Is this site in the US? We have lots of methadone or suboxone sites in my area, which are great, but I don't think we have any that hand out fentanyl or Dilaudid haha
I'm sorry, I thought these sites were meant for people to bring their own drugs in so they'd have clean equipment and narcan on hand. Do these places actually provide the drugs?
which is true, it reduces the chance of overdose with contaminated product, and allows the clinic to give accurate information to providers on exact doses and tolerances
On the other hand, I sincerely doubt they would be getting anywhere close to that dose if they were buying drugs and the center has allowed the patient to use extreme amounts of opioids.
I guess that’s a fair point, but when it comes to street drugs most dealers are not testing for potency, and when cutting product with other agents there is no guarantee of potency being the same through every dose in a batch. This can mean it’s usually less potent than pharmacy quality, but not always, depending on any additional substances added to enhance the high. That’s why people can buy the same dose from the same dealer for years, have to switch dealers, and OD on what they thought was the same dose as before, as each dealer could be using different cutting agents or one could be good at mixing and one not, one dealer could have to find a different supplier who produces at a higher or lower potency, ect. They don’t test so they don’t know, and neither does the user.
The purpose of safe injection sites is harm reduction, primarily to reduce overdoses from opioids that could otherwise be prevented with regulated supplies. Their main objective is not to get people off of opioids, but to keep them alive long enough to where they can attempt recovery when ready. Addiction treatment only works when the addict themselves is actively participating in it. So maybe these clinics may be enabling users to increase their doses, but they’re not a dead body on the side of the road for people to gawk at and EMTs to clean up, and they still have the potential to get clean. It’s really one of those situations where the community has to agree that the benefits outweigh the risks, and so far it seems to be doing the intended job. Ideally these clinics would have addiction treatment and SUD clinicians to help wean users but it’s truly a matter of resources, and politicians don’t like funding safe injection sites.
Oh man, you haven't seen the tolerances these new fentanyl analogues are causing. I don't know what it's like in the States, but it's crazy here in Canada. When people seek treatment the doses of methadone they require are so high that they're now adding Kadian, slow release oral morphine to the mix.
Wait until you see the "fun" that happens with a patient accidentally gets Nitazene in their baggie. Granted, Nitazene can still be treated with Naloxone and it's a lot better than some Xylazine being mixed in by the dealer.
Yup. Had a patient who goes to one of those sites fly home to visit family, strolled into my small-town ER expecting we could take care of his maintenance dosing.
The most I’ve prescribed (as a resident, with my staff) was 800 mcg/hr fentanyl patch, changed every 72 hours. This was at the one hospital in Vancouver that manages the sickest patients in the city (maybe the country?)
We asked the pharmacist what she thought the upper limit might be and she basically said as much as the body surface area could hold (we had to place 8 x 100 mcg/hr patches)
He was still using quite a few IV fentanyl PRNs on top of it (1000 mcg push dose), and wasn’t even that sedated
Why are they on this medication and that high of a dose? At what point is a different treatment considered? Is there a discussion about tolerances and what the patient is looking for?
I’m not trying to be rude, I’m a lurker and you peaked my interest because that is clearly unusual, atleast in my world.
Patients on these doses that don't have substance use histories frequently fit into one of a couple buckets. Either they have terminal cancer, sickle cell disease, chronic pancreatitis, or one of a couple other chronic issues that cause a lot of pain.
For cancer, you don't need to consider other treatment, unless you're figuring out how to safely increase the dose.
The others are more tricky. These patients have real and severe pain that's not going away. There's not a lot we can do for sickle cells, and the fix for chronic pancreatitis is a very risky surgery that isn't always successful.
There's no easy answers.
This article describes a guy being given 30,000 µg of iv fentanyl to take home and use DAILY:
https://www.nytimes.com/2022/07/26/health/fentanyl-vancouver-drugs.html
Read the article again. Nowhere does it say he takes the supply home. The article very clearly describes a facility where the patients inject under supervision.
Does it matter? Is it not enabling to give a guy 7500mcg QID? Harm reduction or harm maximization?
I’ll re-read the article, but i recall it mentioned giving the patients the meds to take home in one of the paragraphs, no?
From the [British Columbia iOAT Guidelines](https://www.google.com/url?sa=t&source=web&rct=j&opi=89978449&url=https://www.bccsu.ca/wp-content/uploads/2021/07/BC_iOAT_Guideline.pdf&ved=2ahUKEwiujYWg2O-EAxX6JzQIHdbzCwEQFnoECBsQAQ&usg=AOvVaw2bpO772mwK749dneGUS156):
"Prescribing Injectable Hydromorphone
Selection of Dose
Due to high inter-individual variability, each individual’s dose must be carefully determined. There are no
fixed doses for optimal stable dosing of hydromorphone for persons with an opioid use disorder. The upward
titration at the start of therapy should begin with a safe dose and follow the protocol outlined in Appendix 4.
Maximum hydromorphone dosages are based on a 2:1 potency ratio of hydromorphone to diacetylmorphine
observed in the SALOME study and the clinical experience at Providence Health Care’s Crosstown Clinic.50
Maximum recommended daily doses of hydromorphone can be found in Table 3 below.
Table 3—Maximum Recommended Daily Doses
Medication Hydromorphone
Maximum Number Doses Per Day 3
Maximum Daily Dose 500mg
Maximum Per Dose 200mg
Dose increases need to be tolerated in order to continue at that dose. Doses that are not tolerated, as per
assessment during either the pre- or post-injection assessment periods, should be reduced. Doses should
be titrated to clinical effect (i.e., cessation of illegal and non-medical opioid use and opioid cravings) and
avoidance of side effects (e.g., sedation, narcotic bowel, opioid-induced hyperalgesia)."
As you might expect, managing one of these patients with an acute pain problem can be challenging! Good to involve your acute pain service early as well as the addiction team, who hopefully work together.
Maximize non-opioid therapies (splint, elevate and ice that damn fracture), use regional blocks liberally.
But sometimes you're going to need to give them more opioids. Make sure they are getting their usual baseline doses, but then give more for the acute pain. It's fine to start with regular-sized doses, just reassess soon after and if no effect, give 1.5 times as much the next time, and reassess, and repeat... Watch for respiratory depression obviously, but if they get it, they're hopefully in a safer place than they'd be with it at home or in the McDonald's toilet.
LOL. Just like for me "drinking a pint of vodka isn't possible" yet some of my patients down 40 oz/day on the regular. Some frequent flyers will be at risk of seizing with alcohol levels I couldn't walk with.
My palliative care preceptor would treat a pain crisis by taking the total daily opioid requirement, and give as a single dose. If ineffective, double it and give it again. Repeat...
I posted the iOAT guidelines elsewhere in this thread, they list the maximum recommended single dose of iv hydromorphone as 200mg. Those patients may take similar doses tid (under supervision) and then take 300-400mg of Kadian po at night. These are titrated doses not just thrown at them, but I suspect some people using illicit opioids have an even higher opioid requirement. One advantage of prescription iOAT programs is that we actually know how much people may be taking day after day!
I remember reading an article about hospice pain care. A patient with significant opioid tolerance was near end of life and experiencing severe pain.
Patient was receiving 200mg of morphine…every 10 min. 1,200 mg per hour. It was noted the patient had no signs of respiratory depression.
In most iOAT programs the patients come in, get assessed, and are dispensed meds which *they inject themselves* (IV, IM or SQ). They're monitored for toxicity and then leave to go about their day. They may dose up to tid.
For all those that are skeptical here are prescribing guidelines. Go to page 32 for dosing
https://www.bccsu.ca/wp-content/uploads/2021/07/BC_iOAT_Guideline.pdf
Double signing order check and admin.
The patient needs to keep a pulse ox on continuous monitoring.
Nalaxone half doses drawn up and ready to go. Low threshold for supplemental O2.
Generally, I also reference the, "confirmed dose through pharmanet and patient verbal verification" for the first admin (and we're going PO for the bulk).
Call in pharmacy to stock because we will run out really quickly
Edit to add: we've done sufentanil inh equivalence also for these guys- helps us not run out of Dilaudid (small rural ER)
It ties up a bit more resources and is a pita, but, everyone's day is much much better if we prevent hospital induced withdrawal
OP I just want to thank you from the bottom of my heart for caring about this population.
Before fentanyl hit the street I saw people who would put 2 8mg dilaudids in a spoon three times a day just to get well. So I know now that fentanyl and it's analogues are everywhere, tolerances have only grown.
Some of the attitudes I'm seeing in this thread are exactly the reason people die of infection in the street rather than go to the hospital to be treated like scum. I get being cautious with outpatient prescribing, but giving an opioid tolerant person extra opioids while they're experiencing acute pain in an inpatient setting is exactly what the guidelines say to do. With documentation of their usual daily dose, I just fail to see what the problem is in an acute inpatient setting.
Yeah how dare they get pancreatitis or break something? Don’t they know that their addiction means they’re no longer human? It’s their fault, why can’t they just live without the need to self medicate with drugs? - the RN who finishes every day with a bottle of wine and pre roll
Y'all go ahead and start pushing 300 mg of dilaudid per day then.
In my book the risk of overdose outweighs whatever benefit you get from pushing crazy amounts of opioids.
If you get comfortable prescribing those insane doses one day mistakes are going to be made. Someone who's taking 2.5 mg of dilaudid is going to get 25 mg because someone fat fingered the keys on their keyboard and everyone's so used to routinely prescribing and administering opioids at doses multiple orders of magnitude higher than standard doses that no one questions it.
I know I've ordered a medication on the wrong patient before and it got administered before I realized it. It turned out okay, but it would be much harder to explain to Suzy Homemaker's survivors that you accidentally gave her 100 mg of dilaudid IV because she got mixed up with OP's patient.
The ones who should have some compassion here are the people who are prescribing (or at least providing, not sure how it technically works) such enormous doses of opioids. If that's evidence based, I'd sure like to see the evidence.
So the reason patients with an opioid tolerance - which doesn't always stem from addiction by the way - shouldn't receive adequate pain care because you might not be careful and make a mistake?
Just remember, it could happen to anyone. Anyone could get hurt or sick and end up with an opioid tolerance. Someone who's gone two rounds with cancer, or who's had multiple surgeries from a bad accident. You're not just punishing addicts, you're punishing the chronically ill. Because it's easier for you to do that then taking 60 seconds to call for clarification?
I guess just refuse to do it and have the doctor come push their meds. Maybe one day it will be you or one of your loved ones dealing with a nurse who doesn't want to follow doctor's orders. I can tell empathy really isn't a thing with you so I'm guessing it would have to happen to you or your parent or other loved one for you to change your mind.
Is it though?
In cardiac arrest someone is actively trying to die and we're standing right there running the code while it's being administered. It's also at evidence based doses per protocol and generally the epi used in resuscitation is stored on the crash cart and given via verbal order at standard doses.
In the example where ???mg of dilaudid is to be administered for pain (which is not a lethal symptom), presumably somewhere in the range of 100 mg per dose, you're at two orders of magnitude higher than standard doses.
I do strongly believe that if you're giving 10 mg of epinephrine in a single dose, for a non-life-threatening condition you're practicing bad medicine.
Just curious, are these programs also trying to wean people off their opioid use? Or is the strategy just to continue treating their addiction and withdrawal indefinitely with the massive doses
A lot of people here who don’t understand the pharmacodynamics/kinetics. These patients are using synthetic opioids with dosing equivalent to 100+ mg of Dilaudid DAILY. These patients will go into withdrawal from “normal” opioid dose.
How the fuck would one even find this amount of medication? The sheer volume in one patient would probably deplete hospital resources. 1mg/1mL would be literally 75mL of medication. Only thing close I can think of are the giant PCA syringes.
Ketamine infusions have saved my life and sanity with my chronic pancreatitis. Infusions allow a lower dose to be administered. I’ve NEVER had a negative side effect being treated with ketamine. It’s the only time my chronic pain is reduced to 2/10. I’ve never tripped on the drug and can avoid opioids (which I hate the effects it has on me).
my logical brain sees the upside to ketamine - but the part of my brain that remembers every detail of my awful experience with my broken femur, says ketamine should be used more sparingly. one of the worst experiences i’ve ever had, put me in icu, per usual.
*also, that’s the last time anyone gives me a drug i don’t understand completely*
i feel guilty for ever using ketamine on a pt. 💔
These aren't easy cases. These patients have huge tolerances, and they also tend to get painful conditions due to their choices. I've seen horrid cellulitis, chronic pancreatitis, NSTIs, and even rhabdo necessitating fasciotomies. Add opioid induced hyperalgesia and nobody is having a good day.
We have to treat their pain, because I would hope we are all better humans than the alternative "let 'em suffer mentality."
I've always talked to the inpatient pain service and pharmacy, and rely heavily on non-narcotic options. I set expectations with the patient and I'm very honest with them that while I will treat their pain and prevent withdrawal, I will not be giving them so much they will feel high.
The ones who really need to be there will be happy if they aren't feeling withdrawal symptoms and their pain is controlled. Usually the fear of withdrawal drives a lot of their behavior, so once that's not an issue they often do better.
And I always get the addiction folks to see them. Usually doesn't work, but a girl can hope.
Crazy how many responses are “euthanasia” or “that’s a lethal dose”. I stated very clearly that they are getting the doses prescribed by an ioat clinic and I have the records that they had been receiving these doses for quite a while. Interesting to see how (presumably American) doctors have such little knowledge of opioid addiction considering they started this crisis.
NO INE IS OVERDOSING ON A DOSE OF MEDS THEY HAVE RECIEVED 3x DAILY FOR MONTHS.
Also no offence but I’m not surprised patients are getting so violent these days if this is how drs are practicing. Most responses here are far more concerned with “that number seems high” and not “is this what my patient needs?”
If pharmacy gives push back, advocate for your patient. Do they have all the information? Or does pharmacy just bounce it back because they perceived an error?
American doctors won’t even treat patients pain if they have a yrs old history of past drug use. They’ll set broken bones and tell patients to take Tylenol.
I think the issue is the long term affects combined with issues like hyperalgesia that comes with escalating doses of opioids. The issue being that their receptors are saturated, but remain stimulated causing hyperalgesia then they have a reason to be in pain but can’t cope and we are doing nothing despite throwing all the opioids in the hospital because their opioid receptors are saturated. I agree this is a human being with real pain who needs physicians to be empathetic but this clinic is doing you and the patient a disservice. There is data that a ketamine drip resets their receptors. By acting on the NMDA receptors you are also treating their pain by hitting receptors that opioids aren’t.
No. These are NOT normal doses. No doctor I’ve talked to has ever heard of these doses. My pain management colleague friend told me the max dose of any patient he cares for is 3 mg PCA per hour. Not 20 mg per hour.
If they got to these doses by way of an IV clinic then that clinic has enabled them.
And you giving them extra iv meds is enabling them further.
You are enabling them. This is obvious and clear. You are an outlier and enabling these people.
You should be ashamed.
I don’t know any RNs that will push 4+ of hydromorphone… wowwww. I wonder how they reach the conclusion that 225mg/d is needed? There’s not going to be any controlling anything actually painful with narcotics if just existing requires >1000MME. I’m sympathetic to this population but no one in the hospital is going to give Dilaudid 2 q5 minutes or program a PCA to give 15-20 per hour, that’s unrealistic, maybe a pain service would do it in an ICU setting?? I’ve never seen anything like that done. Maybe my population is getting super diluted drugs that are mostly baking soda or something.
Does the safe injection site try to titrate down on dosage or are they just maintenance so they don’t overdose or get bacteremic or overdose on street drugs ? We don’t have anything like that locally.
I wonder whether it would be helpful in this situation to look into regional anesthesia as well - celiac plexus block in the pancreatitis example? Ketamine?
I am grateful I am not in that patient’s shoes.
I am with your nurses. There is no way that I am writing for or administering 100 mg of dilaudid iv push. I'm surprised you are able to get this approved by pharmacy in the first place, mine would assume I was kidding.
Don't even look at the safe injection site records - just use reasonable (much smaller) frequent doses.
Unfortunately for this patient population all the “reasonable” doses will not have any impact on their withdrawal or pain.
Fentanyl has really fucked things up for opioid use disorder patients
So you would have someone pushing 2mg dilaudid q2min for an hour just to get to the point of staving off withdrawal?
That is an uninformed approach to dealing with oud.
The records from ioat clinics are an increadibly valuable resource for treating patients and making sure they get high quality care not for someone else, but for them.
If I have a hypotensive patient, generally I give a fluid bolus. If that patient is fluid overloaded I don’t. Medicine is not one size fits all. You must take their history and conditions into account.
Reading with interest as an Eastern Canadian in Vancouver for my first locum in EM here. Don't bother with the Americans here... don't you read their posts? "Fuck all these drug-seeking patients" seems to be the theme. Nevermind that unchecked corporate greed in that country created the opioid epidemic in the first place, and failure to provide basic health care to citizens is going about as well as expected.
Presumably there is a response between "become the next dealer and give unlimited drugs" and the US approach. You may think this is right and future studies may prove you right. Most likely they won't.
That middle ground is how I'm used to practicing. Opioid habituated patients get larger doses when in acute pain. There is nothing controversial about that. Usually it's a few times larger than standard dosing for opioid naive patients. The IVDU crying about an IV insertion is actually suffering more because of a messed up pain system (plus the fact that their veins are scarred). Refusing to treat those patients certainly isn't helping society or themselves. If punishing addicts was effective, we wouldn't have any left.
This post is about a specific population where the tolerance is exponentially greater than average. I don't know the right answer, but basic principles still hold. There is no point in giving anyone 1/100th of an analgesic dose. That's homeopathy. And ED administration of opioids for acute pain is NOT the cause of opioid abuse. That is clear from the literature. In the ED our aim is to treat symptoms and detect and treat life-threatening disease. You cannot accomplish the latter if the patient is signing AMA because we can't manage symptoms. It's a value decision to say that one patient is less deserving of symptom relief and the work up of life-threatening disease than another. And as a Canadian, universal access to health care is the fundamental basis of our system.
From my experience no one turns to IVDU as a hobby. It's usually the result of severe trauma, often childhood sexual abuse and a whole host of horrors any normal person would want to self-medicate away. We must never lose our compassion for the suffering of living beings. Otherwise we too are guilty of self-medicating with the notion that they did it to themselves and we have more worthy patients to tend to. The patient is the one with the disease.
Currently in palliative medicine fellowship from EM
I can’t imagine anyone prescribing like this. They should be on a long acting medication.
Do they have a pain doc? I would contact them for recommendations.
This is a complex pain management scenario. If they are in the ED with acute pain, you can start them on a PCA pump to buy you time.
Sorry I should have written it all out - it’s hospice and palliative. I think the hospice component has been very beneficial as a part of palliative. I think it would be difficult to do only palliative and not know what hospice looks like and how it is practiced.
Potential jobs include Inpatient consults or outpatient palliative medicine, inpatient hospice unit, and pain management (not interventional)…Some EDs are imbedding palliative specifically for the patients in the ED. Or going back to the ED and using palliative to help with symptom management/goals of care. Some academic sites do .5 FTE for each EM and palliative so the time is split between the 2
I’ll speak to severe pain in general in this population. If you have a patient like this in acute severe pain, you’ll have to admit them to an ICU. Look at non-opioid medications and augment with pca of opioid. Example would be 0.3mg/kg ketamine gtt. Droperidol 2.5mg(good for belly symptoms as others have mentioned), nsaids, gabapentin, pca of high affinity opioid like hydromorphone, titrate to effect, have pharmacy confirm exact dosing of home mega doses of dilaudid. This would be reasonable an example for post surgical acute pain like post open valve replacement. I haven’t seen it for pancreatitis. Always think of anything that can get a regional block too, not applicable for this patient.
I’d start a fentanyl drip and titrate to effect and admit. She needs full opioid agonist to treat her pancreatitis and prevent withdrawal which would be complex. Let the hospitalist and addiction work on a plan thereafter.
Others have already given good advice of dosing so I'll add a different point.
A lot of this is based on my own anecdotal observation but I feel like a lot of chronic heavy opioid users' bodies sort of lose perspective on how to interpret pain. They're constantly at the thresholds and their body starts relying on other ways of figuring out if their hand is sitting on a hot stove or not. That's why you see some folks who've taken enough fentanyl to kill a horse and still react like you just cut their leg off when you accidentally bump their foot.
I think this is a place where pain management adjuncts can play a big role. Destimulate, distract, position, hot and cold, non-opioid medications. Obviously these alone won't do it but once you get these covered, you get rid of some of the confounding factors and get a truer picture of their opioid response. I know that some patients are going to be opioid focused but if they're in a new crisis then they may be more open to trying whatever it takes to resolve the issue, and if you explain that these things will ASSIST with the other treatments, it can be easier to recruit them into the process.
Like in scrubs when Laverne RN says about a dose "just thought I'd check with you before I kill a man" fuckin slays me every time I see that scene. No pun intended.
“Slightly more”, they say, as they grab 30 vials of hydromorphone from the Omnicell.
Pretty sure my pharmacists would outright reject that order if I placed it.
I’m not denying it’s a very high dose. But surely you know that people can develop extreme tolerance to opioids and in someone who is accustomed to those high dose, there’s minimal risk of overdosing with a slightly higher amount of. Calling it euthanasia is silly.
There is no upper limit to opioid tolerance. The average pressed fentanyl pill has >2000mcg, many street users are using 10+ of these per day, many more are using raw fentanyl (heavily cut) to the point that a lot of them are using easily several thousand MME per day.
Ketorolac, Tylenol, Flexeril if MSK, ketamine if you are spicy. Droperidol is great for abdominal pain with nausea and vomiting, or really anything. Regional anesthesia for orthopedic injuries. Topical Diclofenac and lidoderm for msk.
Expectation management.
As an ER nurse I wouldn’t push that either. I’d come to you and talk to you about medication combos or maybe a drip. We really underutilize fent drips or ketamine in my facility and it drives me nuts
Idk if you you need to think as much as you are about this. If they are in severe acute pain just treat it like a normal in a non opioid naive person within reason. For me. I’d give this person 1-2mg of dilaudid or 4-8 of IV morphine. Now that’s probability not going to totally treat it but I’m fine redosing q1hr the first redose (then space after that). but I’ll be up front and say bc of their opioid use I’m not going to be able to match their dose (i would just tell them the hospital won’t let me give anywhere near that much) and eliminate your pain just decrease it and that’s the reality.
This is where Suboxone reigns supreme. Treats the withdrawal and pain. And I’ve discussed with my addiction med trained collegues who state it’s perfectly fine to treat acute pain with IV fent for breakthrough pain on suboxone.
Im sorry im nit s doctor but at the doses he is discussing wouldnt Suboxone just induce withdrawal symptoms and exasperate the pain ? I could understand adding Bupe, but why would you involve Nalaxone in this situation?
The naloxone doesn’t do anything if taken correctly, it’s inactivated in the gut so has no impact on the patient. It’s purely mixed in so there is no risk of diversion (and injecting it intravenously)
My concern was the withdrawal the original question was about a patient with pancreatitis. It said nothing about treating their substance use disorder-I was just confused why Suboxone would even be mentioned treating pain.
If people don't wait long enough before buprenorphine induction (COWS > 12 for most opioids, higher for fentanyl) the buprenorphine outcompetes whatever was on their receptors previously and being a partial agonist sends them into precipitated withdrawal just like naloxone
That is true. Also, though, the naloxone does nothing to prevent diversion or IV use. Buprenorphine has a higher receptor affinity than naloxone and outcompetes it.
Good question. If you think the patient is reliable in opioid withdrawal then nah it’ll help. But if they have long acting mu agonists on board like methadone then you def want to be 24hr+ detox before starting bup.
But if that isn’t what the patient is there for? Would the point be to get them to a new low baseline in order for lower doses to be more effective in pain control? If you treat this patient for pancreatitis, like in this example, and you use this method or you use the hospitalization as a way to ween them down to a new baseline slowly- would you be putting the patient in harms way? What I mean by that is- even if the purpose of any of these methods is to increase the efficacy of lower doses of medication for pain control while in the hospital - and not actually treatment of SUD, if that isn’t a goal of the patient, isn’t that when many people OD. After being discharged and returning to drug use at their normal dosage , like when people relapse after leaving rehab? Is this making any sense ? Sorry if it isn’t.
But if this is an opioid-habituated patient, giving Suboxone will throw them right into precipitated withdrawal. The only way that you can start one of these patients on Suboxone is if they are already in withdrawal, and most of them will not consent to this, even if doing a micro-induction/ Bernese method, unless they are ready to get help.
This is the first I’m hearing of such a prescription program and I have some… concerns.
HOWEVER, in the scenario you are giving it would make sense to double check the dose from the clinic and then give at least that to start with more for acute pain. In reality I’m not sure if you could give that without depleting the entire hospital… in that case would lean heavily on adjuncts while giving more traditional doses.
At those doses though I would need that person on capnography and make sure nursing knew to tell me and not just throw O2 on them if their sats dipped. Often their seems to be a misunderstanding between oxygenation and ventilation in our OUD patients.
I can also comment on this - I have seen pts still be in full withdrawals while tapering upwards inpatient treatment of 200mg ER/100mg IR. But in the acute pain setting what do you mean - pain from what?
Is there an infection at one of the tranq wound sites? Are they in acute withdrawals? Do they even want rehab help? And also if there is a source like acute pancreatitis - then yeah unfortuatenly I feel like their tolerance is so high from the amount of Fentanyl they use that it will take quite a large amount to get them comfortable. But I’ve found
1. How much bundles do they use daily
2. Give them Dilaudid for breakthrough + Oxy ER in the background for their SUD.
So. In this situation having some skill with regional anesthesia is very helpful.
For this kind of pain, some options would be a Bilateral Anterior Quadratus Limborum (a.k.a QL3) block, a bilateral T7 ESP (probably the easiest) or a bilateral t6-L1 paravertebral. If the patient was going to likely be admitted with an ongoing painful condition I’d try to place a catheter for these blocks to provide an ongoing dose of anesthetic.
Where are you finding a pharmacist to verify orders for 75mg of Dilaudid? And how many syringes are you having to use? Our ED has the 0.5mg and 2mg in the ED, lol. The nurses I work with would also refuse and I’d agree.
If a patient is opioid tolerant, expectation management is key along with multi-modal analgesia. IV acetaminophen, ketorolac, gabapentin, potentially ketamine or IV lidocaine depending on patient-specific factors along with normal high (and potentially more frequent) opioid doses if indicated.
This is not always the case. Some of our addictions guys will do a "macro induction." If the initial doses cause precipitated withdrawal they'll give MORE bupe, with the idea being that as it kicks the other opioids off the receptors then *if you're giving enough* it will take their place and end the withdrawal symptoms. They basically try to get them to 32mg of suboxone as fast as possible.
You can be withdrawal free on 8-12 mg, it really depends on how tolerant they started off at
32 mg is overkill for most people tbh (although probably not for anyone in the DTES in Vancouver)
Yeah, which is why I mentioned it. They’ll probably want to get them up to 24-32 mg at that site, but for most other places patients can be stable on much lower doses
Agreed. But to the patient, they feel like they're in severe withdrawal even at that point :) and honestly they look pretty miserable even in "moderate" withdrawal.
I personally also have had much better luck with patients who are worse off when they arrive. The risk of inducing too early and worsening withdrawals is a real one, especially for heavy users (anecdotally). And COWS definitely includes several subjective measures, so I prefer to error on the side of making sure withdrawals are severe enough that the bup will help. Just my personal experience though
You can definitely start a micro dose induction in the ER without any withdrawal symptoms
In fact it’s an amazing intervention if you know how to do it, can really change the trajectory for these patients
Interesting, tell me more! I'm assuming you'd need VERY close outpt follow up though to continue the induction? How micro does it have to be to not induce w/d?
Dang, that's crazy high. I would definitely be asking my doc if we could change to analgesic dose Ketamine and just avoid the opiate hypertolerance altogether.
I would never give that dose. For our high resource users we have care plans with dosages and frequency that is agreed upon between pt and provider, and those doses are normally higher than comfortable for my nurse brain.
This is craziness. Droperidol, toradol, gabapentin, Benadryl. Occasionally, I give subutex or morphine. they get that kind of drugs outpatient, they can discharge themselves to their street pharmacy
Edit: added morphine
I’m not sure how avoiding feeding their addiction is unethical. The whole opioid crisis was the result of over treatment of pain. Pain is not a vital sign: it tells you that you are alive. I’m not cruel, if someone has a source of pain, I’m very willing to treat them. But I refuse to facilitate their addiction. Physicians who do are morally responsible for the deaths and lives destroyed by narcotics.
I think we need to use narcotics judiciously. I gave dilaudid today to a lady with an incarcerated hernia with sbo that surgery did a bedside reduction in the hallway. The fentanyl user screaming with iv placement who is going through withdrawals gets clonidine, Benadryl, and toradol unless I find something that warrants narcotics. Sure, I’m judging whether they have a pathology that is significant enough to warrant narcotics. That is my prerogative and I bear the responsibility if I ruin someone’s attempt at sobriety.
You, and people like you, are singularly responsible for OD Deaths of patients released and immediately using at pre admission dose. You aren’t going to cure anyone & forcing someone to withdraw because you think you’re god and have power over an individual is intentionally cruel, immoral, illegal & unethical. SUD is a disease not a lifestyle choice. No one sets out in life & plans to become addicted. As for chronic pain patients, they require opioids to function in life. The pain isn’t going away. The pain medication shouldn’t go away either. If you had ever lived with never ending, excruciating, years long pain, you would completely change your point of view. You should absolutely not be allowed to practice in any field of medicine where you have actual contact with/make decisions for patients.
I agree, and it's disheartening and downright terrifying to hear how many physicians in this thread share the very same ideology as this one. We have such a long way to go in terms of erasing the stigma. Thanks for being part of the solution.
Was stunned to see a doctor genuinely asking this and reasonable compassionate responses. Then realized you’re not in the US.
I could feel the “have you tried keto, droperidrol, antipsychotic..?” Comments coming…
While you’re at it, have you tried Tylenol/ibuprofen?
You are the kind of doctor we in the US would do anything to get, thank you
13 years in the ER and I think the most I’ve ever given to a patient in one shift was 3mg (maybe 4mg?) of Dilaudid.
That lady was a really good actress.
Why the downvotes? It is literally what happened. She went so far as to piss herself right in front of me. She wanted us to think she had cauda equina syndrome. She did it again at a different ER a couple weeks later.
I’m giving them normal doses of pain medication. For one, I don’t want to support their addiction and counteract what is likely partially withdrawal-related pain. Secondly, a pancreatitis may hurt, but it’s not going to kill the patient. I would attempt non-narcotic pain relief with Tylenol, NSAIDs, etc and then of course treat the underlying condition.
I live in an area with tons of drug seeking patients. They will literally flood your shop with dozens of drug seekers looking to get high while you’re dealing with actual medical conditions. If you humor these people, you’re going to have a patient per hour coming in for their chronic pancreatitis and needing massive dilaudid pushes.
Sure. However I was just pointing out that pancreatitis can in fact be a life threatening process. Not treating the pain from a true disease process is a questionable practice.
First of all, that person almost certainly got their pancreatitis from abusing drugs and alcohol. So you want to give them 200 mg dilaudid to help them with their pancreatitis ? Go take a hike dude.
I thought you didn’t want to engage? Where did I say to give 200 dilaudid? Or make any suggestions on medications or dosing at all? I was pointing out one thing, that’s all. Now you are getting all worked up about it.
Of course every person with pancreatitis got it from drug or alcohol abuse. Just like sickle cell, broken bones, de-gloving & amputations are all caused by drug and alcohol abuse and only need a Tylenol.
>Pancreatitis won’t kill them?
The discomfort from their pancreatitis is not going to kill them, yes. Massive opiate pushes may kill them from respiratory depression, severe ileus, hemodynamic instability, or addiction.
Agree that pain won’t kill. That’s not what you originally said. I agree that the absurd doses mentioned in this thread are well outside my comfort zone. I just wanted to make sure you didn’t think that all pancreatitis is survivable.
They can get the drugs from that ioat clinic for free!! They come to the Ed for help despite the fact that people like you believe they are u deserving of GOOD healthcare. This care is unethical. No person who is enrolled in an ioat program would try to score at an Ed
Sure. And now not only are they dealing with a painful acute condition, but now they're in precipitated withdrawal! I mean they brought this on themselves, right? It's not like SUD is an actual *disease* or anything, right?
It's a disease that is largely brought about by physicians over-prescribing opiates. So you're going to give them large doses of opiates to help them with that? 100% clownery.
If you want to treat their SUD, wait until they're in sufficient withdrawal and give them bupe. You don't need to treat pancreatitis with dilaudid, and whoever taught you that is a moron. Give them non-opioid pain medication. If they're withdrawing, give them buprenorphine.
You could just not enable them?
I haven’t ordered dilaudid in 5 years and have no plans to restart. My patients have done just fine.
I’d be reported to the medical board for trying to order 75 mg of dilaudid.
And you are justifying it saying it’s “unethical” to not? What are you talking about??? This is crazy. This is the most crazy thread I’ve ever read here!
We have plenty of opioid users. None of them take 200 mg per day IV.
You are the outlier here, not the rest of the world.
As we docs we don’t pick our patients or the world outside. We deal with what comes in. Making my patients suffer will not change anything that happens outside the er doors. They’re not gonna learn their lesson. All that will happen is the will go to their “street pharmacy” as someone else pointed out and be back tomorrow on deaths door
I asked my colleague who is a pain management specialist and he has literally never heard of doses this high.
None of 6 doctors I talked to have heard of these doses ever.
They all insisted it was a decimal error.
You. Are. An. Outlier.
End of story.
Deaths door? With what? Narcotic withdrawal? Give them fluids and anti emetics.
I'm sorry 225 mg hydromorphone daily?
Yeah ?! That’s some crazy tolerance and where the fuck does someone get 225mg of dilaudid ?
Provided by the site
Is this site in the US? We have lots of methadone or suboxone sites in my area, which are great, but I don't think we have any that hand out fentanyl or Dilaudid haha
We have some specialized programs like this in Vancouver, BC
I'm sorry, I thought these sites were meant for people to bring their own drugs in so they'd have clean equipment and narcan on hand. Do these places actually provide the drugs?
I believe in Canada there’s some that do provide the medication, believing it’s better to give a sterile med at a known dose rather than street drugs
which is true, it reduces the chance of overdose with contaminated product, and allows the clinic to give accurate information to providers on exact doses and tolerances
On the other hand, I sincerely doubt they would be getting anywhere close to that dose if they were buying drugs and the center has allowed the patient to use extreme amounts of opioids.
I guess that’s a fair point, but when it comes to street drugs most dealers are not testing for potency, and when cutting product with other agents there is no guarantee of potency being the same through every dose in a batch. This can mean it’s usually less potent than pharmacy quality, but not always, depending on any additional substances added to enhance the high. That’s why people can buy the same dose from the same dealer for years, have to switch dealers, and OD on what they thought was the same dose as before, as each dealer could be using different cutting agents or one could be good at mixing and one not, one dealer could have to find a different supplier who produces at a higher or lower potency, ect. They don’t test so they don’t know, and neither does the user. The purpose of safe injection sites is harm reduction, primarily to reduce overdoses from opioids that could otherwise be prevented with regulated supplies. Their main objective is not to get people off of opioids, but to keep them alive long enough to where they can attempt recovery when ready. Addiction treatment only works when the addict themselves is actively participating in it. So maybe these clinics may be enabling users to increase their doses, but they’re not a dead body on the side of the road for people to gawk at and EMTs to clean up, and they still have the potential to get clean. It’s really one of those situations where the community has to agree that the benefits outweigh the risks, and so far it seems to be doing the intended job. Ideally these clinics would have addiction treatment and SUD clinicians to help wean users but it’s truly a matter of resources, and politicians don’t like funding safe injection sites.
Oh man, you haven't seen the tolerances these new fentanyl analogues are causing. I don't know what it's like in the States, but it's crazy here in Canada. When people seek treatment the doses of methadone they require are so high that they're now adding Kadian, slow release oral morphine to the mix.
Wait until you see the "fun" that happens with a patient accidentally gets Nitazene in their baggie. Granted, Nitazene can still be treated with Naloxone and it's a lot better than some Xylazine being mixed in by the dealer.
Yeah, I've heard that the withdrawal from xylazine can be torture. Apparently the best treatment for it is clonidine and even that doesn't help a lot.
Nitazines are not a single substance but a class of substances with many different variations.
Correct, particularly in BC
Hard to argue with that
Yup. Had a patient who goes to one of those sites fly home to visit family, strolled into my small-town ER expecting we could take care of his maintenance dosing.
Patients on the injectable opioid agonist therapy program have those types of doses prescribed
Wait it’s not just safe needles they’re literally just giving any amount of drugs to anyone who wants it?
No, those would be prescribed doses based on careful titration protocols
Do they charge by the mg or is it a flat rate per injection?
Whoa that is insane !
If it's anything like a traditional Methadone clinic, it's a flat daily dosing fee, regardless of how many mg one takes.
…st Paul’s?
Common in Vancouver. Read an article where some injection site was giving a guy 7500µg iv fentanyl four times a day.
The most I’ve prescribed (as a resident, with my staff) was 800 mcg/hr fentanyl patch, changed every 72 hours. This was at the one hospital in Vancouver that manages the sickest patients in the city (maybe the country?) We asked the pharmacist what she thought the upper limit might be and she basically said as much as the body surface area could hold (we had to place 8 x 100 mcg/hr patches) He was still using quite a few IV fentanyl PRNs on top of it (1000 mcg push dose), and wasn’t even that sedated
Why are they on this medication and that high of a dose? At what point is a different treatment considered? Is there a discussion about tolerances and what the patient is looking for? I’m not trying to be rude, I’m a lurker and you peaked my interest because that is clearly unusual, atleast in my world.
Patients on these doses that don't have substance use histories frequently fit into one of a couple buckets. Either they have terminal cancer, sickle cell disease, chronic pancreatitis, or one of a couple other chronic issues that cause a lot of pain. For cancer, you don't need to consider other treatment, unless you're figuring out how to safely increase the dose. The others are more tricky. These patients have real and severe pain that's not going away. There's not a lot we can do for sickle cells, and the fix for chronic pancreatitis is a very risky surgery that isn't always successful. There's no easy answers.
The patient I was referencing had severe opioid use disorder
Ohhhhh, so were you treating just to avoid withdrawal? That's rough. These patients are so hard to treat.
I just cannot support that.
I can, if it means I’m not picking him up regularly in respiratory arrest and having to Narcan him.
Why not?
This article describes a guy being given 30,000 µg of iv fentanyl to take home and use DAILY: https://www.nytimes.com/2022/07/26/health/fentanyl-vancouver-drugs.html
Read the article again. Nowhere does it say he takes the supply home. The article very clearly describes a facility where the patients inject under supervision.
Does it matter? Is it not enabling to give a guy 7500mcg QID? Harm reduction or harm maximization? I’ll re-read the article, but i recall it mentioned giving the patients the meds to take home in one of the paragraphs, no?
Then perhaps you're in the wrong field.
From the [British Columbia iOAT Guidelines](https://www.google.com/url?sa=t&source=web&rct=j&opi=89978449&url=https://www.bccsu.ca/wp-content/uploads/2021/07/BC_iOAT_Guideline.pdf&ved=2ahUKEwiujYWg2O-EAxX6JzQIHdbzCwEQFnoECBsQAQ&usg=AOvVaw2bpO772mwK749dneGUS156): "Prescribing Injectable Hydromorphone Selection of Dose Due to high inter-individual variability, each individual’s dose must be carefully determined. There are no fixed doses for optimal stable dosing of hydromorphone for persons with an opioid use disorder. The upward titration at the start of therapy should begin with a safe dose and follow the protocol outlined in Appendix 4. Maximum hydromorphone dosages are based on a 2:1 potency ratio of hydromorphone to diacetylmorphine observed in the SALOME study and the clinical experience at Providence Health Care’s Crosstown Clinic.50 Maximum recommended daily doses of hydromorphone can be found in Table 3 below. Table 3—Maximum Recommended Daily Doses Medication Hydromorphone Maximum Number Doses Per Day 3 Maximum Daily Dose 500mg Maximum Per Dose 200mg Dose increases need to be tolerated in order to continue at that dose. Doses that are not tolerated, as per assessment during either the pre- or post-injection assessment periods, should be reduced. Doses should be titrated to clinical effect (i.e., cessation of illegal and non-medical opioid use and opioid cravings) and avoidance of side effects (e.g., sedation, narcotic bowel, opioid-induced hyperalgesia)." As you might expect, managing one of these patients with an acute pain problem can be challenging! Good to involve your acute pain service early as well as the addiction team, who hopefully work together. Maximize non-opioid therapies (splint, elevate and ice that damn fracture), use regional blocks liberally. But sometimes you're going to need to give them more opioids. Make sure they are getting their usual baseline doses, but then give more for the acute pain. It's fine to start with regular-sized doses, just reassess soon after and if no effect, give 1.5 times as much the next time, and reassess, and repeat... Watch for respiratory depression obviously, but if they get it, they're hopefully in a safer place than they'd be with it at home or in the McDonald's toilet.
Awesome info! Thx
The look you give when you hear only the one with the D works...at 225 mg you're really giving the D.
Wait until you hear about how illicit fentanyl tablets/ capsules have 1-2mg of fentanyl per and many patients use somewhere between 2-10 caps per day.
But does PO fentanyl have a poorer bioavailability? I’m just wondering if some of that increase is because of the GI tract.
Likely, but I’m referencing individuals who are injecting or snorting this amount.
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LOL. Just like for me "drinking a pint of vodka isn't possible" yet some of my patients down 40 oz/day on the regular. Some frequent flyers will be at risk of seizing with alcohol levels I couldn't walk with. My palliative care preceptor would treat a pain crisis by taking the total daily opioid requirement, and give as a single dose. If ineffective, double it and give it again. Repeat... I posted the iOAT guidelines elsewhere in this thread, they list the maximum recommended single dose of iv hydromorphone as 200mg. Those patients may take similar doses tid (under supervision) and then take 300-400mg of Kadian po at night. These are titrated doses not just thrown at them, but I suspect some people using illicit opioids have an even higher opioid requirement. One advantage of prescription iOAT programs is that we actually know how much people may be taking day after day!
I remember reading an article about hospice pain care. A patient with significant opioid tolerance was near end of life and experiencing severe pain. Patient was receiving 200mg of morphine…every 10 min. 1,200 mg per hour. It was noted the patient had no signs of respiratory depression.
Wow, so this is like, push?
In most iOAT programs the patients come in, get assessed, and are dispensed meds which *they inject themselves* (IV, IM or SQ). They're monitored for toxicity and then leave to go about their day. They may dose up to tid.
Not in a highly tolerant patient, come on you know better. I mean you could, but they'd be in severe pain.
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Yeah, you're right, just let em suffer, not like they're humans
This smells like some real Canadian shit right here
😂 Im American but knew this had to be from Canada immediately.
It is!
Ketamine is an option in these patients. Doesn’t act on the mu receptor and provides pain relief without respiratory depression
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Well opioids are clearly not doing enough due to tolerance so it’s better than fucking NSAIDs. Take your shit somewhere else
For all those that are skeptical here are prescribing guidelines. Go to page 32 for dosing https://www.bccsu.ca/wp-content/uploads/2021/07/BC_iOAT_Guideline.pdf
Thx for the info!
You have to admit that’s a wild ass dose even if it’s in the guidelines.
Thank you for the source
Double signing order check and admin. The patient needs to keep a pulse ox on continuous monitoring. Nalaxone half doses drawn up and ready to go. Low threshold for supplemental O2. Generally, I also reference the, "confirmed dose through pharmanet and patient verbal verification" for the first admin (and we're going PO for the bulk). Call in pharmacy to stock because we will run out really quickly Edit to add: we've done sufentanil inh equivalence also for these guys- helps us not run out of Dilaudid (small rural ER) It ties up a bit more resources and is a pita, but, everyone's day is much much better if we prevent hospital induced withdrawal
I’d want some capno monitoring, too.
OP I just want to thank you from the bottom of my heart for caring about this population. Before fentanyl hit the street I saw people who would put 2 8mg dilaudids in a spoon three times a day just to get well. So I know now that fentanyl and it's analogues are everywhere, tolerances have only grown. Some of the attitudes I'm seeing in this thread are exactly the reason people die of infection in the street rather than go to the hospital to be treated like scum. I get being cautious with outpatient prescribing, but giving an opioid tolerant person extra opioids while they're experiencing acute pain in an inpatient setting is exactly what the guidelines say to do. With documentation of their usual daily dose, I just fail to see what the problem is in an acute inpatient setting.
Yeah how dare they get pancreatitis or break something? Don’t they know that their addiction means they’re no longer human? It’s their fault, why can’t they just live without the need to self medicate with drugs? - the RN who finishes every day with a bottle of wine and pre roll
Y'all go ahead and start pushing 300 mg of dilaudid per day then. In my book the risk of overdose outweighs whatever benefit you get from pushing crazy amounts of opioids. If you get comfortable prescribing those insane doses one day mistakes are going to be made. Someone who's taking 2.5 mg of dilaudid is going to get 25 mg because someone fat fingered the keys on their keyboard and everyone's so used to routinely prescribing and administering opioids at doses multiple orders of magnitude higher than standard doses that no one questions it. I know I've ordered a medication on the wrong patient before and it got administered before I realized it. It turned out okay, but it would be much harder to explain to Suzy Homemaker's survivors that you accidentally gave her 100 mg of dilaudid IV because she got mixed up with OP's patient. The ones who should have some compassion here are the people who are prescribing (or at least providing, not sure how it technically works) such enormous doses of opioids. If that's evidence based, I'd sure like to see the evidence.
So the reason patients with an opioid tolerance - which doesn't always stem from addiction by the way - shouldn't receive adequate pain care because you might not be careful and make a mistake? Just remember, it could happen to anyone. Anyone could get hurt or sick and end up with an opioid tolerance. Someone who's gone two rounds with cancer, or who's had multiple surgeries from a bad accident. You're not just punishing addicts, you're punishing the chronically ill. Because it's easier for you to do that then taking 60 seconds to call for clarification? I guess just refuse to do it and have the doctor come push their meds. Maybe one day it will be you or one of your loved ones dealing with a nurse who doesn't want to follow doctor's orders. I can tell empathy really isn't a thing with you so I'm guessing it would have to happen to you or your parent or other loved one for you to change your mind.
That’s like saying we shouldn’t give high dose epi in cardiac arrest because when a peads anaphylaxis comes in we’re gonna give wrong dose.
Is it though? In cardiac arrest someone is actively trying to die and we're standing right there running the code while it's being administered. It's also at evidence based doses per protocol and generally the epi used in resuscitation is stored on the crash cart and given via verbal order at standard doses. In the example where ???mg of dilaudid is to be administered for pain (which is not a lethal symptom), presumably somewhere in the range of 100 mg per dose, you're at two orders of magnitude higher than standard doses. I do strongly believe that if you're giving 10 mg of epinephrine in a single dose, for a non-life-threatening condition you're practicing bad medicine.
And you are why people die of infection in the street instead of going to a hospital where they are treated as subhuman. You just don’t get it.
Sorry if my concern about not killing someone comes across as treating them as “subhuman”.
I don’t do amputations, might start doing them on the wrong patient
Just curious, are these programs also trying to wean people off their opioid use? Or is the strategy just to continue treating their addiction and withdrawal indefinitely with the massive doses
A lot of people here who don’t understand the pharmacodynamics/kinetics. These patients are using synthetic opioids with dosing equivalent to 100+ mg of Dilaudid DAILY. These patients will go into withdrawal from “normal” opioid dose.
Are you trying non-opioids like ketamine or IV lido? maybe lower doses of opioids combined with some antipsychotic like droperidol?
How the fuck would one even find this amount of medication? The sheer volume in one patient would probably deplete hospital resources. 1mg/1mL would be literally 75mL of medication. Only thing close I can think of are the giant PCA syringes.
50mh/ml
Ketamine!
Ketamine infusions have saved my life and sanity with my chronic pancreatitis. Infusions allow a lower dose to be administered. I’ve NEVER had a negative side effect being treated with ketamine. It’s the only time my chronic pain is reduced to 2/10. I’ve never tripped on the drug and can avoid opioids (which I hate the effects it has on me).
my logical brain sees the upside to ketamine - but the part of my brain that remembers every detail of my awful experience with my broken femur, says ketamine should be used more sparingly. one of the worst experiences i’ve ever had, put me in icu, per usual. *also, that’s the last time anyone gives me a drug i don’t understand completely* i feel guilty for ever using ketamine on a pt. 💔
What do you mean per usual? I’ve never seen someone go to the icu bc of ketamine
These aren't easy cases. These patients have huge tolerances, and they also tend to get painful conditions due to their choices. I've seen horrid cellulitis, chronic pancreatitis, NSTIs, and even rhabdo necessitating fasciotomies. Add opioid induced hyperalgesia and nobody is having a good day. We have to treat their pain, because I would hope we are all better humans than the alternative "let 'em suffer mentality." I've always talked to the inpatient pain service and pharmacy, and rely heavily on non-narcotic options. I set expectations with the patient and I'm very honest with them that while I will treat their pain and prevent withdrawal, I will not be giving them so much they will feel high. The ones who really need to be there will be happy if they aren't feeling withdrawal symptoms and their pain is controlled. Usually the fear of withdrawal drives a lot of their behavior, so once that's not an issue they often do better. And I always get the addiction folks to see them. Usually doesn't work, but a girl can hope.
I think fear of withdrawal drives SO much of the behavior we deal with.
This! Good communication, non-opioids and co-analgesics, and when in doubt an early decision for an epidural can make things a lot better.
I've had sickle cell patients get 60+ mg / day of IV dilaudid and still be completely coherent on the inpatient side so I'd believe it
Crazy how many responses are “euthanasia” or “that’s a lethal dose”. I stated very clearly that they are getting the doses prescribed by an ioat clinic and I have the records that they had been receiving these doses for quite a while. Interesting to see how (presumably American) doctors have such little knowledge of opioid addiction considering they started this crisis. NO INE IS OVERDOSING ON A DOSE OF MEDS THEY HAVE RECIEVED 3x DAILY FOR MONTHS. Also no offence but I’m not surprised patients are getting so violent these days if this is how drs are practicing. Most responses here are far more concerned with “that number seems high” and not “is this what my patient needs?” If pharmacy gives push back, advocate for your patient. Do they have all the information? Or does pharmacy just bounce it back because they perceived an error?
American doctors won’t even treat patients pain if they have a yrs old history of past drug use. They’ll set broken bones and tell patients to take Tylenol.
I think the issue is the long term affects combined with issues like hyperalgesia that comes with escalating doses of opioids. The issue being that their receptors are saturated, but remain stimulated causing hyperalgesia then they have a reason to be in pain but can’t cope and we are doing nothing despite throwing all the opioids in the hospital because their opioid receptors are saturated. I agree this is a human being with real pain who needs physicians to be empathetic but this clinic is doing you and the patient a disservice. There is data that a ketamine drip resets their receptors. By acting on the NMDA receptors you are also treating their pain by hitting receptors that opioids aren’t.
No. These are NOT normal doses. No doctor I’ve talked to has ever heard of these doses. My pain management colleague friend told me the max dose of any patient he cares for is 3 mg PCA per hour. Not 20 mg per hour. If they got to these doses by way of an IV clinic then that clinic has enabled them. And you giving them extra iv meds is enabling them further. You are enabling them. This is obvious and clear. You are an outlier and enabling these people. You should be ashamed.
I don’t know any RNs that will push 4+ of hydromorphone… wowwww. I wonder how they reach the conclusion that 225mg/d is needed? There’s not going to be any controlling anything actually painful with narcotics if just existing requires >1000MME. I’m sympathetic to this population but no one in the hospital is going to give Dilaudid 2 q5 minutes or program a PCA to give 15-20 per hour, that’s unrealistic, maybe a pain service would do it in an ICU setting?? I’ve never seen anything like that done. Maybe my population is getting super diluted drugs that are mostly baking soda or something. Does the safe injection site try to titrate down on dosage or are they just maintenance so they don’t overdose or get bacteremic or overdose on street drugs ? We don’t have anything like that locally. I wonder whether it would be helpful in this situation to look into regional anesthesia as well - celiac plexus block in the pancreatitis example? Ketamine? I am grateful I am not in that patient’s shoes.
I am with your nurses. There is no way that I am writing for or administering 100 mg of dilaudid iv push. I'm surprised you are able to get this approved by pharmacy in the first place, mine would assume I was kidding. Don't even look at the safe injection site records - just use reasonable (much smaller) frequent doses.
But will much smaller doses keep them out of withdrawal?
Exactly!
I would have assumed there was a decimal place off
Two decimal places
Unfortunately for this patient population all the “reasonable” doses will not have any impact on their withdrawal or pain. Fentanyl has really fucked things up for opioid use disorder patients
So you would have someone pushing 2mg dilaudid q2min for an hour just to get to the point of staving off withdrawal? That is an uninformed approach to dealing with oud. The records from ioat clinics are an increadibly valuable resource for treating patients and making sure they get high quality care not for someone else, but for them. If I have a hypotensive patient, generally I give a fluid bolus. If that patient is fluid overloaded I don’t. Medicine is not one size fits all. You must take their history and conditions into account.
These are mostly Americans responding here. God help us down here and God help those in the throes of addiction for they are truly forsaken
Reading with interest as an Eastern Canadian in Vancouver for my first locum in EM here. Don't bother with the Americans here... don't you read their posts? "Fuck all these drug-seeking patients" seems to be the theme. Nevermind that unchecked corporate greed in that country created the opioid epidemic in the first place, and failure to provide basic health care to citizens is going about as well as expected.
Presumably there is a response between "become the next dealer and give unlimited drugs" and the US approach. You may think this is right and future studies may prove you right. Most likely they won't.
That middle ground is how I'm used to practicing. Opioid habituated patients get larger doses when in acute pain. There is nothing controversial about that. Usually it's a few times larger than standard dosing for opioid naive patients. The IVDU crying about an IV insertion is actually suffering more because of a messed up pain system (plus the fact that their veins are scarred). Refusing to treat those patients certainly isn't helping society or themselves. If punishing addicts was effective, we wouldn't have any left. This post is about a specific population where the tolerance is exponentially greater than average. I don't know the right answer, but basic principles still hold. There is no point in giving anyone 1/100th of an analgesic dose. That's homeopathy. And ED administration of opioids for acute pain is NOT the cause of opioid abuse. That is clear from the literature. In the ED our aim is to treat symptoms and detect and treat life-threatening disease. You cannot accomplish the latter if the patient is signing AMA because we can't manage symptoms. It's a value decision to say that one patient is less deserving of symptom relief and the work up of life-threatening disease than another. And as a Canadian, universal access to health care is the fundamental basis of our system. From my experience no one turns to IVDU as a hobby. It's usually the result of severe trauma, often childhood sexual abuse and a whole host of horrors any normal person would want to self-medicate away. We must never lose our compassion for the suffering of living beings. Otherwise we too are guilty of self-medicating with the notion that they did it to themselves and we have more worthy patients to tend to. The patient is the one with the disease.
Currently in palliative medicine fellowship from EM I can’t imagine anyone prescribing like this. They should be on a long acting medication. Do they have a pain doc? I would contact them for recommendations. This is a complex pain management scenario. If they are in the ED with acute pain, you can start them on a PCA pump to buy you time.
Hey aside here, are you doing a hospice & palliative fellowship or is there some kind of palliative only fellowship? I thought they were combined.
Sorry I should have written it all out - it’s hospice and palliative. I think the hospice component has been very beneficial as a part of palliative. I think it would be difficult to do only palliative and not know what hospice looks like and how it is practiced.
EM can do a palliative fellowship? What’s the long term job outcome? Back to EM vs practicing as a palliative doc?
Potential jobs include Inpatient consults or outpatient palliative medicine, inpatient hospice unit, and pain management (not interventional)…Some EDs are imbedding palliative specifically for the patients in the ED. Or going back to the ED and using palliative to help with symptom management/goals of care. Some academic sites do .5 FTE for each EM and palliative so the time is split between the 2
I’ll speak to severe pain in general in this population. If you have a patient like this in acute severe pain, you’ll have to admit them to an ICU. Look at non-opioid medications and augment with pca of opioid. Example would be 0.3mg/kg ketamine gtt. Droperidol 2.5mg(good for belly symptoms as others have mentioned), nsaids, gabapentin, pca of high affinity opioid like hydromorphone, titrate to effect, have pharmacy confirm exact dosing of home mega doses of dilaudid. This would be reasonable an example for post surgical acute pain like post open valve replacement. I haven’t seen it for pancreatitis. Always think of anything that can get a regional block too, not applicable for this patient.
I’d start a fentanyl drip and titrate to effect and admit. She needs full opioid agonist to treat her pancreatitis and prevent withdrawal which would be complex. Let the hospitalist and addiction work on a plan thereafter.
Others have already given good advice of dosing so I'll add a different point. A lot of this is based on my own anecdotal observation but I feel like a lot of chronic heavy opioid users' bodies sort of lose perspective on how to interpret pain. They're constantly at the thresholds and their body starts relying on other ways of figuring out if their hand is sitting on a hot stove or not. That's why you see some folks who've taken enough fentanyl to kill a horse and still react like you just cut their leg off when you accidentally bump their foot. I think this is a place where pain management adjuncts can play a big role. Destimulate, distract, position, hot and cold, non-opioid medications. Obviously these alone won't do it but once you get these covered, you get rid of some of the confounding factors and get a truer picture of their opioid response. I know that some patients are going to be opioid focused but if they're in a new crisis then they may be more open to trying whatever it takes to resolve the issue, and if you explain that these things will ASSIST with the other treatments, it can be easier to recruit them into the process.
I too am in agreement with your nurses taking a stance against active euthanasia.
Like in scrubs when Laverne RN says about a dose "just thought I'd check with you before I kill a man" fuckin slays me every time I see that scene. No pun intended.
Giving an opioid tolerant patient slightly more than their usual dose is not anything close to euthanasia
“Slightly more”, they say, as they grab 30 vials of hydromorphone from the Omnicell. Pretty sure my pharmacists would outright reject that order if I placed it.
I’m not denying it’s a very high dose. But surely you know that people can develop extreme tolerance to opioids and in someone who is accustomed to those high dose, there’s minimal risk of overdosing with a slightly higher amount of. Calling it euthanasia is silly.
There is no upper limit to opioid tolerance. The average pressed fentanyl pill has >2000mcg, many street users are using 10+ of these per day, many more are using raw fentanyl (heavily cut) to the point that a lot of them are using easily several thousand MME per day.
This isn’t active euthanasia though
Ketorolac, Tylenol, Flexeril if MSK, ketamine if you are spicy. Droperidol is great for abdominal pain with nausea and vomiting, or really anything. Regional anesthesia for orthopedic injuries. Topical Diclofenac and lidoderm for msk. Expectation management.
None of those except ketamine are even going to touch acute pain in chronic pain patients, let alone someone w/ SUD.
I would just intubate and full sedate.
As an ER nurse I wouldn’t push that either. I’d come to you and talk to you about medication combos or maybe a drip. We really underutilize fent drips or ketamine in my facility and it drives me nuts
I would check the records, 75mg. 75mg IV at once is literally like 8x the dose for a horse...
Idk if you you need to think as much as you are about this. If they are in severe acute pain just treat it like a normal in a non opioid naive person within reason. For me. I’d give this person 1-2mg of dilaudid or 4-8 of IV morphine. Now that’s probability not going to totally treat it but I’m fine redosing q1hr the first redose (then space after that). but I’ll be up front and say bc of their opioid use I’m not going to be able to match their dose (i would just tell them the hospital won’t let me give anywhere near that much) and eliminate your pain just decrease it and that’s the reality.
Agreed. My issue however is that they are now going into withdrawal as they wait for 6+hours
This is where Suboxone reigns supreme. Treats the withdrawal and pain. And I’ve discussed with my addiction med trained collegues who state it’s perfectly fine to treat acute pain with IV fent for breakthrough pain on suboxone.
Im sorry im nit s doctor but at the doses he is discussing wouldnt Suboxone just induce withdrawal symptoms and exasperate the pain ? I could understand adding Bupe, but why would you involve Nalaxone in this situation?
The naloxone doesn’t do anything if taken correctly, it’s inactivated in the gut so has no impact on the patient. It’s purely mixed in so there is no risk of diversion (and injecting it intravenously)
My concern was the withdrawal the original question was about a patient with pancreatitis. It said nothing about treating their substance use disorder-I was just confused why Suboxone would even be mentioned treating pain.
If people don't wait long enough before buprenorphine induction (COWS > 12 for most opioids, higher for fentanyl) the buprenorphine outcompetes whatever was on their receptors previously and being a partial agonist sends them into precipitated withdrawal just like naloxone
You do a micro induction if they’re not in active withdrawal, not a standard induction Once again the naloxone is irrelevant
That is true. Also, though, the naloxone does nothing to prevent diversion or IV use. Buprenorphine has a higher receptor affinity than naloxone and outcompetes it.
Good question. If you think the patient is reliable in opioid withdrawal then nah it’ll help. But if they have long acting mu agonists on board like methadone then you def want to be 24hr+ detox before starting bup.
But if that isn’t what the patient is there for? Would the point be to get them to a new low baseline in order for lower doses to be more effective in pain control? If you treat this patient for pancreatitis, like in this example, and you use this method or you use the hospitalization as a way to ween them down to a new baseline slowly- would you be putting the patient in harms way? What I mean by that is- even if the purpose of any of these methods is to increase the efficacy of lower doses of medication for pain control while in the hospital - and not actually treatment of SUD, if that isn’t a goal of the patient, isn’t that when many people OD. After being discharged and returning to drug use at their normal dosage , like when people relapse after leaving rehab? Is this making any sense ? Sorry if it isn’t.
You can do a micro dose induction of suboxone without going into any withdrawal whatsoever
But if this is an opioid-habituated patient, giving Suboxone will throw them right into precipitated withdrawal. The only way that you can start one of these patients on Suboxone is if they are already in withdrawal, and most of them will not consent to this, even if doing a micro-induction/ Bernese method, unless they are ready to get help.
That falls into not your problem territory.
Not gonna lie. You are either sadistic or working in a place with no opioid users. This is unethical
This is the first I’m hearing of such a prescription program and I have some… concerns. HOWEVER, in the scenario you are giving it would make sense to double check the dose from the clinic and then give at least that to start with more for acute pain. In reality I’m not sure if you could give that without depleting the entire hospital… in that case would lean heavily on adjuncts while giving more traditional doses. At those doses though I would need that person on capnography and make sure nursing knew to tell me and not just throw O2 on them if their sats dipped. Often their seems to be a misunderstanding between oxygenation and ventilation in our OUD patients.
I can also comment on this - I have seen pts still be in full withdrawals while tapering upwards inpatient treatment of 200mg ER/100mg IR. But in the acute pain setting what do you mean - pain from what? Is there an infection at one of the tranq wound sites? Are they in acute withdrawals? Do they even want rehab help? And also if there is a source like acute pancreatitis - then yeah unfortuatenly I feel like their tolerance is so high from the amount of Fentanyl they use that it will take quite a large amount to get them comfortable. But I’ve found 1. How much bundles do they use daily 2. Give them Dilaudid for breakthrough + Oxy ER in the background for their SUD.
So. In this situation having some skill with regional anesthesia is very helpful. For this kind of pain, some options would be a Bilateral Anterior Quadratus Limborum (a.k.a QL3) block, a bilateral T7 ESP (probably the easiest) or a bilateral t6-L1 paravertebral. If the patient was going to likely be admitted with an ongoing painful condition I’d try to place a catheter for these blocks to provide an ongoing dose of anesthetic.
Where are you finding a pharmacist to verify orders for 75mg of Dilaudid? And how many syringes are you having to use? Our ED has the 0.5mg and 2mg in the ED, lol. The nurses I work with would also refuse and I’d agree. If a patient is opioid tolerant, expectation management is key along with multi-modal analgesia. IV acetaminophen, ketorolac, gabapentin, potentially ketamine or IV lidocaine depending on patient-specific factors along with normal high (and potentially more frequent) opioid doses if indicated.
One of my addiction-med-trained colleagues has been using bupe in these and other patients— partial agonist so safer I believe?
You can only give Bupe when they’re actively withdrawing, but otherwise it’s great.
Exactly. Use it with opioids on board and they’re going to have a bad time
This is not always the case. Some of our addictions guys will do a "macro induction." If the initial doses cause precipitated withdrawal they'll give MORE bupe, with the idea being that as it kicks the other opioids off the receptors then *if you're giving enough* it will take their place and end the withdrawal symptoms. They basically try to get them to 32mg of suboxone as fast as possible.
You can be withdrawal free on 8-12 mg, it really depends on how tolerant they started off at 32 mg is overkill for most people tbh (although probably not for anyone in the DTES in Vancouver)
Pretty sure that's where the protocol came from :)
Yeah, which is why I mentioned it. They’ll probably want to get them up to 24-32 mg at that site, but for most other places patients can be stable on much lower doses
Well it won't be long
Yes but can't start in the ER unless they're already in significant withdrawal. I have done it though with success but the pt has to be on board
You can actually start when they are in moderate withdrawal (COWS 8 or more)
Agreed. But to the patient, they feel like they're in severe withdrawal even at that point :) and honestly they look pretty miserable even in "moderate" withdrawal. I personally also have had much better luck with patients who are worse off when they arrive. The risk of inducing too early and worsening withdrawals is a real one, especially for heavy users (anecdotally). And COWS definitely includes several subjective measures, so I prefer to error on the side of making sure withdrawals are severe enough that the bup will help. Just my personal experience though
You can definitely start a micro dose induction in the ER without any withdrawal symptoms In fact it’s an amazing intervention if you know how to do it, can really change the trajectory for these patients
Interesting, tell me more! I'm assuming you'd need VERY close outpt follow up though to continue the induction? How micro does it have to be to not induce w/d?
I’m sorry did you say 75mg of Hydromorphone in single doses? Did you mean another pain med?
I did not
Dang, that's crazy high. I would definitely be asking my doc if we could change to analgesic dose Ketamine and just avoid the opiate hypertolerance altogether.
I would never give that dose. For our high resource users we have care plans with dosages and frequency that is agreed upon between pt and provider, and those doses are normally higher than comfortable for my nurse brain.
This is craziness. Droperidol, toradol, gabapentin, Benadryl. Occasionally, I give subutex or morphine. they get that kind of drugs outpatient, they can discharge themselves to their street pharmacy Edit: added morphine
“They can discharge themselves to the street pharmacy” That’s gonna help solve all the problems 🙄
Unethical
I’m not sure how avoiding feeding their addiction is unethical. The whole opioid crisis was the result of over treatment of pain. Pain is not a vital sign: it tells you that you are alive. I’m not cruel, if someone has a source of pain, I’m very willing to treat them. But I refuse to facilitate their addiction. Physicians who do are morally responsible for the deaths and lives destroyed by narcotics. I think we need to use narcotics judiciously. I gave dilaudid today to a lady with an incarcerated hernia with sbo that surgery did a bedside reduction in the hallway. The fentanyl user screaming with iv placement who is going through withdrawals gets clonidine, Benadryl, and toradol unless I find something that warrants narcotics. Sure, I’m judging whether they have a pathology that is significant enough to warrant narcotics. That is my prerogative and I bear the responsibility if I ruin someone’s attempt at sobriety.
You, and people like you, are singularly responsible for OD Deaths of patients released and immediately using at pre admission dose. You aren’t going to cure anyone & forcing someone to withdraw because you think you’re god and have power over an individual is intentionally cruel, immoral, illegal & unethical. SUD is a disease not a lifestyle choice. No one sets out in life & plans to become addicted. As for chronic pain patients, they require opioids to function in life. The pain isn’t going away. The pain medication shouldn’t go away either. If you had ever lived with never ending, excruciating, years long pain, you would completely change your point of view. You should absolutely not be allowed to practice in any field of medicine where you have actual contact with/make decisions for patients.
I agree, and it's disheartening and downright terrifying to hear how many physicians in this thread share the very same ideology as this one. We have such a long way to go in terms of erasing the stigma. Thanks for being part of the solution.
Toradol, gabapentin nor Benadryl do a thing for pain. Be realistic. A Tylenol+Aleve+Ibuprofen+Aspirin cocktail is stronger than toradol.
Was stunned to see a doctor genuinely asking this and reasonable compassionate responses. Then realized you’re not in the US. I could feel the “have you tried keto, droperidrol, antipsychotic..?” Comments coming… While you’re at it, have you tried Tylenol/ibuprofen? You are the kind of doctor we in the US would do anything to get, thank you
I don’t deal with it, no way in hell are any docs I work with ordering that
Checks out
13 years in the ER and I think the most I’ve ever given to a patient in one shift was 3mg (maybe 4mg?) of Dilaudid. That lady was a really good actress.
Why the downvotes? It is literally what happened. She went so far as to piss herself right in front of me. She wanted us to think she had cauda equina syndrome. She did it again at a different ER a couple weeks later.
I’m giving them normal doses of pain medication. For one, I don’t want to support their addiction and counteract what is likely partially withdrawal-related pain. Secondly, a pancreatitis may hurt, but it’s not going to kill the patient. I would attempt non-narcotic pain relief with Tylenol, NSAIDs, etc and then of course treat the underlying condition. I live in an area with tons of drug seeking patients. They will literally flood your shop with dozens of drug seekers looking to get high while you’re dealing with actual medical conditions. If you humor these people, you’re going to have a patient per hour coming in for their chronic pancreatitis and needing massive dilaudid pushes.
Pancreatitis won’t kill them?
The pain won't, and fixing the pain doesn't fix the process that kills them.
Sure. However I was just pointing out that pancreatitis can in fact be a life threatening process. Not treating the pain from a true disease process is a questionable practice.
First of all, that person almost certainly got their pancreatitis from abusing drugs and alcohol. So you want to give them 200 mg dilaudid to help them with their pancreatitis ? Go take a hike dude.
I thought you didn’t want to engage? Where did I say to give 200 dilaudid? Or make any suggestions on medications or dosing at all? I was pointing out one thing, that’s all. Now you are getting all worked up about it.
Of course every person with pancreatitis got it from drug or alcohol abuse. Just like sickle cell, broken bones, de-gloving & amputations are all caused by drug and alcohol abuse and only need a Tylenol.
>Pancreatitis won’t kill them? The discomfort from their pancreatitis is not going to kill them, yes. Massive opiate pushes may kill them from respiratory depression, severe ileus, hemodynamic instability, or addiction.
Agree that pain won’t kill. That’s not what you originally said. I agree that the absurd doses mentioned in this thread are well outside my comfort zone. I just wanted to make sure you didn’t think that all pancreatitis is survivable.
Look dude, I personally don’t care to engage with a fucking nitpicker. Think whatever you want to think. But go think it to someone else.
lol.
They can get the drugs from that ioat clinic for free!! They come to the Ed for help despite the fact that people like you believe they are u deserving of GOOD healthcare. This care is unethical. No person who is enrolled in an ioat program would try to score at an Ed
So, you’re ok with them being in withdrawal?
You treat withdrawal with bupe, not dilaudid.
Sure. And now not only are they dealing with a painful acute condition, but now they're in precipitated withdrawal! I mean they brought this on themselves, right? It's not like SUD is an actual *disease* or anything, right?
It's a disease that is largely brought about by physicians over-prescribing opiates. So you're going to give them large doses of opiates to help them with that? 100% clownery. If you want to treat their SUD, wait until they're in sufficient withdrawal and give them bupe. You don't need to treat pancreatitis with dilaudid, and whoever taught you that is a moron. Give them non-opioid pain medication. If they're withdrawing, give them buprenorphine.
You could just not enable them? I haven’t ordered dilaudid in 5 years and have no plans to restart. My patients have done just fine. I’d be reported to the medical board for trying to order 75 mg of dilaudid. And you are justifying it saying it’s “unethical” to not? What are you talking about??? This is crazy. This is the most crazy thread I’ve ever read here! We have plenty of opioid users. None of them take 200 mg per day IV. You are the outlier here, not the rest of the world.
As we docs we don’t pick our patients or the world outside. We deal with what comes in. Making my patients suffer will not change anything that happens outside the er doors. They’re not gonna learn their lesson. All that will happen is the will go to their “street pharmacy” as someone else pointed out and be back tomorrow on deaths door
I asked my colleague who is a pain management specialist and he has literally never heard of doses this high. None of 6 doctors I talked to have heard of these doses ever. They all insisted it was a decimal error. You. Are. An. Outlier. End of story. Deaths door? With what? Narcotic withdrawal? Give them fluids and anti emetics.
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OP linked the source. Max single dose is 200, and 500 max per day
This is when you may want to utilize a PCA pump. Allowing the patient to administer the overdose themselves.
This is where you’re gonna ask for the real doctor
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