If you want to give someone a pain killer
stronger than an NSAID but not a narcotic, tramadol is a reasonable
choice. It is very well tolerated in some patients.
If you want to talk about medications with a malignant side effect
profile and a narrow therapeutic index, narcotics will be at the top
of your list.
If you can say that tramadol doesn't have malignant side effects, you haven't spent enough time looking at it.
It isn't "narcotic" in the sense that it isn't scheduled. It is still on opioid like drug with mu receptor agonism. It is still habit
forming and has significant addiction potential. Seizures occur in overdose as does serotonin syndrome. It is metabolized by the CYP2D6 system, so there is errectic metabolism and significant drug-drug interaction. 10-20% of patients out there are going to metabolize it fairly slowly and have risk of significant side effects by taking it normally.
Risks to opioids: close to zero with normal dosing, especially with someone who is tolerant. In overdose, sure there is respiratory
depression, but I have a reversal agent. And it still takes alot, in someone who is tolerant to get significant respiratory depression.
Oh yeah...you can still get respiratory depression with Tramadol. You just usually see the other side effects and toxicity first.
It IS your problem. Aside from the fact that narcotic addiction ruins
peoples' lives, given all the complications related to narcotics
(falls, MVAs, fatal overdose, constipation), these are some of the
most dangerous drugs you can prescribe.
But you see, I'm not going to fix them by denying someone a prescription. What I am going to end up doing is denying someone who has a painful condition from getting some analgesics. So I give a liar a couple days worth of vicodin. Big deal. I'd rather do that then have someone in pain for several days because they can't get into see their doctor.
Would you just randomly fill
prescriptions for digoxin and warfarin if people wanted those too?
A semi ridiculous question. If they have the appropriate indications and I do the appropriate testing, then yes, I can and I have. I don't have a pain test yet and the indication is that someone says they are in pain. So, just as it is appropriate to prescribe someone on warfarin for a-fib a short term refill when they are having trouble seeing their doctor, it is appropriate to give someone a short term refill of their pain medication when they have trouble seeing their doctor.
And do be careful giving that Tramadol to people on Warfarin. Nasty little interaction there.
Why do you think that these people come to the ED and waste your time in the first place? Because they count on "easy marks" who would
rather give them what they want than be honest and tell them to beat
it.
Aside from the fact that your DEA license is contingent upon it, you
have a moral duty to avoid prescribing narcotics which you believe may
be diverted.
Well, if I suspect they are being diverted, then I won't write them. But if I think the person is going to take them, then I have no issues writing a 'script. The DEA isn't a going to pull your license or even investigate because you write the occasional vicodin script to someone who abuses drugs.
Secondarily, people with a diagnosed pain condition who
are under the care of a pain management specialist should get their
care from that practitioner rather than be trying to get narcotics
outside of their agreed upon dosing. They are wrong to be there even
asking you for the prescription in the first place.
You have a very jaded and Puritanical view of pain management. Most patients who are coming to the ED complaining of chronic painful conditions actually have some degree of pain. While they may be exaggerating and doing all kind of unethical/illegal things, they do actually have pain. And patients with chronic painful condition have different responses to pain than those who do not. There is a distinct change in receptor physiology and response.
Frankly, most of my patients barely have a PCP, let alone a pain management doctor. And if they are out of their meds, I'm happy to discuss treatment with their pain doc, but unless there is some information that suggests they are lying or otherwise doing something illegal that they have a "pain contract" is not, in and of itself a reason not to give strong opioids.
Why? Simple: You can't agree upon an opioid dose. The very notion is ridiculous. I actual started laughing when I read that. The dose is based on physiologic response to receptor firings. You can't negotiate that. In fact, I would question any pain docs belief about their patient's opioid use if they used those terms.
What the contract does is agree that the patient won't get opioids from another source. So, I'll look into that. You'd be amazed that the crazy stories are actually sometimes true. The last time I got a story, it turned out that the patient's doctor had actually retired and that the doc he referred my patient to had refused to see him as the guy had Medicaid. But no, the patient isn't automatically wrong just being in the ED.
Even insured patients have a 1-2 month wait to get into their doctor. Even an emergent appointment can take 1-2 weeks and that assumes my patient even has a phone to call the office. Sicklers can't get into see their hemotologists faster than 3-4 days from now. Exacerbation of chronic back pain? It is going to take a month or more.
But they are all in pain now.
So it is my moral duty to treat my patients appropriately, but my calculus is very different. Denying someone with a painful condition opioids out of a false sense of moral outrage is bad medicine. Using a high side effect drug in lieu of a lower side effect drug for the same reason is also bad too. And if I end up getting taken for a few opioid prescriptions, so be it. I don't care. Let those few have 'em. I'd much rather treat someone and provide them relief, then deny appropriate therapy while playing the smug moral crusader.
Ultimately I'm not going to fix anyone's drug habit. And I'm actually pretty unlikely to hurt anyone as they will just go somewhere else or hit the street for their fix. What I am likely to do is help those people that actually have pain. Think what you want, I can sleep soundly at night.