Ideas to avoid being wrongly labled

For one of my pain management patients to go to ER for pain crisis, they must call my office and speak with either doc, or myself. One of us is also, ALWAYS on call. If we triage them into the ED, one of us calls ahead and makes arrangements and will go ahead and give some orders.

It's time consuming, but it lets the patients know you are taking their pain seriously, and makes sure they are adquately treated in the ED.

I have often thought about a card system (I think it is a GREAT idea), I just want to make sure that when I have a patient in the ED, they REALLY need to be in the ED. If a patient is having only a mild increase in pain, they can often be given an extra doseage of their PRN or called in a stronger PRN. This saves them the "dreaded trip" to ER, free's up ED resources, and doesn't cost anyone a ER visit for something that really doesn't need to be there. Now, for moderate to severe pain, patients usually go straight to the ED.

Dave

I could NEVER imagine sending a patient to ED or elsewhere, and NOT call ahead or make some sort of referral.

Yes, people know who we are, and what we do, but... Can you imagine walking in and saying "I take Methadone and Dilaudid for pain. Yea, and some Ativan for anxiety and oh... Zanaflex." And yea, I'm having major pain issues. So what if I have cancer.

With the drug abuse problem in our area, the would be laughed out of the ED. Subjective pain, yea right!

Besides this, I don't want an ER doc ordering Nubain or Stadol, when I have a patient on pure opioid agonists. Not everyone understands the balance that is required, and not all pain medications are equal. When they think enough of my skills to come and see me regularly, I am certainly not going to leave them hanging when they are sick enough to be in the ED or Hospitalized.

Dave, who needs to call in some orders... right now :)

So what IS the deal with nubain and stadol ordered with morphine? I thought they could not be given together, and once had a patient who got both and they seemed to cancel out each other- she got NO relief.

Stadol and Nubain are what's called mixed opioid antagonists. Basically, you get some of the chemical structure that is like MS04, Demerol, ect... But you also get a chemical structure that is like Narcan. You DO NOT WANT to give a Narcan like drug when you have a patient who is in a pain crisis, when already on opioid therapy (unless you're treating overdose, over sedation, ect...)

Just not a good mixeroo!

Dave

Ya know I think I am going to talk to my MD about the card thing. We are talking small towns vill here care is so not coordinated. Luckily however my Md is very open and compassionate. He was very upset when I didnt recieve proper pain care because they did not contact him. I think he just might go for the card thing. Dave I like the way you coordinate your care I wish they did more of that around here. Even in the field I am currently in we have 4 different MD's that take call and ya get something different from everyone of them. Have people never heard of continuity of care? BTW dont ya just love that we have this site now?

Besides this, I don't want an ER doc ordering Nubain or Stadol, when I have a patient on pure opioid agonists

Crikey...this is so true. Great way to make somebody feel even sicker.

Thanks Dave, no wonder my lady was hurting.

giving nubain to a pt on chronic pain management will make em puke just as sure as narcan....they get really pissed as well....

I am a nurse I also have fibromyalgia and a host of other things. I have chronic pain it is ligetamit and there is medical testing that proves there are causes for the pain ie. severe arthritis. It seems to me there should be a way to be able to present in a pain crisis at an ER without being mislabled. My idea is that the primary physician could make up some sort of card we could carry. It could contain info such as DX's and what meds we are on and what works best for our pain crisis? I dont know if this is possible but that is my idea. The hope would be that it would exbidite our treatment and alevieate suspision. What do you all think.

I think it's a great idea. If nothing else maybe it will put a stop to nurses giving patients that look, you know the look, the one that says "you're nothing but a drug-seeker and I'm going to make it my mission to see that you aren't given anything but Toradol"

wrong posting.....oops

NUBAIN (nalbuphine hydrochloride) is a synthetic opioid agonist-antagonist analgesic of the phenanthrene series. It is chemically related to both the widely used opioid antagonist, naloxone, and the potent opioid analgesic, oxymorphone. Chemically nalbuphine hydrochloride is 17-(cyclobutylmethyl)-4,5(alpha)-epoxymorphinan-3,6(alpha),14-triol hydrochloride. Nalbuphine hydrochloride molecular weight is 393.91 and is soluble in H 2 O (35.5 mg/mL @ 25°C) and ethanol (0.8%); insoluble in CHCl 3 and ether. Nalbuphine hydrochloride has pKa values of 8.71 and 9.96. The molecular formula is C 21 H 27 NO 4 - HCl.

CLINICAL PHARMACOLOGY

NUBAIN is a potent analgesic. Its analgesic potency is essentially equivalent to that of morphine on a milligram basis. Receptor studies show that NUBAIN binds to mu, kappa, and delta receptors, but not to sigma receptors. NUBAIN is primarily a kappa agonist/partial mu antagonist analgesic.

The onset of action of NUBAIN occurs within 2 to 3 minutes after intravenous administration, and in less than 15 minutes following subcutaneous or intramuscular injection. The plasma half-life of nalbuphine is 5 hours, and in clinical studies the duration of analgesic activity has been reported to range from 3 to 6 hours.

The opioid antagonist activity of NUBAIN is one-fourth as potent as nalorphine and 10 times that of pentazocine.

NUBAIN may produce the same degree of respiratory depression as equianalgesic doses of morphine. However, NUBAIN exhibits a ceiling effect such that increases in dose greater than 30 mg do not produce further respiratory depression in the absence of other CNS active medications affecting respiration.

NUBAIN by itself has potent opioid antagonist activity at doses equal to or lower than its analgesic dose. When administered following or concurrent with mu agonist opioid analgesics (e.g., morphine, oxymorphone, fentanyl), NUBAIN may partially reverse or block opioid-induced respiratory depression from the mu agonist analgesic. NUBAIN may precipitate withdrawal in patients dependent on opioid drugs. NUBAIN should be used with caution in patients who have been receiving mu opioid analgesics on a regular basis.

Significant Interactions

Interaction with other Central Nervous System Depressants.

Although Nubain possesses narcotic antagonist activity, there is evidence that in non dependent patients it will not antagonise a narcotic analgesic administered just before, concurrently, or just after an injection of Nubain. Therefore, patients receiving a narcotic analgesic, general anesthetics, phenothiazines, or other tranquilizers, sedatives, hypnotics, or other CNS depressants (including alcohol) concomitantly with Nubain may exhibit an additive effect. When such combined therapy is contemplated, the dose of one or both agents should be reduced.

Patients Dependent on Opioids

Patients who have been taking opioids chronically may experience withdrawal symptoms upon the administration of NUBAIN. If unduly troublesome, opioid withdrawal symptoms can be controlled by the slow intravenous administration of small increments of morphine, until relief occurs. If the previous analgesic was morphine, meperidine, codeine, or other opioid with similar duration of activity, one-fourth of the anticipated dose of NUBAIN can be administered initially and the patient observed for signs of withdrawal, i.e., abdominal cramps, nausea and vomiting, lacrimation, rhinorrhea, anxiety, restlessness, elevation of temperature or piloerection. If untoward symptoms do not occur, progressively larger doses may be tried at appropriate intervals until the desired level of analgesia is obtained with NUBAIN.