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Cantorsdust posted:This is a big part of it. Running chains of hospitals is now big healthcare business. They meticulously track patient satisfaction scores, pain scores, etc for each doctor. And hospitals themselves are tracked on the same scores by both private sources online and publicly. I know Medicare was considering penalizing you a certain percentage of your reimbursement if your patient satisfaction was too low. They're not talking about it, they've been doing it since 2012. You can lose at least 1% of ALL reimbursements if you don't make your patients happy and that number is going up every year. One question on all of the surveys that patients get is something along the lines of "were you happy with your pain control?". A lot of states have prescription monitoring programs that aren't used. I had a guy who, in the six months that the report covered, had seen something like a dozen prescribers filled over 3,500 pills of pretty much every flavor of oral opiate and benzo. I scanned the report into his record, summarized the results in my discharge summary and handed the patient the report before telling him he wouldn't be getting any with any opiates since, well, he filled about 200 hydromorphone tablets last week and should be well covered. He can take those, the allopurinol/colchicine/indomethacin I did prescribe him for his gout. Kentucky now requires that all prescribers have access to the prescription monitoring program, whereas in most states it's voluntary. Half the people I work with don't even know about the state PMP. Kentucky also requires that prescribers run a report and document the results before writing outpatient prescriptions. When combined with the pill-mill busting measures (they moved across state lines) it radically decreased the number of prescription opiates in the state. They've been since replaced with a heroin epidemic. I can't find them anywhere but there are also TV commericals for a gut-specific Narcan called methylnaltrexone used to treat opiod induced constipation. I've used it a couple of times in the inpatient setting and I'm not super impressed. Brown bombs and lactulose have gotten better, cheaper results.
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Feb 16, 2016 23:45
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Macaroni Surprise posted:Working as an addiction counselor has made me a massive fan of medical marijuana for pain. The potential danger is so much lower than even low-dose opiates that in my mind it should be used as a first-pass medication to cope with chronic pain. I'd rather have any client addicted to marijuana over painkillers. After having to do manual disimpactions, seeing bowels get cut out, people straight up die in front of you, people threaten me with violence for not sending them home on dilaudid pills I agree. The worst I've seen is cannabis induced hyper emesis. Dude was smoking over an ounce a week and just would not stop vomiting. We just pumped him with fluids and asked him to please not smoke so much. I'll take that over having to fish rock hard chunks of poo poo out of of some dude any day.
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Mar 9, 2016 14:24
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deathbysnusnu posted:I see a lot of this from the health care provider side of things. I'm a doctor in Kentucky and dealing with people who are addicted to opioids is probably the most challenging part of my day. Mostly because the addiction itself puts you and the patient in an almost oppositional relationship by default on the inpatient side of things. The heroin tends to cause health problems that tends to put you in the hospital that tends to put you into an environment with professionally placed IV access and a pharmacy stocked with dilaudid. I know they're going to withdrawal and that amounts to a temptation I will never understand, and I also know that unless they have something verifiably painful like pancreatitis or an ischemic digit giving them opioids is just feeding the addiction. It takes me a few minutes before walking into the room to get into the head space and remind myself they're here to get help, that they're people too, and that addiction is not something you can choose. It gets tough because there's not a lot of resources for recovery on the discharge end of the stay and even if you can get something set up, not much really works well to assist in recovery beyond social support networks. How's HB-1 and mandatory KASPER working out?
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Apr 4, 2016 15:34
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deathbysnusnu posted:That's a really tough question that we probably won't be able to answer for a decade or so. So my take is that heroin use has gone way up because recreational pills are becoming prohibitively hard to get due to KASPER. On the flip side, I'm hoping heroin use overall will go way down in time because most people get on heroin because they first got addicted to pills which is becoming a lot harder now. Hope so. I am pushing my hospital to move to mandatory registration with the local background check system for all providers in our system. The ultimate goal is to get a system Mandated background check on all substances as part of hospital policy. I do it on everyone before I give them narcotics of any kind. Usually comes up with nothing, sometimes it's a 40 page report for 6 months with over 3000 pills of dilaudid/Percocet/norco/Xanax/Valium and god knows what else.
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Apr 4, 2016 19:12
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moller posted:See also adding acetaminophen to codeine and similar. You can "discourage abuse" by killing the poo poo out of people. That's not why the add acetaminophen to codeine or other opiates. Dying of acute liver failure from Tylenol OD is ugly. Real ugly, and expensive. Like days to weeks of ICU and slow decline plus or minus a liver transplant and a lifetime of followup and immunosuppression. Lot cheaper to just OD on the opiate, usually.
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Apr 26, 2016 16:06
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rkajdi posted:Isn't that partially because Tylenol poisoning is one of those no-poo poo, will kill you and there's nothing we can do things? I know we had a researcher on post use Tylenol overdose as a way to kill himself, and it was surprising that it both worked so well and was such a long and excruciating way to die. Depends on when they show up. If they walk up to the emergency room and say "I ate a bottle of Tylenol" they can get a big load of charcoal and that helps bind up the big wad of drug they have lying in their stomach and keeps it from being absorbed. On top of that you infuse acetylcysteine which limits the damage that Tylenol does to the liver. It's not an antidote like narcan or flumazenil but it basically supports the liver while it processes all the extra Tylenol. You keep pumping them full of acetylcysteine until the Tylenol levels drop to a certain level. It works really well, and if a patient shows up early enough they'll (probably) be fine. We see a lot of it and we've gotten good at treating it, something like 96% of patients who have an acute OD do fine if the get therapy in a timely manner The people that don't do well are the ones that wait too long or have a combined OD , pass out and are found down hours later. Or the ones that are chronically overdosing and show up already in liver failure. Tylenol is tremendously safe when you stay at or beneath the recommended dosages, we use it even in chronic liver failure patients who are yellower than a taxi, albeit at a lower dose.
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Apr 28, 2016 20:42
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PT6A posted:Asking for money from a friend/acquaintance would seem to be a more effective way of getting drugs than to ask a doctor to do something outright illegal, though. I'd rather give an addict money than risk my own freedom by actually supplying the drugs. Of course, I'd probably try to avoid either one. They always ask even when there's a big sign behind me saying "no oxy/norco/Percocet/Vicodin/Xanax scripts". I walk to my car with my white coat on and have been hit up by people on the parking lot. There was a mess student who lived near the hospital that had to stop wearing their short white coat because they got harassed for opiates on more than one occasion just walking home.
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May 29, 2016 18:44
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smg77 posted:Yeah it looks like loperamide overdoses are becoming a thing. I bet we'll see it restricted like pseudoephedrine before much longer. There was a TCC goon that died of an overdose of Imodium as I recall.
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Jun 9, 2016 16:27
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Lote posted:There's a good amount that "survive" an OD and end up being in a coma with little to no brain left and needing a breathing machine. They'll "live" in a nursing home until an infection from a pressure sore or pneumonia gets them. There aren't any good statistics about how many people end up like this and they may not eventually be included in the number of overdose deaths. People don't realize this enough. You go into the ICU for any reason you are hosed unless proven otherwise. It's a last ditch effort to keep you alive and oftentimes ends in that same sad scenario of slow, painful decline and inevitable death by inches. I can't see fentanyl being intrinsically more prone to causing anoxic brain injury than other opiates, the mechanism is the same. The difference is the circumstances of the overdose, time down and the wildly variable potency that makes ODing so commonplace ODs are the number one source of brain death and spare parts for the transplant machine at my hospital. We are a rich white people hospital so not a lot of ODs are dumped on our doorstep, but we get more than a few ICU transfers for neuro eval or MRI or what have you from the less rich less white parts of the state that had overdoses on some flavor of opiates. It's always tragic and miserable for everyone involved. The transfers are the worst because coming here gives the family false hope and these people are usually young and for the most part healthy-ish. A lot of the time we just keep their organs alive long enough to be transplantable.
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May 25, 2017 21:06
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Dmitri-9 posted:They are treating fentanyl like a drug problem but they should be treating it like an industrial contaminant or chemical weapon and crack down on the super labs that are making this stuff. The "super labs" are in the same places that legitimate fentanyl &c come from. Namely, China, India, etc. Cracking down on precursor manufacture basically made qualuuddes go away entirely but I don't see that with fentanyl or anything else as there are legitimate uses for those drugs as well as for their precursors.
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May 25, 2017 22:58
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ToxicSlurpee posted:Cross-contamination is a massive, massive issue with something as strong as fentanyl, though. You can be killed by somebody opening a bag of it in the same room as you. That stuff does not gently caress around. It doesn't take much of it at all accidentally finding its way into something else to make people die. Aside from the opioid epidemic police in some places now just carry naloxone everywhere they go because fentanyl is so deadly. Get a call for an overdose, find a dead person, get a bit of fentanyl in your system, now you're dead too! Hurray! With it becoming increasingly common it's actually kind of horrifying. That's a little extreme, but the stuff is dosed medically in micrograms. Look up the phenazepam threads in TCC if you want an idea of what a great idea it is to eyeball something that potent.
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May 25, 2017 23:36
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Lote posted:People that use IV drugs almost always have Hepatitis C. A decent number have HIV. We transplant hepc livers now, they just get harvoni afterwards. I actually have not had an IV OD, it's always pills here.
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May 26, 2017 04:14
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Albino Squirrel posted:Haha, seriously? That seems... weird to me. Well not everyone with HepC gets cirrhosis, so if the liver is good and works, gently caress it, stick it in there and start harvoni on discharge. They have only done HCV+ livers in people that already had HCV though. They're doing HCV+ kidneys to HCV+ donors too. It's been a great thing since we are so drat short of spare people parts anything that increases the available number by even a few hundred a year has a huge impact.
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May 27, 2017 22:53
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It's the same problem that the people taking phenazepam had. Have? You have a drug that has to be dosed an extremely tiny amounts that requires specialized equipment to even measure, being taken by people that think that you can dose micrograms with an eyeball and a toothpick. You might get lucky, or you might lose a week of your life and wake up with a new piano. Or you might end up dead.
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Feb 21, 2018 18:42
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A Spherical Sponge posted:idk if the pain as a vital sign groups were astroturfed at all. I think it is a legitimately held medical opinion which was likely exploited by Purdue and others. I have seen this article going around which is basically just a record of people who've committed suicide due to their access to opiates, which they required for their severe chronic pain conditions, being suddenly cut off with just a rapid taper because their doctors are afraid of losing their licenses, or people in severe acute pain being denied access to opiates because of ER staff misinterpreting the new CDC guidelines. The American Pain Society, which does receive large amounts of pharmaceutical industry funding, came up with the "fifth vital sign" bullshit. Not coincidentally they started pushing it hard around the time OxyContin came to market. By 2001 the joint commission made sure it was forced down everyone's throats.
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Mar 29, 2018 05:15
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