and show up at the ER all the time. But let me give a different type of case.

 

If a patient is being followed by a headache specialist, under aggressive treatments for prevention, and home care, but they still come into the ER or the PCP office 1-2/month for parenteral treatment with opioids, how do you interpret this behavior? See the survey.

[EMEDPA]

1-2 x/mo is a bit much....a few times/yr i can see but more than that i think there is a compliance issue going on...i have a family member with severe migraines. In the last 15 years she has been to the er 3 times...mostly for intractable n/v. Received narcs 1 of 3 visits.

[winterallsummer]

From the perspective of a PCT who has worked nearly 4 years with CD patients, there is no where near enough information in the original post to decide if the pt is a drug seeker or not. There is a lot more to the story. What other behaviors does the pt show that might help make a decision? Is the pt going to the same ER and only 2x/month for the shot or are they visiting multiple ERs? Is there any sort of pattern regarding the times they go in for a shot?

[jmj11]

From the perspective of a PCT who has worked nearly 4 years with CD patients, there is no where near enough information in the original post to decide if the pt is a drug seeker or not. There is a lot more to the story. What other behaviors does the pt show that might help make a decision? Is the pt going to the same ER and only 2x/month for the shot or are they visiting multiple ERs? Is there any sort of pattern regarding the times they go in for a shot?

 

The patient is not visiting any other ER or clinic. They have an aggressive home treatment program, not only preventative medications but self-injection of DHE-45 + 3 Dilaudid 3 MG suppositories for rescue per month and has a narcotic contract with their headache care giver.

[Joelseff]

The patient is not visiting any other ER or clinic. They have an aggressive home treatment program, not only preventative medications but self-injection of DHE-45 + 3 Dilaudid 3 MG suppositories for rescue per month and has a narcotic contract with their headache care giver.

 

I would refer to the pain contract hopefully established with the HA specialist.

 

Sent from my HTC MT4GS using Tapatalk

[eonbluemantra]

The patient is not visiting any other ER or clinic. They have an aggressive home treatment program, not only preventative medications but self-injection of DHE-45 + 3 Dilaudid 3 MG suppositories for rescue per month and has a narcotic contract with their headache care giver.

 

Under these circumstances I went with option #4

[physasst]

1-2 x/mo is a bit much....a few times/yr i can see but more than that i think there is a compliance issue going on...i have a family member with severe migraines. In the last 15 years she has been to the er 3 times...mostly for intractable n/v. Received narcs 1 of 3 visits.

 

Agree with this. 1-2 visits per month is too much. They wouldn't likely receive narcs from me.

 

Depakote, DHE, Toradol, Compazine (if they ever make any more), etc.etc.etc.

 

They would likely be flagged in my ER.......

[jmj11]

Agree with this. 1-2 visits per month is too much. They wouldn't likely receive narcs from me.

 

Depakote, DHE, Toradol, Compazine (if they ever make any more), etc.etc.etc.

 

They would likely be flagged in my ER.......

 

Mike, speaking of your ER, my newborn grandson just went through your ER about two hours ago. He is admitted upstairs. Possibly RSV.

[physasst]

Mike, speaking of your ER, my newborn grandson just went through your ER about two hours ago. He is admitted upstairs. Possibly RSV.

 

Jeepers, sorry to hear Mike....

 

Hope he's okay. I'm at home today, working on family stuff and research papers....

 

Mike

[jmj11]

I want to discuss this situation a little further and raise some points and I will be back to add more later if there is interest.

 

In the US about (combining men and women) about 12.5% have migraine headaches. Depending on the study, about 3-4% have chronic migraine, meaning at least 15 days per month of migraine headaches. Of the chronic migraine group (and you can mix in a few from the general migraine category) there are about 25% that are considered "refractory." The working definition of "refractory" is:

 

Primary diagnosis A. ICHD-II migraine or chronicmigraine

Refractory B. Headaches cause significant

interference with function or quality

of life despite modification of triggers,

lifestyle factors, and adequate trials of

acute and preventive medicines with

established efficacy

1. Failed adequate trials of

preventive medicines, alone or in

combination, from at least 2 of 4

drug classes:

• Beta blockers

• Anticonvulsants

• Tricyclics

• Calcium channel blockers

2. Failed adequate trials of abortive

medicines from the following

classes, unless contraindicated:

• Both a triptan and DHE

intranasal or injectable

formulation

• Either nonsteroidal

anti-inflammatory drugs or

combination analgesics

Adequate trial Period of time during which an

appropriate dose of medicine is

administered, typically at least

2 months at optimal or

maximum-tolerated dose, unless

terminated early due to adverse effects

Modifiers 1. With or without medication overuse,

as defined by ICHD-II

2. With significant disability, as defined

by MIDAS 11

The writers of a recent article on the is concept of refractory migraine gave the follow summary:

 

SUMMARY

There are 2 different levels of RM patients.There

are those at the level of primary care who may have an

inaccurate, competing (medication-overuse), or

comorbid (anxiety) diagnosis that may be undetected,

making successful treatment challenging.Attention to

lifestyle (eg, sleep hygiene, caffeine, alcohol) and

disease-modifying risk factors (eg, obesity) and

comorbid illnesses (eg, depression, anxiety), utilizing

nonpharmacological techniques (stress-reduction

techniques, cognitive–behavioral therapy), optimizing

acute and preventive treatments, and judicious use of

interventional techniques (eg, occipital nerve block)

will result in successful outcomes for many “refractory”

patients – assuming time, patience (physician

and patient), close follow-up, and a therapeutic alliance.

There remains a small group of truly refractory

patients who are not responsive even to a skilled multidisciplinary

approach using the myriad of drugs and

techniques at the disposal of the most highly qualified

physicians.While there are a variety of reasons for this,

from the sublime (eg, secondary gain) to the behavioral

(Axis II disorders), to the influence of gonadal

sex steroids and genetic heterogeneity in pain modulation

and analgesic response, to the complex diseasedriven

(central sensitization) or drug-induced

(opioids) changes in central nociceptive pain systems,

even these patients may benefit from a chronic pain

rehabilitation program enabling them to improve

their level of function and quality of life while reducing

the “suffering” element of chronic pain. Future

research will undoubtedly bring about an era where

management and chronic pain prevention will inevitably

be driven by genotype-specific treatments.

 

 

My clinic covers an area of about 650,000 people. Out of that group, roughly 19,000 have chronic migraine. Out of the region I cover, about 5,000 have truly refractory migraine. Now, looking at the above summary, of the 5,000, if you eliminate those who contribute to their refractory nature by the overuse of pain medications (medication over use headache syndrome), psychogenic comorbidities and etc., you are still left with about 2,000 people in my area whose lives are extremely compromised by their migraines and have failed aggressive treatments by knowledge headache specialist (namely us or the other headache clinics in Seattle) and have done everything possible to get better but due to no fault of their own, they can not.

 

When I started this post I had just had a conversation with an ER doc about one patient and a NP about a second patient. To keep this from getting too long I will talk about the later.

 

This lady is 38 years old. We are the third headache clinic to follow her. I will describe the treatments she has endured over the past 15 years:

 

Preventative Medications:

 

TCAs (at least three different ones)

mirtazepine

propranolol

nadolol

verapamil

topiramate

zonisamide

valproic acid

pregabalin

gabepentin

nemantine

cyperheptadine

candesartan

 

and presently I have her on a combination of methergine, zonisamide and nadolol.

 

I will add that she has been on several other combinations of the above assortment of medications and she has tried them all at therapeutic doses.

 

She has had the following procedures:

 

occipital nerve blocks,

trigger point injections,

facet joint blocks and ablations,

and Botox. I am also doing Botox again.

 

She has tried the following abortive medications:

 

All oral triptans,

Ergotamine tartrate,

DHE 45 via IV infusion and still uses it SQ at home for her moderate level headaches.

dihydroergotamine nasal spray

IV therapies: virtually all neuroleptics, depacon, magnesium + many others.

She has tried virtually all analgesics. I presently give her 3-3 MG dilaudid suppositories per month.

 

 

CAM:

chiropractic,

Acupuncture,

supplements

 

Mental Health:

years of biofeedback, psycho (cognitive) therapy.

 

 

With that said, she still has headaches about 20 days per month. Of those, 10 are moderate level. Of the 10 which are severe, she is able to manage 7-8 them with the combination of DHE-45 and or Dilaudid suppositories or sometimes she will still use sumatriptan (by SQ if she can catch it early). She still has 3 headaches per month that are extremely severe and comes on rapidly (usually awakens with them). If she does not get an IM injection of Demerol or Dilaudid, she will have to miss her work. The company is about to lay her off if she misses more work. She is the sole provider for her family.

 

The NP on the phone made two remarkable statements. 1) She can look at the patient and tell that she is not in real pain (if anyone on this earth can judge the pain of someone else by looking at them, that provider deserves to win the Nobel prize in medicine because such talent would be extremely remarkable as researchers have been looking for decades for a way to objectively measure pain, using many techniques, including fMRI and PET and can not). and she said 2) obviously the patient is just a drug seeker and the reason she isn't getting better is that she is in rebound.

 

My response to her was, so . . . despite all the effort this patient has put into getting better, she is really just faking her headaches to get drugs? Surely she could just buy them off the street much, much, much easier that what she has done just to fake headaches. Secondly Since I was a co-author on the original article, introducing the concept of "Rebound Headache" back in 1983, I will say with the full support of the world wide headache community, that if you add up all the symptomatic medications she's on, you can not demonstrate that she is having rebound or is in rebound.

 

I also told her that headache sufferers have the greatest discrimination of any patient in any setting. While there are patients (as mentioned in the beginning) who contribute to their refractory nature, there are many good people who suffer from horrible pain due to a genetic predisposition (and sometimes injuries) and they had given heroic measures to get better and still do not. It is a great injustice to them to assume they are "drug seekers", or nut jobs just because the treatments we have tried don't work.

 

This patient I was just talking about lives on a remote island and her only choice for parenteral meds is to visit her PCP's office. Each time she comes in, it pisses them off.

 

So think about that the next time you make huge assumptions, lumping all headache patients in the sample stereotype.

 

My next step is to set her up to do home Demerol IM injections. I wish there had been a better way, but this is reality.

[taotaox1]

A few seekers get some drugs they don't really need........ but people with serious, life destroying suffering have a second chance at life

 

or

 

Less drug seekers get drugs............. but also some people with real suffering are sentenced to a life of horrible pain and suffering.

 

 

Seems like an easy choice to me. Great write up JMJ.

 

Sounds like you are doing good work helping people that really need it.

[ventana]

Mike

Has she tried methadone? (not that I have any experience in HA - I had one HA patient on 80mg of methadone with a similar Hx though many many regional and national ha specialists for 20+ years) and the methadone was the only thing that worked - he was a college professor and reliable and far smarter then me on his own HA history and management

 

 

 

You bring up a very interesting and challenging point - when a specialist is truly far and above any type of local knowledge and the ER has to pinch hit for opiates....... very challenging situation and honestly you need to do everything possible to keep this person out of the ER as she does not belong there. (IMHO) This is a know effect and even a know treatment - it is not an emergency and the ER should not be a dispensary - My biggest concern is that she will not get the medicines that she deserves and have to run the gauntlet of providers every time she has to go - she will get flagged, harassed, made to feel like an addict and questioned way more then needed. This is just the fact of life in the ER right now and honestly we have to do better at not handing out opiates and benzo's to every one claiming a headache or backache in the ER - this however is not fair to your patient, BUT you patient is not experiencing an emergency.....

 

two thoughts - do an in-service to the ER providers about this patient OR possibly get her set up as an EOP (emergency outpatient procedure - this is where a community doc writes the order and sends the patient in for the med through the ER but they are never seen or triaged by the ER - basically the ER is the infusion room - we do it for ABX and Chemo all the time - avoids the ER copay and solves the logistics of ER evaluation and bias)

Set her up somehow with the meds at home (scary proposition but maybe doable)seems like the very nature of injectable schedule II drugs would preclude them from being kept at home of a non-hospice patient - maybe a trade out program where she has one injection at the house and can trade the empty syringe to you (or the pharmacy) for a new one so you keep exact control over the use......

 

just thoughts and honestly a very difficult position that is unique to your exceptional level of care and knowledge.......

[jmj11]

Mike

Has she tried methadone? (not that I have any experience in HA - I had one HA patient on 80mg of methadone with a similar Hx though many many regional and national ha specialists for 20+ years) and the methadone was the only thing that worked - he was a college professor and reliable and far smarter then me on his own HA history and management

 

 

 

You bring up a very interesting and challenging point - when a specialist is truly far and above any type of local knowledge and the ER has to pinch hit for opiates....... very challenging situation and honestly you need to do everything possible to keep this person out of the ER as she does not belong there. (IMHO) This is a know effect and even a know treatment - it is not an emergency and the ER should not be a dispensary - My biggest concern is that she will not get the medicines that she deserves and have to run the gauntlet of providers every time she has to go - she will get flagged, harassed, made to feel like an addict and questioned way more then needed. This is just the fact of life in the ER right now and honestly we have to do better at not handing out opiates and benzo's to every one claiming a headache or backache in the ER - this however is not fair to your patient, BUT you patient is not experiencing an emergency.....

 

two thoughts - do an in-service to the ER providers about this patient OR possibly get her set up as an EOP (emergency outpatient procedure - this is where a community doc writes the order and sends the patient in for the med through the ER but they are never seen or triaged by the ER - basically the ER is the infusion room - we do it for ABX and Chemo all the time - avoids the ER copay and solves the logistics of ER evaluation and bias)

Set her up somehow with the meds at home (scary proposition but maybe doable)seems like the very nature of injectable schedule II drugs would preclude them from being kept at home of a non-hospice patient - maybe a trade out program where she has one injection at the house and can trade the empty syringe to you (or the pharmacy) for a new one so you keep exact control over the use......

 

just thoughts and honestly a very difficult position that is unique to your exceptional level of care and knowledge.......

 

I agree that there is a very limited place for methadone or other chronic opioids in refractory migraine . . . very limited. The reason is, opioids simple cover up the pain and do nothing about the disease state. Most of the time the disease state is treatable. Daily opioids will turn a treatable migraine disorder into a refractory one, so it is only a means of last resort. When we get to that point I send patients to a pain clinic with expertise in chronic opioids and is a designated "pain clinic."

 

There are some complications, such as in this patient's case, where she lives on a remote island. That island does not have an ER but a PCP clinic that offers after hours service for emergencies. She only goes in during business hours. It pisses them off every time she comes in . . . for reasons, which are not clear as they are PCP.

 

I have one patient for whom I have home parenteral opioids but it was complicated. He was visiting the ER once a month and we went through the other treatments (mentioned previously) and did not work. So eventually I sent up with his pharmacy an IM injection of Demerol once a month. He has to pick up the dose, and then his aunt, an RN gives it to him.

 

None of the local ERs allows me to write orders. I use to be able to do that when I had privileges at one hospital. I've tried to set up out patient (after hours) treatments in various infusion centers. I thought I had it done at one hospital. The ER was on board. The infusion center was on board. But then the hospital admin met and killed the idea. Simply, they figured that their reimbursement for migraine treatment would be much higher in the ER setting than in an infusion center.

 

The perfect world was when I worked at Mayo Clinic. We had a 24-7 infusion center. For the patients we managed, we had standing orders for their meds, which we renewed monthly. The patients loved it, the ER loved it and etc.

 

My take home message is that assuming patients who show up for a pain shot for migraine are "drug seeking" is an injustice to many sincere patients. There have been ancient stereotypes and biases against headache sufferers that don't exist in other disease states.

[winterallsummer]

IMHO, the patient is likely not drug seeking. There may be a psychological component, however I do not think this is the underlying problem. That is, the patient may have developed the mindset of "headaches are ruining my life, when I have one my life is terrible, thus even a "manageable" one I must treat at the ER". However, to say she is outright drug seeking...

 

I have worked with many CD patients as my career as PCT (start PA school in summer) and have seen people go through things you would never expect to get drugs. However, if your patient were truly an outright drug seeker, she takes the cake. Aside from buying illicit drugs (some people who will do outrageous things including endagering themselves still do not justify this for some reason), she could have much more easily faked fibromyalgia, chronic back pain, you name it, and gotten much "better" drugs as far as pleasure seeking is involved, than faking headaches. I do not see how botox is beneficial for her if she is not having headaches.

 

Some clinicians, perhaps the NP you mentioned, are very aggressive when it comes to thinking someone is a drug seeker. They may have been fooled in the past or have some personal vendetta against drug seekers, and as a result they too easily label someone a drug seeker. Just because she is annoyed with caring for the patient does not make the patient a drug seeker. The mere fact that she is so confident shows she has probably not fairly assessed the patient. So taking these things into consideration - and the fact that there may be a psychological facet to the problem, albeit not the major underlying problem - I am voting the "no fault of their own" option.