Thread by @Jim__Jackson

Today I’m going to discuss an important and frequently misunderstood topic among physicians of all specialties, that of narcotic tolerance. A thread. #pain #chronicpain #tolerance 1/x

If someone is on chronic opioid therapy, they may present with conditions that require additional therapy. Whether it is a recent surgery, a flareup of their chronic condition, or a new injury, you should realize that despite their current medication regimen, 2/x

they may require additional therapy to relieve their pain. They have built up a tolerance to narcotics. This means they need more of the drug to obtain the same analgesic effect. 3/x

In my experience both as a patient and as someone who treats many complex and difficult chronic pain patients on a multitude of medication regimens, I can tell you that if they are coming to see you because their current medications are not adequately treating their pain, 4/x

you should not be satisfied that just because they have pain meds at home that their current dose will be adequate. It clearly is not – that’s why they are coming to see you. 5/x

They have probably agonized about making that call or trip because they know they are likely to be looked down upon, ridiculed, made to wait hours, or otherwise mistreated as they have so many times before at other facilities. Something else should be done. 6/x

I have one unfortunate patient with RSD who literally has PTSD from the mistreatment she has suffered at various emergency departments and pain specialists. 7/x

If you can add an adjunct non-narcotic medication to help them that is effective, that is sometimes enough. But not always. And that’s not what I’m discussing in this thread. NSAIDS are wonderfully effective drugs and they should be considered first line agents. 8/x

Also, things like physical therapy, biofeedback, or ice/heat can help some, but it is not likely to help immediately to get them out of their current crisis. And they’ve probably already tried those things at home. 9/x

Often, they need the type of medications that have worked for thousands of years, and it’s frequently the one derived from the poppy plant. 10/x

Many doctors have a “policy” that they only give x amount of narcotics no matter what. These doctors are the ones who need to learn more about tolerance to narcotics, and those are the ones to whom this thread is addressed. 11/x

If they are taking 60 mg of oxycodone at home daily, one Tylenol #3 is not going to help them and it is basically a “fuck you, get out of my ER” to them. Don’t be that doctor. 12/x

I have patients who were already taking regimens like 20 mg of oral dilaudid or 400 mg of oral Demerol daily at home and were offered only 1 mg of dilaudid and that was it because that was the doctor’s “policy.” 13/x

This is NEVER going to be enough to help someone like that through their acute on chronic pain crisis. If you want to start with that dose and repeat as necessary until they (and you) are comfortable, that is appropriate. You can always give more but it’s harder to take away 14/x

Often the best thing you can do is look at the old chart and see what they have required and tolerated previously. 15/x

What I hear a lot is that the docs are afraid of jeopardizing their license so they can only give so much medication. This is completely idiotic and in no way reflected in reality. 16/x

It is true that if we prescribe to a known drug abuser, any amount of narcotic we give them can put our license in jeopardy, but *administering* narcotics to someone who has been managed for months or years on a stable narcotic regimen, 17/x

getting all of their meds from one pharmacy and one doctor (not doctor shopping) is not going to be problematic at all. These are not the patients you need to worry about. 18/x

To be ultimately safe, contacting the patient’s prescriber (usually a pain specialist but sometimes a PCP) can protect the patient from getting fired by that particular doctor and is generally good coordination of care. 19/x

Administering drugs in the ER is completely different than *prescribing* medications to them when they already have a prescriber and pain meds at home. Prescribing meds to them should be done rarely and cautiously and usually only after discussion with their pain specialist, 20/x

My main takeaway is that if you are going to administer narcotics in the ER to a patient already maintained on chronic opiate therapy, you may need to administer more than you would to an opioid naïve patient. 21/x

A sickle cell patient may need 8 mg of dilaudid at a time. Someone on even 50 MMEs of hydrocodone daily will often need 2-4 mg of DIlaudid or more to get them comfortable depending on the condition they present with. 22/x

If you want to give it 1 mg at a time, go for it but don’t stop at 1 mg because you have a stupid “policy,” you think you are helping them somehow. or you think you are protecting your license. You are not. 23/x

If you have a policy to only give 1 mg no matter what, just realize that you are not practicing good pain management and be prepared to administer more as needed. 24/x

If you are going to get in trouble from the state or the DEA for giving narcotics to someone, they don’t care if it’s one Tylonol #3 or 4 mg of Dilaudid. The amount doesn’t matter. It’s who you are giving it to (and to a lesser extent on how many visits). 25/x

I strongly recommend not prescribing or administering narcotics to doctor shoppers or drug abusers unless exceptional circumstances exist.

That's it, thanks for listening. Comments are welcome. 26/26

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