More Lies About Pain Management In The ED by Michael Heller, M.D.

Michael Heller, M.D.I ordered 40 mg of Demerol IV the other day for a patient with abdominal pain, nausea and vomiting. The 3rd year resident had never used this exotic drug and the nurse thought that maybe it couldn’t be given IV (I told her I’d be delighted to administer it). Another, older nurse, had given it many times in the early part of the century but had never given it without Phenergan (I am not making this up) and since IV Phenergan is now verboten (especially since some idiot accidentally gave it intrarterially and a jury of Einsteins thought that this should make the manufacturer liable: I am not making this up, either), the nurse thought that it would not be possible to use the drug any more!

This idiotic demonization of meperidine - probably our most effective and best tolerated narcotic - stems from one of those fads that sweep across medicine every so often, without any empiric evidence to support it. Basically, a long-known theoretical issue - that Demerol has a long-lasting and potentially neurotoxic metabolite- got converted into a policy that discouraged or banned the use of the drug, even in settings where it never caused any problems at all. Yes, I’m talking about the ED, where we never give 500 mg of Demerol and we never see any seizures from it.

My opinion (based on 30 years of experience and lots of reading) is that morphine is a fine drug when you break your leg or cut off your arm but is a dumb-ass drug for headache or abdominal pain, especially when there is nausea or vomiting, which is usually the case.

And this is not surprising; it’s been known for years that morphine releases more histamine and stimulates the vomiting centers more than the other parenteral narcotics. It’s also been known for years that despite the “equipotency” tables, all narcotics are not alike in their effects. Whatever the reason, patients prefer Demerol over morphine by a significant margin. Somehow, this preference has been used as a reason to NOT use meperidine as it somehow makes patients “feel too good” or gives them a high or something. That’s a great idea: identify a drug that is dirt cheap, fabulously effective, and strongly preferred by patients, Then add 50 years of experience in the ED setting which proves its safety. Then abandon it in favor of a less effective, more toxic alternative (guess what? Morphine has a toxic metabolite, too!). Why? Because some self- appointed group of non-clinicians says so.

I wish I was making this up.

Comments

[shadowfax]

I really don't know what to say to this.

You've been practicing for a while, surely you might have noticed the abuse profile for Demerol is about tenfold higher that of the next most popular opioid, Dilaudid? You say patients "like" it, but here's the thing: they like it not because it's effective at relieving pain (it is), but because at equianalgesic doses it is far more serotoninergic than hydromorphone. In short: Demerol may or may not relieve your pain, but it will reliably get you high. That high is far more habituating than other opioids.

Demerol is a decent back-up drug for when there are no good alternatives. But it's best left out of the Pyxis. I and the other clinicians in our ER lobbied to get rid of that drug, and it's been gone from our ER for several years.

And guess what's happened? The chronic migraineurs' visit rates have dropped by 60%, and once they were educated that Demerol was no longer an option, those that continued to come were amenable to more appropriate therapies (like imitrex, reglan, toradol, or oral analgesics).

So I for one am happy to consign Demerol to the reliquary of rotating tourniquets and bloodletting. Good riddance.

[Sue Ieraci]

In most parts of Australia, including where I work, Meperidine (Pethidine to us) has been gradually removed from standard practice - both in hospitals and in the community. Not because it is a bad drug, but because of the addictive properties. IN the wider community, this is a real issue. Many community practitioners have become habituated to pethidine from their doctors' bags. The many people who came to ED asking for Pethidine (Demerol) don;t do that any more. We use morphine almost exclusively. Pethidine isn't totally gone, but now reserved for the very few real indications (real allergy to morphine, severe vomiting from morphine). Morphine is a good drug, but doesn't give you a pleasant experience. Pethidine is a good drug, but too many patients and doctors enjoyed its effects, so we have decided not to use it any more.

I also, have been around for a long time, from when using pethidine was second nature. Now it barely crosses my mind. Let go - it will be OK!

[Rich Boggs]

I've also been in Emergency Medicine a long time. I completed my residency in EM in June 1986. In July 1986, I suffered a herniated disc in my back which was treated conservatively for about 6 months before I had surgery. After surgery I had multiple complications which left me disabled for about 6 months with multiple inpatient visits. During that time I was treat with iv meperidine on a frequently scheduled basis. I'll admit that I received a lot of meperidine during that time and didn't have any of the complications due to toxic metabolites that everyone (including myself) mention. I did learn that it wasn't a very good pain medicine but you did enjoy the sensation it gave you. I can remember feeling the burn go up my arm, stop at my axilla, count to 3 and WOW who cares if my back hurts, I felt good even though I still had the pain. No I didn't become dependent but I understand why people prefer meperidine. I've never had morphine so I can't comment on it. I've had dilaudid for renal colic and you do get pain relief (ketoralac helped more) without the "wow". My patients have received morphine or dilaudid since my experience in the hospital, not because of the fear of toxic metabolites but because I want their pain treated effectively, not "WOW" and maybe some pain control.

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