06 October 2008

Riding that train

Every so often I see a blog post that makes me want to shout out "Amen!" (Sometimes I do, which invariably startles the wife.) The oddly-eponymed "ERP" over at ER Stories put one such up the other day, on the topic of Demerol and migraines.

I too stopped using Demerol for migraines a few years back. That's not quite accurate: I never used Demerol for migraines. In my training, we avoided Demerol assiduously in favor of other, better analgesics. When I came to community practice, I was surprised to find Demerol as the "standard" med for pain, in particular for headaches. The frequent patients in our community were pretty habituated to this drug, and it caused no end of headaches for me when I started saying "no" to the Demerol request for patients with headaches. Fortunately, I was not alone, as a number of other new docs in our group had come out of training with a similar perspective, and we successfully lobbied to have Demerol removed from the ER formulary for exactly the same reasons that ERP cites.

There are a few main knocks against Demerol. One is the "toxic metabolite" argument, which, while true, is a pretty hypothetical concern. The big problem, in our eyes, was that Demerol is a powerful agonist (activator) of serotonin in a manner which is disproportionate to its analgesic (pain-relieving) properties. Serotonin is a neurotransmitter which is responsible for a variety of functions, among them a general sense of pleasure or well-being (very broadly put). Demerol also stimulates the dopamine and norepinephrine systems in a similar manner. The neuropharmacologic effects of Demerol are actually not dissimilar from those of cocaine. Conversely, Demerol has been shown to be no more effective for pain relief (actually, less effective) than other pain relievers such as morphine.

All of which is to say that Demerol may or may not relieve your pain, but it will reliably make you high. And if I give you a dose which does relieve your pain, it will make you much more high than a comparable dose of morphine would have.

Which is why it is an enticing but terrible drug for migraines. (I should say, for "migraines," since a large proportion of the "migraine" headaches that present to our ER are actually not migrainous, but the term "migraine" has entered the popular vernacular as meaning any severe, recurrent headache. So it's practically impossible to convince someone that their headaches are myofascial and not a migraine; I don't even really try any more. (But I digress.)) When someone comes in with a severe headache, and they receive Demerol, they often in short order report that they "feel great" and are ready to go home, happy and grateful. But the meds wear off, and glory be, here they are back in the ER 24 hours later with the same damn headache!

Worse, there is a powerful psychological association developed between the "rush" you get with IV Demerol and the pain relief. I've experimented with equianalgesic doses of oral and IV Demerol. IV hits the blood-brain barrier much faster and all at once with an almost-audible "rush" and the euphoria which results is dramatic and intense. However, orally, the med gets absorbed and distributed much more gradually. Absent the "rush," I've seen some patients on the threshold of respiratory arrest from narcotics insist they were still in terrible pain.

The problem is that they were not looking for pain relief, they were (perhaps subconsciously) looking for the rush. When I started in the community, there were legions of patients who insisted that "only Demerol" worked for them. Interestingly, when our ER and several other ERs in our area all started to move away of Demerol for headaches, there was a period of transition, when we often had to deal with angry or unhappy patients who insisted that they simply needed Demerol. Eventually, though, it seemed that the patients in our area had been weaned off of that drug, and now the frequency of patients with recurrent or intractable headaches seems far lower than it was before.

My interpretation of this is that the population of patients who had become addicted (iatrogenically addicted, I might add) to Demerol had been successfully detoxed, and thus were no longer (or more infrequently) presenting to the ER seeking their meds. This is an anecdotal impression: I wish I could compare the frequency of headache as chief complaint in our ER over the past decade, but I am not sure I can get that data.

I would like to point out that while it's easy to deride some of these people as "addicts" or "seekers," there were physicians on the other end of those needles which created the addictions in the first place. It is easy to "make them happy" and get them out of the ER, but I believe it is a great disservice to patients to create or perpetuate the addiction which drives them to the ER again and again. It's harder to say no, but in the long run, it can in some cases be better for everyone involved.

There's no standard template, but for headaches in my ER, my current practice is: a sumatriptan (such as imitrex) if the headache actually sounds like a true migraine, with toradol, reglan, IV fluids, and, if necessary, oral narcotics. Dilaudid works well, but is, IMHO, simply "Demerol-lite." If someone absolutely cannot take an oral med, Dilaudid is a tolerable alternative, but is not ideal and I avoid it if I can.

Seems to work OK. I don't get nearly as many complaints any more, which is a positive indicator, I think!

9 comments:

Nurse K said...

Thanks, dood, for a good medical post. :) I wasn't aware why people got so HIGHHHHHHHHHHH from demerol.

I've always assumed ERP stood for ER Physician, but who knows. Shadowfax sounds like people doing secretarial duties in a haunted office or something.

Branson Page said...

I've found that the vast majority of true migraneurs that I treat improve with Reglan, Toradol, Benadryl, and fluids alone. I rarely if ever give sumatriptans, and my standard discussion with a migraine chief complaint is that narcotics don't actually treat the root cause of migraines... therefore I don't use them. Of course I give in occasionally.

As a complete aside, I saw my first true cluster headache last week. 100% oxygen by facemask for 20 minutes and the patient went from head buried in pillow with tears to pain free and walking out the door. Very cool.

NeoNurseChic said...

As a chronic migraineur since 1/01 (nearly 8 years without a second of pain free time, unfortunately) and a chronic clusterhead (for 5 years) as well as a nurse (neonatal, for over 3 years), I agree wholeheartedly with your post.

Some things used in our university ER for migraine: fluids, reglan, toradol, benadryl, DHE (definitely need reglan first for this - or something comparable), and occasionally I've heard of a few other things being given such as solumedrol, depacon (or depakote if can't be given IV), even haldol. While I've had the chronic migraine for nearly 8 years, I can count on one hand the number of times I've gone to the ER for it, and that was only when having severe neurologic deficits creep up (vertigo, vision loss, memory loss, confusion) or in one or two cases a SEVERE attack that I could not manage with home meds. Those who deal with true chronic migraine or severe episodic migraine are often treated at headache centers or by specialists who have armed them with a good armada at home: DHE, Triptans, and other things - to use in the case that prevents fail. Pain medication really is not the best treatment because, as Branson Page says, it just covers the pain instead of working on the attack itself. Many people say, "Well such and such pain med cured my migraine!" - Unfortunately they don't realize that if the migraine (or whatever type of headache being labeled "migraine") is gone when the pain meds wear off, it is because the migraine has run its course, and not because the pain medication aborted it...

I actually spent a few months working in headache research at a well-known headache center, and was a trainee member of the American Headache Society for a time, and I hate to say this but any of the times I went to the ER for headache (which, as I said were VERY few - especially given the nature of my headaches!), I told them that I worked in these areas - hoping to distinguish myself from the "migraine" patient - aka drug seeker, or otherwise non true-migraine/headache patient. I've only been treated poorly in the ER a couple of times, and those occasions were not at the university hospital, connected to the headache center. Additionally, I did my nursing honors project on creating a nursing student curriculum on migraine and headaches, including pathophysiology, nursing management, and pharmacology - all to be done in just 1 teaching session each, but just much more informative, up-to-date, accurate, and thorough than the nursing education I had seen on the topic, but without taking more time than a single class each.

With regards to the cluster headaches, I again agree with Branson Page that using 100% O2 with nonrebreather mask for 15-20 minutes, especially if given at the beginning of the attack really works for a number of sufferers. Although most CH'ers probably don't present to ER at the beginning of the attack! Tho with the nature of cluster headache, likely by the time they are seen in the ER, the former attack may have ended and a new one begun. Complex thing, that. Some people are looking for an abortive for a particularly gruesome, long-lasting attack, whereas others are looking for something that will halt an endless stream of attack after attack, often for days/weeks - but this is better handled by a neurologist. O2, if done properly, truly does work for likely a majority of cluster sufferers, and those of us who suffer try to get others with CH to at least TRY oxygen. It really is a wonderful thing when it works! Those diagnosed with cluster headache often know that pain medications really do not touch CH pain, although some disagree.

I'll stop my rambling now! I haven't actually read ERP's post yet, but I intend to. I know my post here may be taken with a rolling of eyes, as I am both a chronic migraineur and CH'er, despite being a nurse, but I DO understand issues on both sides of the table, and I have always been on a platform that the ER is NOT the place to go to for headache management except in rare circumstances. Coincidentally, I worked in the ER (as a patient registrar, before becoming a nurse) the same summer I worked in headache research as I was paid for the ER job, but not the research position, which I was doing to gain experience to apply for medical school. Recently I learned in one of Scalpel's older posts, he referenced discussions with me in a post basically bashing the concept of admitting migraine and headache sufferers to the hospital for inpatient therapy. I know the stigma, and the drain, but I attempt to speak from some place of middle ground. I had intended to go to medical school with the goal of becoming a headache neurologist, but when hospital stays/medical issues became too much of a burden, I had to give up the idea of going to med school. Fortunately, I was able to still have a career in health care by becoming a nurse, and while I never imagined I'd end up working as a neonatal nurse, it has been a great career for me. Eventually I'd like to end up working as a nurse practitioner in pediatric neurology, if at all possible. We'll see where it takes me!

As for me, I haven't been to an ER for headache since probably 2005. I have had to go for other things (injuries, both times, I believe), and I was always nervous about how coincidentally also being a headache patient would affect my treatment. I've always been a quiet, low-maintenance patient really, so I guess that's helped - for the most part, I've always received excellent treatment in ERs (for headache or other things). In May, I finally had a bilateral occipital and right supraorbital nerve stimulator implanted in an attempt to treat neuritis/the headache conditions. Unfortunately, it had to come out last month due to MSSA infection, and have been out of work on IV antibiotics, but will be returning to my job on Monday. Also unfortunately, I will be out of work again - but for the fortunate replacement of the nerve stimulator, as it was the first thing in nearly 8 years that has TRULY helped. I am grateful for that!

All this (apologize for the rambling personal disclosure) to say that I agree - demerol is NOT the drug of choice for headache or migraine. And I would have to state that I think opioids are rarely a good treatment option for headaches/migraine at all, though I know we'll never stop people from requesting them/physicians from giving them, and sometimes they are deemed necessary, when all else fails, I suppose. But I think the vast majority tend to respond to other methods of truly attacking the migraine, as opposed to covering the pain.

Oh and one last thing, demerol is one of the few things considered safe to give during pregnancy to treat a bad migraine. Although compazine is also used during pregnancy, and may be more of a benefit to attacking the true source of the migraine.

Take care,
Carrie :)

red rabbit said...

Interesting post. Explains my feeling when given demerol (for perfed appendix with peritonitis) that I still had lots of pain, but I didn't mind because it was... over there somewhere.

I like maxeran (reglan) for migraine, but I have had a few patients get EPS on me, and my rate is not so far improved by benadryl. Toradol... hmmm.

Kim said...

Although I will surely never be in your ER I have to say thank you for this. As I said over at erstories, I would much rather be offered medication that doesn't make me high if it's an option. That pain + altered status thing is just way too scary.

Anonymous said...

I have suffered from debilitating migraines for the last 8 years or so. A few migraines have led me to seek help from my local ER, especially in the beginning when I did not know what was wrong. The pain comes on so fast and the vomitting follows almost immediately. All without warning and the serious ones do not end without IV medication and fluids.

Thankfully not all of them are this severe and most I can tackle at home. Triptans worked for a few years but suddenly never did again and caused severe cardiac side effects.

I was given demerol the first time but it never worked again after that and in subsequent doses the pain returned quickly. Unfortunately it is the only thing my Family Physician uses in his office.

I have had terrible reactions when reglan is given with toradol (even with benadry and ativan given as well) and prefer another anti-nausea medication, like zofran. All these drugs barely make a dent in the pain and vomitting. I am lucky that my doctor has priviledges at the hospital nearest my home, and that the ER docs & nurses there know my situation and history, they having been the ones to diagnose me all those years ago, and that they know the only things that have ever halted the pain and vomitting in its tracks are fluids, morphine and zofran. (and no, never once gotten a high from these drugs. Sleep finally comes when the pain subsides or due to shear exhaustion, but no high)

I was once told by a cardiologist that morphine acts on the blood vessels in some way and that is why it works so well for migraines. Don't know if it is true but am thankful for it the few times I have needed it.

I know some, if not all, of the ER bloggers are probably rolling their eyes as they read my story and I can understand they have had too many drug seekers come through and most probably have never had this type of excrutiating head pain. You really don't care what they give you as long as they help you. Thank you for allowing me to share my experiences, Elle.

QueenMAB said...

Thank you for posting such a detailed explaination about why ERs moved away from demerol, and what it does in your body and to your head.
I have made periodic visits to the ER, sometimes as frequently as once a month, for severe diagnosed migraines with vomiting until 2004. I hope to never return to the ER with a migraine. I unfortunately do not respond very well to triptains, and this causes my migraines to be unbelievable to some doctors. But at the point where I go to the ER all I care about is finding some relief to either break the current cycle or a way to stop vomiting and sleep through as much of the current migraine as I can.
Hopefully you share your knowledge of alternative treatments with other ER docs.

Anonymous said...

Good post. I still remember a pain management lecture during 2nd year med school where the anesthesiologist said to us, "If there's only one thing you remember from my lecture, let it be this: demerol is bad. Never use it!"

To this day, those were the only wise words I remember from his lecture. In fact, I don't remember ever working in a hospital where demerol was on the formulary...then again I've only worked in academic centers, never in a community ER yet.

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