giving Narcotics like candy

[emtI4now]

I took Imitrex for my migraines, I thought I was gonna die. It made it so much worse, I truly thought I was going to stroke out.

Now I am on a maintenance preventative drug and a PRN pain med that works if I take it immediately when one is beginning.

[Just Plain Ruff]

but for those who do not know this, the po form has not produced the cardiac events that the injectible form has. It's a slightly different formula.

I would be very careful when getting this injectible. The PO form is fine to take but the injectible has quite a few risks.

[kevkei]

Try the Imitrex nasal spray, get the best of both worlds. Faster onsed (than PO) less undesired and adverse side effects (IM)

[Dustdevil]

None of that is nearly as much fun as Demerol.

[Guest]

Demeral is good

[MedicShannon]

See, now the only thing that Demerol does to me is make me sleep...and that is it. Now Dilaudid... I get Beetlejuice syndrome

What is Beetlejuice syndrome? It is the temporary feeling of my head shrinking into my neck...its great.

The other thing I like about Dilaudid... I can actually have a conversation with someone and remember what was said.

[Ace844]

See, now the only thing that Demerol does to me is make me sleep...and that is it. Now Dilaudid... I get Beetlejuice syndrome

What is Beetlejuice syndrome? It is the temporary feeling of my head shrinking into my neck...its great.

The other thing I like about Dilaudid... I can actually have a conversation with someone and remember what was said.

If you don'r like dilaudid, and you can convince them that you're not drug seeking, get them to give you Fentanyl instead...GOOD STUFF!!!!! 8)

Ace844

[Dustdevil]

Unfortunately, I've had way more than my fair share of serious injuries in my lifetime. Consequently, I have had the opportunity to experience just about all of the known analgesics at one time or another. Trust me, I'm not bragging. :?

But interestingly enough, the most absolutely whacked out of mind I have ever been was on the non-narcotic synthetics. Stadol and Ultram are highly hallucinogenic! I really don't remember if they actually killed the pain or not. All I remember is that I simply didn't care if I was hurting anymore.

[Ace844]

Morphine at 0.1 Mg/kg Does Not Control Severe Pain

NEW YORK (Reuters Health) Nov 02 - Intravenous morphine at 0.1 mg/kg does not effectively control severe acute pain in most patients, according to researchers at the Albert Einstein College of Medicine in the Bronx.

Lead author Dr. Polly E. Bijur and colleagues prospectively evaluated the analgesic effect of 0.1 mg/kg intravenous morphine in 119 patients, between 21 and 65 years old, who presented to the emergency department with acute, severe pain.

The subjects rated the intensity of their pain on a validated 11-point verbal numeric scale that ranged from 0 (no pain) to 10 (worst possible pain) immediately before they received the morphine and 30 minutes later. The median baseline pain score was 10.

The main outcome measure was the proportion of patients whose pain decreased by less than 50% during the 30-minute interval, according to the report in the October issue of the Annals of Emergency Medicine.

Eighty patients (67%) who received intravenous morphine at 0.1 mg/kg reported a less than 50% decrease in pain from baseline. Overall, 19 patients (16%) had no change in pain or an increase in pain in the 30-minute interval. None of the patients required an opioid antagonist at any time during or after the study period.

"Acute pain might be better controlled in the ER by increasing the dose of morphine or using alternative opioid analgesics if patient safety can be assured," Dr. Bijur said in an interview with Reuters Health. "Administering multiple small doses of morphine until pain is controlled is an optimal strategy, though difficult to achieve in a busy ER setting."

The investigator noted that they are currently comparing a 50% higher dose of morphine, 0.15 mg/kg, with the standard dose. In addition, the team is conducting studies of hydromorphone (Dilaudid), another potent opioid analgesic.

"Pain is seriously under-treated in the ER and we feel it is an ethical obligation for physicians to adequately manage pain and alleviate suffering of our patients," Dr. Bijur explained.

Ann Emerg Med 2005;46:362-367.

Eleven Common Myths About Pain Control

According to the most recent studies, widely prevalent assumptions with little, if any, basis in fact are leading clinicians to use analgesic drugs ineffectively.

By Robert Dachs, MD

Dr. Dachs is chairman, department of emergency medicine, Westerly Hospital, Westerly, Rhode Island.

The message is loud and clear: timely and compassionate pain management is expected for all patients with acutely painful conditions. Professional organizations, most notably the American Pain Society, as well as our anesthesiology and nursing colleagues, hospital administrators, regulators, and the public at large have championed this issue and raised it to its current prominence. In an attempt to meet these expectations, a critical look at common myths associated with acute pain care can be enlightening.

MYTH 1

Physicians, nurses, and prehospital care providers do a good job of providing adequate analgesia to patients in pain.

The data are unequivocal: on average, health care providers do a terrible job of managing acute pain. Physicians order inadequate doses of analgesics or no analgesia at all for patients in pain. Nurses, when given a dose range for analgesics, tend to give lower doses or withhold analgesia in PRN cases. Even prehospital care providers with access to analgesics rarely give these drugs to patients with painful conditions such as suspected extremity fractures.

This widespread practice of not providing adequate analgesia has been termed oligoanalgesia, and it has been documented in emergency departments, intensive care units, and medical and surgical wards here in the United States and abroad. Further, certain groups of patients are particularly likely to be on the receiving end of this practice. Both the very young and very old, for example, often receive inadequate analgesia. Dr. Knox Todd and colleagues have demonstrated that Hispanic and African American patients with extremity fractures receive less analgesia than white patients with these same conditions.

A good working knowledge of how to provide appropriate analgesia, together with an honest self-appraisal by all health care providers, is necessary to combat this disservice to our patients.

MYTH 2

Codeine is an effective analgesic and antitussive.

Codeine is a very weak analgesic. In standard doses, codeine produces no more pain relief than NSAIDs or acetaminophen alone. When acetaminophen plus codeine was compared with the NSAID du jour in multiple studies involving postsurgical pain or acute musculoskeletal injuries, the combination was noted to have equivalent analgesic efficacy. Further, when deCrean reviewed 24 trials comparing acetaminophen with codeine to acetaminophen alone, he found only a 5% difference in pain intensity between the agents, as rated by subjects on a 1 to 10 scale (British Medical Journal, vol. 313, p. 321, 1996). This difference is statistically significant, but it has no clinical significance.

Codeine's adverse effects, on the other hand, are legendary. Nausea, vomiting, and constipation are common. Geriatricians often note that codeine produces the "terrible C's"–confusion and constipation–in their patient population.

As for controlling a cough, codeine in standard doses has no more antitussive effect than placebo. The bottom line with this drug is that in the absence of any clear benefit and considering its troublesome side effects, it is difficult to recommend codeine as an analgesic or as an antitussive.

MYTH 3

Propoxyphene is an effective and safe analgesic.

Propoxyphene possesses negligible analgesic effects. When researchers at Texas A&M compared propoxyphene with ibuprofen 400 mg and placebo in patients with acute musculoskeletal trauma, no clinical difference in pain relief was noted between propoxyphene and placebo. Further, a review of 26 trials of propoxyphene with acetaminophen versus acetaminophen alone concluded that there was no evidence to support the use of the combination product.

Propoxyphene and its metabolites have been associated with cardiotoxicity, neurologic sequelae, and death. The major metabolite, norpropoxyphene, has a half life of 30 to 36 hours and produces local anesthetic and antiarrhythmic effects similar to those of lidocaine and quinidine. When it accumulates, either from chronic administration or acute overdose, norpropoxyphene can produce arrhythmias, cardiogenic shock, mental status changes, seizures, coma, and death.

Consensus committees have clearly indicated that propoxyphene should not be given to geriatric patients. In fact, the argument can be made that this drug should not be given to any patient, regardless of age.

Fortunately, there are better choices than codeine and propoxyphene for pain management. Hydrocodone and oxycodone, with and without acetaminophen, are effective analgesics. Oxycodone is available in a long-acting preparation. Transnasal butorphanol is also effective, but it is expensive.

MYTH 4

Morphine 2 mg IV provides adequate analgesia in healthy adults.

The American College of Critical Care Medicine has recognized morphine as the drug of choice in critically ill patients who require analgesia. The dose is a 0.05 to 0.1 mg/kg bolus; it can then be rapidly increased to achieve the desired effect. In many emergency departments, morphine doses of 10, 20, or 30 mg in the first hour are not unusual. Unfortunately, the all-too-common order of 2 mg of morphine will often leave patients in pain.

MYTH 5

"Meperidine 50 mg with hydroxyzine 25 mg IM q4hrs prn" is an appropriate order for hospitalized patients.

This order is so common many physicians can recite it by rote. But how appropriate is it?

Meperidine's clinical effect is very short-lived, often lasting only two or three hours. The need for subsequent repetitive doses can result in deleterious central nervous system side effects. This is because meperidine's inactive metabolite, normeperidine, has a long half-life, and when it accumulates it produces central nervous system excitation and the risk of seizures. That is why many experts recommend avoiding or minimizing meperidine use in hospitalized patients.

If meperidine is necessary, the addition of an antiemetic (traditionally, hydroxyzine) will not potentiate the effect of the narcotic, as is widely believed. While an antiemetic may make the patient drowsy and decrease nausea, the clinician should not lower the dose of the analgesic if an antiemetic is added. And hydroxyzine should never be chosen as the antiemetic. The drug can only be given intramuscularly and is extraordinarily painful and irritating to soft tissue.

Again, better choices exist. Adequate doses of morphine would be the first-line choice. Fentanyl is an excellent alternative in hemodynamically unstable patients or those with exaggerated histamine response to morphine. Hydromorphone is another excellent alternative.

MYTH 6

Use of narcotic analgesic agents will result in chronic opioid dependence.

Avoiding the use of appropriate narcotic analgesia out of fear of inducing chronic opioid dependence and drug-seeking behavior is completely unfounded. Researchers at Boston University reviewed the records of 11,882 patients given narcotics during a hospital stay and found only four patients who later developed an opioid dependence.

When a clinician subscribes to this myth and avoids using these drugs, he or she may actually help perpetuate a course of chronic pain and unwittingly create a reliance on analgesics in patients. With undertreatment of acute pain, recruitment of increasing numbers of nerve fibers occurs. The ensuing windup of the sensory nervous system can result in long-standing modification in pain sensation. Consequently, early and aggressive use of analgesics followed by a rapid tapering of the dose is encouraged in patients with acute pain.

MYTH 7

Injectable ketorolac is more effective and has less gastrointestinal toxicity than oral NSAIDs.

Many clinicians mistakenly believe that ketorolac possesses some magical analgesic property because it can be administered intramuscularly or intravenously. Study after study, however, has refuted this theory. Also, regardless of the route of administration, ketorolac's ability to inhibit prostaglandin synthesis can disrupt the stomach's mucosal barrier. Therefore, even though the drug is not taken orally, gastrointestinal toxicity is still possible.

MYTH 8

NSAIDs have more analgesic effect than acetaminophen.

In a landmark study, Bradley and colleagues randomly assigned patients with osteoarthritis of the knee to receive either 4000 mg acetaminophen, 1200 mg ibuprofen, or 2400 mg ibuprofen per day. The result: acetaminophen was just as effective as either dose of ibuprofen (New England Journal of Medicine, vol. 325, p. 87, 1991).

It seems reasonable that 4000 mg acetaminophen and 1200 mg ibuprofen per day would produce similar results. But why doesn't the 2400-mg/day dose of ibuprofen produce additional analgesic effect? Because increased doses of NSAIDs further inhibit prostaglandin synthesis. This is useful in managing patients with prostaglandin-mediated diseases such as rheumatoid arthritis. However, when it comes to analgesia, NSAIDs have a ceiling effect–that is, no further analgesic effect will occur with increased doses. Therefore, 2400 mg/day of ibuprofen in non-prostaglandin-mediated diseases such as osteoarthritis and soft tissue injury will produce no additional analgesia.

MYTH 9

NSAIDs should be first-line agents in soft-tissue injuries such as ankle sprains.

NSAIDs do have a role in the care of patients with acutely painful conditions that involve a prostaglandin-mediated process. Examples of such conditions include renal colic, biliary colic, dysmenorrhea, and gout. Soft-tissue injuries, however, are not primarily prostaglandin-mediated events, and there are no data to support NSAID use for such injuries.

In addition, when treating patients with non-life-threatening conditions such as sprains and strains, the clinician must seriously consider the dangers associated with NSAIDs. Wolfe and colleagues documented that the mortality rate associated with NSAID use in 1997 was equivalent to the mortality rate from AIDS in the United States that same year (New England Journal of Medicine, vol. 340, p.1888, 1999). Cautious use of these agents is clearly warranted.

MYTH 10

COX-2 inhibitors are more effective than traditional NSAIDs in controlling pain.

When it comes to analgesic efficacy, the newer COX-2 inhibitors, celecoxib and rofecoxib, are no more potent than their traditional counterparts. Even the question of whether these newer agents produce fewer gastrointestinal complications than NSAIDs is up for debate. Two recent high-profile studies found a 50% decrease in the rate of gastrointestinal complications with COX-2 inhibitors. However, both studies were manufacturer-supported trials with design flaws that may invalidate the findings. Further, the CLASS trial noted that no decrease in the rate of gastrointestinal complications was associated with celecoxib use in patients taking just one aspirin a day.

MYTH 11

Tramadol is an effective analgesic.

In separate studies, pain relief with tramadol has been shown to be inferior to hydrocodone with acetaminophen and codeine with acetaminophen and no more effective than placebo. This lack of analgesic effect was noted with both the 50- and 100-mg doses. Tramadol is simply not an effective analgesic.

ELIMINATING OLIGOANALGESIA

The goal of eliminating the practice of oligoanalgesia should be at the top of every primary care provider's agenda. Being aware of common myths associated with pain management is a key step in moving toward this goal.

[Ace844]

Hi ALL,

Here’s some more info on analgesia for you all to peruse…..

Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences, part of the Taylor & Francis Group

Issue: Volume 10, Number 1 / January-March 2006

Pages: 71 - 76

URL: Linking Options

DOI: 10.1080/10903120500366086

Effects of an Educational Intervention on Prehospital Pain Management

Scott C. French A1, A2, Nabil P. Salama A1, Serena Baqai A1, Sonja Raslavicus A1, Jill Ramaker A3, Shu B. Chan A1

A1 Resurrection Emergency medicine Residency program, Resurrection medical Center, Chicago, Illinois

A2 St. Francis Hospital, Resurrection Hospital, Evanston, Illinois

A3 Evanston Hospital, Evanston Northwestern Healthcare, Evanston, Illinois

Abstract:

Introduction. Pain is a common symptom evaluated by emergency medical services (EMS) providers. Hospital pain management programs began in the early 1990s based on a multidisciplinary approach and principles of total quality improvement. To date, these programs have had limited exposure in the prehospital setting. Objectives. To evaluate the effects of a pain management educational intervention (EI) for paramedic caregivers. Methods. All ambulance providers from ten urban and suburban fire departments and two private ambulance companies participated in a three-hour EI during a quality improvement project. A survey was performed prior to the EI and repeated one month after the EI. A two-month collection of EMS runs for pain complaints was performed prior to the EI and repeated one month after the EI. Data analysis was performed using descriptive statistics and chi-square tests. Results. The authors reviewed 397 surveys and 439 EMS runs for pain. Overall, after the EI, paramedics' knowledge of basic pain management principles increased from 57.3% to 74.9% (17.5%; 95% confidence interval (CI): 14.9%–20.2%; p < 0.001). Paramedics' utilization of nonpharmacologic pain therapies improved by 32.2% (95% CI: 25.3%–39.2%; p < 0.001), but there was no significant change in the use of pain medication (20.2% to 24.5%). There were 51.0% (95% CI: 44.1%–57.9%; p < 0.001) improvement in documentation of pain severity, 24% (95% CI: 21.2%–26.8%; p < 0.001) improvement in documentation of pain characteristics, and 13% (95% CI: 7.4%–18.7%; p < 0.001) improvement in pain reassessment following intervention. Conclusion. As a result of a three-hour educational intervention, paramedics had an increased understanding of pain principles, were more likely to provide prehospital nonpharmacologic pain therapy, and were more likely to document the results of their interventions.

( Safety and Effectiveness of Fentanyl Administration for Prehospital Pain Management Arthur Kanowitz A1 @ Thomas M. Dunn A2, A3, Elyse M. Kanowitz A4, William W. Dunn A1, A5, Kayleen VanBuskirk A4 A1 Pridemark Paramedic Services, Arvada, Colorado

A2 University of Northern Colorado, Department of Psychology, Greeley, Colorado

A3 Pridemark Paramedic Services, Boulder, Colorado

A4 Department of Biology, Colorado Springs, Colorado

A5 Paramedic Division, Denver Health Medical Center, Denver, Colorado)

Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences, part of the Taylor & Francis Group

Issue: Volume 10, Number 1 / January-March 2006

Pages: 1 - 7

URL: Linking Options

DOI: 10.1080/10903120500373264

Safety and Effectiveness of Fentanyl Administration for Prehospital Pain Management

Arthur Kanowitz A1, Thomas M. Dunn A2, A3, Elyse M. Kanowitz A4, William W. Dunn A1, A5, Kayleen VanBuskirk A4

A1 Pridemark Paramedic Services, Arvada, Colorado

A2 University of Northern Colorado, Department of Psychology, Greeley, Colorado

A3 Pridemark Paramedic Services, Boulder, Colorado

A4 Department of Biology, Colorado Springs, Colorado

A5 Paramedic Division, Denver Health Medical Center, Denver, Colorado

Abstract:

Objective. To determine the safety and effectiveness of fentanyl administration for prehospital pain management. Methods. This was a retrospective chart review of patients transported by ambulance during 2002–2003 who were administered fentanyl citrate in an out-of-hospital setting. Pre- and post-pain-management data were abstracted, including vital signs, verbal numeric pain scale scores, medications administered, and recovery interventions. In addition, the emergency department (ED) charts of a subgroup of these patients were reviewed for similar data elements. Results. Of 2,129 patients who received fentanyl for prehospital analgesia, only 12 (0.6%) had a vital sign abnormality that could have been caused by the administration of fentanyl. Only one (0.2%) of the 611 patients who had both field and ED charts reviewed had a vital sign abnormality that necessitated a recovery intervention. There were no admissions to the hospital, nor patient deaths, attributed to fentanyl use. There was a statistically significant improvement in subjective pain scale scores (8.4 to 3.7). Clinically, this correlates with improvement from severe to mild pain. Conclusion. This study showed that fentanyl was effective in decreasing pain scores without causing significant hypotension, respiratory depression, hypoxemia, or sedation. Thus, fentanyl citrate can be used safely and effectively for pain management in the out-of-hospital arena.

hope this helps,

ACE844