What regimen can I give a patient going through opiate withdrawal? 

This is the typical cocktail our psychiatry consultants recommend:

  • Robaxin 500-700 mg q6h prn muscle cramps
  • Bentyl 50 mg prn abdominal pain
  • Clonidine 0.1 mg prn anxiety, hold for systolic blood pressure <90
  • Hydroxyzine 50 mg q6h prn anxiety or insomnia
  • Kaopectate prn diarrhea

Always make sure to check a tox screen to make sure they’re not going through concurrent alcohol or benzo withdrawal!

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What can I give an opiate user or IV drug user for acute pain?

Imagine this scenario: you get a patient transferred from the surgery service. You glance at her home meds and with a flash of dismay, see 60 mg oxycontin BID with 10 mg oxycodone q4h PRN pain for chronic back pain. She just had hip surgery. What do you prescribe for breakthrough pain?

Or this: you are caring for a patient admitted for aspiration pneumonia. Although his breathing seems fine, he complains about the uncomfortable bed and requests something for pain. His social history notes that he currently buys Percs on the street and has used cocaine in the past. Initial doses of 5 mg oxycodone don’t seem to work, and he demands more and more. The nurses grumble about his neediness. What do you do?

I am, despite my bitterness and tough talk, an idealist and softie. I mean, I want to spend my professional life figuring out chronic abdominal pain and treating patients with malabsorption, dysmotility, and postsurgical anatomy. But in my daily practice, I have several fears when prescribing narcotics for inpatients:

  1. I’m feeding into an addiction. Giving them pain meds will make them worse off in the long run.
  2. They are taking advantage of me. They are lying to me or being nice to my face but laughing behind my back.
  3. When they realize they can get whatever they want, they’ll invent more excuses to stay.

 

Acknowledge these fears. Then let go.

What I’ve come to realize is that despite the patients who burn you, pain is real. Pain may stem from many different sources (deconditioning from being morbidly obese, psychiatric disease, dyspnea, social chaos, nerves that are wired differently and a low pain threshold). We may make us think, c’mon, there is NO way you are actually in that much pain…but they do need SOMETHING treated. Often people just don’t have enough insight to tell you exactly what that is. So your first formulation should be: is this actually pain? Is it anxiety? Is it fear at having to return to an abusive partner? Is it poor coping skills/functional status/dementia? Pain meds are not the only answer.

A final point: in those patients who want to be hooked on pain meds, make up stories, and manipulate the system, isn’t it sad that they would waste their lives trying to get addicted? A patient like this probably needs psychiatric help.

But sometimes you do need pain meds for people with complex pain histories. For instance, like patient #1 above, post-surgical patients have a really real reason to have pain: they just had freaking surgery! Many of your patients may have DEPENDENCE but not be ADDICTED. If you have a patient who is already on oxycodone, like #1 above, it’s a no-brainer they’ll require more than 2.5 mg oxycodone q6h.

NB: You should always make sure the whole team, including nurses, psychiatrists, pain specialists, etc are on the same page about an individual’s regimen. Here are some strategies I’ve seen used successfully:

  • Build trust with your patient and taper down gently. When you acknowledge the validity of your patient’s story and show that you care about them as a person, they are much more willing to listen to your suggestions–like, “how about we not do the extra IV dilaudid because I think you’re ready to try the pills? I really want to see you make progress.” In my experience this really separates the people in real pain from the people who have secondary gain.
  • Make sure you have a good non-narcotic foundation. Put people on standing Tylenol. Use flexeril if they specifically have spasms. Use lidocaine cream over painful joints. You wouldn’t believe how much relief a heat pack can give.
  • Use the appropriate meds for pain-like symptoms: benzodiazepines for anxiety, low-dose antipsychotics for agitation or insomnia, etc.
  • Start the patient on standing pain medications q3-4h instead of PRNs. Relying solely on PRNs is like putting a diabetic only on sliding scale insulin. If they ask for more, increase by 25% at a time until they are satisfied.
  • If one opiate isn’t working, try another. For some reason, different people respond differently to oxycodone or dilaudid or morphine…cross-tolerance is variable, but you can try using an equi-analgesic conversion.
  • I’ve seen methadone work well. It has a 4-8 hr half-life for analgesia (and 24-48 for withdrawal suppression). However it can take several days to titrate and you need to guarantee outpatient followup. If someone comes in already on methadone, you can give them extra narcotics if necessary but you must communicate any changes with their methadone clinic, otherwise, no dice.
  • I would not be so bold as to give known opioid abusers a PCA, but some people have found it works well.
  • Consider a social work consult (especially if you have a patient like #2 above) and offer substance abuse counseling or detox. If you know they’re going to snort or shoot up when they leave, consider writing a suboxone prescription.

References: a concise article from Anaesthesia
Medscape
The school of hard knocks

 

What does a urine tox screen test for? (And how do you interpret the results?)

The urine tox screen is one of the most superficially helpful tests we have. At first glance it seems like a simple “yes/no” answer. I mean, either someone did or didn’t take heroin…or did they? It turns out there is a lot more gray in interpreting the results of a urine tox screen, and it’s important to take your time thinking about the results lest you condemn someone unfairly–or let them get away with abuse.

When should someone be screened? 

It’s possible to stratify patients into high-risk and low-risk abusers but you really should screen everyone who is on a potential drug of abuse. Definitely at the first appointment, and then 2-3 times/year has been shown to be effective. If you are changing a patient’s dose substantially, or if they have more complaints about decline in function, that may be a good time as well.

Which is better, the urine or serum tox screen?

Actually, it’s urine. According to Path Group:

Drugs of abuse can be detected in urine for days to weeks after exposure, in contrast to blood detection which is generally in hours. For example, heroin has a half-life of 6 to 15 minutes in blood, but opiate metabolites may be detected in urine for 2 to 3 days.

Is it possible to get false positives on a urine tox screen?

Yes. One factor is individual pharmacokinetics. There are genetic differences in CYP450 enzyme activity, and if patients are on other CYP450-metabolized medications, they could have different levels of processing medications like opiates. Other factors include whether the patient is obese, what dose they are taking and how frequently, and more.

If you are concerned that there may be a false positive, order confirmatory testing with GC/MS (gas chromatography/mass spectrometry). This is highly specific and reliable.

Opioid Risk has a great summary of what could cause different “false positive” or “false negative” scenarios. (Go to “Interpreting Test Results” on page 5)

Here is a list of some caveats from HealthPartners:

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If a substance is detected, can you tell how long ago it was taken? (Reference)

Substances are detectable for a certain range of time, and the specific times may depend on your institution’s lab.

  • Alcohol 7-12 h
  • Amphetamine 48 h
  • Methamphetamine 48 h
  • Barbiturate Short-acting (eg, pentobarbital) 24 h
  • Long-acting (eg, phenobarbitol) 3 wk
  • Benzodiazepine Short-acting (eg, lorazepam) 3 d
  • Long-acting (eg, diazepam) 30 d
  • Cocaine metabolites 2-4 d
  • Marijuana Single use 3 d, Moderate use (4 times/wk) 5-7 d, Daily use 10-15 d, Long-term heavy smoker 30 d
  • Codeine 48 h
  • Heroin (detected as morphine) 48 h
  • Hydromorphone 2-4 d
  • Methadone 3 d
  • Morphine 48-72 h
  • Oxycodone 2-4 d
  • Propoxyphene 6-48 h
  • Phencyclidine 8 d

What substances will NOT be detected by urine or serum tox screening? [I’ll try to update this as I get more info] 

  • fentanyl

What are some ways that people try to thwart tox screening? 

The length of time a drug can be detected in the urine varies due to several factors, including hydration, dosing, metabolism, body mass, urine pH, duration of use, and a drug’s particular pharmacokinetics.

  • Someone may try to make a drug level “undetectable” by drinking tons of water to dilute their urine. Conversely, someone may try to make it seem like they do have an appropriate level of a prescription drug by dehydrating themselves to concentrate the urine.
  • This has actually happened: someone buys “clean” urine off the street and passes it off as their own during drug testing. This is why some institutions require supervised urination. There are ways to check for this, like temperature-sensitive cups, measuring the specific gravity of the sample, or creatinine concentration (these will all be different in stagnant urine that has not recently exited the body).
  • This is not “thwarting” per se, but if a patient is on a low dose or has long intervals between doses, they may have a false negative because the concentration of drug is below the cutoff on the assay.

 

So how much is a fifth of vodka, anyway? A frame of reference for alcohol container sizes

Men put themselves at risk for alcoholic liver disease when they consume the equivalent of greater than 40-80 g of alcohol per day for 10-12 yrs; for women, it’s 20-40 g per day for 10-12 yrs. (Women tend not to drink as much, but have higher relative rates of alcoholic liver disease and death from cirrhosis than men).

So what about those alcohol container sizes? I don’t know what some of the words like “magnum” mean, and I haven’t known how much fluid a “pint” holds since I had to convert units in 4th grade, but I sagely nod my head when patients tell me and guess how much it is based on how embarrassed they seem.

I won’t learn container sizes from personal experience, that’s for sure. My alcohol tolerance is shot (excuse the punning, please). I’m asleep after half a bottle of beer. So how’s a girl to learn what patients mean when they refer to alcohol container sizes?

Bartending Basics has the answer:

  • The fifth contains 25.4 ounces, or 750 milliliters (ml). [oh crap, that is a LOT of vodka for one person to drink by themselves in one sitting]
  • The 1-liter bottle obviously contains 1000 ml=33.0 oz.
  • A half-gallon bottle actually contains 59.2 ounces, or 1.75 liters.
  • The pint-size bottles now hold 16.9 oz=500 ml
  • The half pint (8 ounces) now contains only 6.8 ounces (200 ml)
  • A split of wine or champagne contains 6.8 ounces, or 200 ml.
  • The smallest miniature bottles, often referred to as airplane or hotel bottles, contain 1.7 fluid ounces, or 50 ml.

 

And here is a Drink Calculator that can convert for you!

Is it okay to give a patient morphine, codeine, etc if they have an “opioid allergy?”

I direct your attention to this great overview in US Pharmacist, Opioids: Allergy vs Pseudoallergy.

A frequent problem on the wards is a patient who comes in with severe pain, who you’d like to give narcotics to, but they claim they have an allergy to morphine. They state that their allergy is “hives,” or “rash,” or “vomiting.” Can you still give them morphine? Can you give any opioid at all?

Based on my reading of the article, the only TRUE opioid allergies are:

  • hives
  • maculopapular rash
  • erythema multiforme
  • pustular rash
  • severe hypotension
  • bronchospasm
  • angioedema

Patient with a true allergy can be given the opioid at a lower dose with administration of an antihistamine, as long as you think the patient can tolerate the adverse effect.

Reactions like nausea, vomiting, itching, agitation and delirium are pseudoallergies. It should be noted that nausea is common, and usually resolves in 5-10 days. (It may also be a side effect of the pain itself.)

However, calling a reaction a pseudoallergy doesn’t mean your problem is solved. You can still give an antihistamine, but likely, the patient will refuse to take a medication they think they have an allergy to. If they have an allergy to a natural opioid like codeine or morphine, you can try a synthetic opioid like meperidine or fentanyl, although these are not preferred in general on the medicine floors. Tramadol is contraindicated.

Interesting note: heroin users say they can tell the difference between fentanyl (no itch) and heroin (sometimes get an itch or mild rash). Important to note that heroin is increasingly cut with fentanyl which gives a “better high” but also is associated with more deaths.

Let’s be clear about delirium

We think we know what a “delirious” patient looks like in the hospital–yelling, throwing things at people, completely alert and dis-oriented x3.

There is the perception that delirium is either completely obtunded or completely manic. In reality, delirium can look like anything between! A delirious person may be able to have a perfectly logical conversation with you until they look outside at the snow on the ground and say, “What a beautiful summer we’re having!”

The critical question to ask is: is cognition impaired? If cognition is impaired, then make a differential based on that. If cognition is NOT impaired, then it may in fact be a psychiatric process at play. For instance, a schizophrenic might have a 30/30 MMSE but will “act crazy”…that’s not delirium. That’s schizophrenia.

When can you use benzos appropriately?

I’ve seen a fair number of elderly patients on benzos at bedtime. The patients claim that it calms their nerves and helps them sleep better.

To which I say, yeah, I’d like to have that, too.

Too often, benzos are used to treat symptoms, and do not address the underlying cause. For instance, I saw one 85 year old patient on TID Ativan, which is VERY IRRESPONSIBLE because it’s like throwing nitro patches on someone with new angina and not doing a stress test.

Benzos are appropriate for people with:

  • short-term treatment of anxiety disorders
  • insomnia for short bouts (2-4 weeks, dosed intermittently) although patients can get rebound insomnia
  • maintenance benzos can be used in people who are refractory to other treatments or who have already become dependent and would have a difficult time withdrawing

Here are some guidelines when prescribing benzos:

  • If it’s the first time someone is taking benzos, don’t prescribe for more than 1 month at a time
  • Always use the lowest effective dose
  • If someone is on maintenance benzos, use a long-acting one and do not exceed the equivalent of 15 mg of diazepam daily
  • In elderly patients, avoid long-acting benzos (these can cause cognitive and gait abnormalities and sedation). Make sure you are not treating depression with benzos, because this will only make it worse.

If a person on high-dose, daily benzos comes into the hospitals, do not stop their benzos as this can precipitate withdrawal. But see if they’d be willing to start on a taper, or reduce their benzos.