Discussions that mention demerol

Pain Management board


I am a migraine sufferer, I get 4-5 migraines a week and mostly I manage them at home. I am on a prevention/abortive/rescue program which enables me to cope. Up until recently this has work well. Our local ER has a new doctor in charge who does not like me, his first reaction to me was that I was a drugseeker! Then after going thru my records he thought I was just a nutcase (I have a long history of depression, if you were in pain all the time you'd be depressed too).

This new ER doctor insisted I had to have a pain contract from my PCP before he'd treat me in the ER. Now I only use the ER for rescue, this is when my migraine reaches a pain level 7 or higher and/or I'm throwing up. Sometimes I go months without this happening, sometimes it happens a couple times a month.

So this pain contract says I can be treated with demerol twice per month. In otherwards they are telling me I can only have two bad migraines per month? My body is going to listen to this?? What if God forbid I have three? Will they send me home in pain or will they treat me but with something else besides demerol?

I also have chronic kidney stones, I get 3-4 per year...these hurt like hell..worse than childbirth. What if I've used up my allotment of demerol on migraines for the month...will they treat the kidney stone or let me suffer? From what I understood the pain contract was only supposed to state what medication I could have for the migraines (and the migraines only) when I discussed it with my PCP and definetly not how often I could get the medication since I can't predict how often I'll need it!!

This seems ridiculous! I'm not a drugseeker, I'm not a nutcase. I'm just an unlucky person in pain....what right to they have to tell me how often I can be treated for the pain and often I have to suffer thru it?? Is this really how a pain contract works?? Help explain it to me please and tell me I'm wrong....:(
Sorry to hear about your problem Shellipoo. Migraines are no fun, that's for sure!

What you're describing from your ER Doc is absurd. First of all, what he's describing is not a typical pain contract. Contracts are usually employed by whatever Doc is primarily treating your pain (could be GP or PM Doc). The contracts state that you will only come to them for pain meds and not use any other Doc besides an ER. If you use an ER for emergency type situations, you are to tell them about your contract and your prior conditions & etc. More than likely, the ER would call your pain Doc.

Pain contracts also cover things like early refills, weekend calls, and other administrative factors. Essentially, a contract is often employed by Docs who Rx regular amts of narcotics to patients...The contracts establish the "ground rules" and expectations of the patient.

I've never heard of an ER limiting the amt of meds, or times you can get treatment per month. I'd be tempted to go over his head, but that's just me. You are exactly right...What if something happens a third time? Also, who says it has to be Demerol? What if something less would work? There are a lot of meds at a ER Doc's disposal besides Demerol.

Docs are supposed to use discretion. Maybe two per month on average may be a good starting point (assuming you agree), but that would have to assume an "average", not a absolute maximum (per month). What if one month, you didn't need any help, but the next month, they come in waves, and you get 3 or 4? This is where that "discretion" is important. And if the frequency became too much for their liking,then they would need to refer you to a pain Doc, or some other type of specialist who would prescribe accordingly.

I would circle back to my GP or whatever Doc is treating your migraines and tell him/her what is going on. I'd see what this Doc recommends. Maybe your Doc could call this ER and give them a "heads up" that you may need their services and why. I'd definitely get some type of new plan implemented....Get the Docs talking somehow, or have a letter written to them and get you a copy for your files...You could even take that with you to the ER if necessary.

I've heard all sorts of ER stories lately, and nothing surprise me...Everything from the very compassionate to no help whatsoever. Again, I think your best option is to talk to your main Doc and see what he/she recommends.

Best of luck to you, and I'm sorry this has happened.

Regards,

Ex
Okay...I'm starting to understand. What I signed sounds much like what you described. About how I will not get narcotics from another doctor, fill prescriptions early and all that.

BUT at the bottom of the contract my PCP wrote (at the ER doctor's instructions) that I am allowed to be treated in the ER with demerol no more than twice per month. It was written by hand below our signatures. That's where my confusion comes in. Exactly what does that mean?! :confused: Does it mean I can only be treated in the ER twice per month? Or does it mean I can only receive demerol twice per month?
I am an ER doc and I'd like to shed a little light onto this problem.

I actually think your doctor is taking some sensible precautions. Here's why:
1) Demerol is a notoriously dangerous drug - read Goldfrank's toxicology if you need more information. It has tons of severe drug interactions and toxic metabolites, to the point where it has been removed from the formulary of most ERs in New York City. Demerol is also known to produce a particular form of euphoria (in part because of its serotonergic activity) that makes it a big-time "seeker" drug. As one toxicologist put it, "it's an okay painkiller but gives a GREAT high." Any ER doctor who has a patient coming in frequently requesting Demerol is smart to be (a) worried about toxic effects and (b) concerned about drug abuse.

2) Opioid medications (dilaudid, morhpine, demerol, tramadol, percocet, vicodin, etc.) are famously bad migraine management drugs. Almost any neurologist will not recommend these as first line - they may be temporarily effective, but tend to enhance migraine rebound.

3) What I recommend is this: if you are one of the few migraine sufferers who can only be effectively treated with narcotics, you are indeed a rarity. Have your neurologist WRITE YOU A LETTER explaining this, with his/her contact information attached, and bring it with you to the ER the next time you have an attack. ENCOURAGE the doctor to call (many people forge such letters - don't act secretively or reluctantly about it). Remember, the ER doctor doesn't work for your neurologist, but they may work with them to treat you. Your ER doc is smart to be careful and not give you a dangerous synthetic narcotic right off the bat for your migraines - she can't just take your word for it. Give her evidence, and you'll probably find she's open to considering it.
I am a chronic migraine sufferer myself and I have to agree with Yeek when they say that narcotics are typically the last line of treatment AND not particularly effective for most people. I'm not implying anything against you. It goes without saying that people respond differently to different treatments. However, I don't understand your need to go to the ER for demerol in the first place.... if your doctor believes that this is a good treatment method for you then why isn't he writing a prescription for a small supply? Also, what current preventative medicine are you on and if you don't mind me asking what other abortive migraine medicines have you tried? Sorry to hear you are suffering so badly. I hope things start to ease up soon<3