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Demerol for Pain Management

Question:

A couple years ago, there was a push at our hospital to avoid using demerol for pain management. The discussion at the time was buildup of breakdown products that were less effective in pain control (so you needed to keep giving demerol for pain), but the buildup was just as effective in killing you.

Per the recent events with Michael Jackson and the possibility that he was receiving chronic Demerol (based on gossip anyway), it makes one wonder if our hospital's past concern about toxicity rang true in Jackson's death. MORE FOLLOWS BENEATH MY REPLY.
 
REPLY (WMR):

During my chairmanship of the AAFP course on colonoscpy 1984-2003, my book described and the accompanying lectures taught demerol as safe, effective, reliable, cheap, and universally available. But, we described a very deliberate and specific protocol of "know your patient(FP 101),start low,go slow, monitor VS, and recovery until stable".
 
While morphine, dilaudid, and fentanyl equivalents exist, I personally have continued with demerol, and, in over 25 years of practice, have never seen a negative outcome from demerol. As one of the "go to" defense witnesses 1985-2005, I never saw a family medicine lawsuit. As an editor and author, I am aware on no published bad outcomes in the family medicine world or in the world of sedation/analgesia for office surgeries such as endoscopy.
 
The numerator of a sensational case report dwarfed the denominator of long term success. Bendectin suffered a similar fate. Drawing conclusions from "celebrity medicine" is particularly treacherous.
 
Problems come from physicians attempting to use IV sedation/ analgesia without any real time spent in mastering 1-2 hours of basic material. This material is almost never taught in current residencies.For this reason I always tested on IV sedation/analgesia principles, and I enncouraged passage of an ACLS course at least every 5 years for the right to do colonoscopy/EGD during the time that I chaired those courses.
 
I have lost touch with the AAFP course, but Bill Coleman, Stu, and others still give the course today. Much of the prevailing caution about demerol is similar to the great sublingual nifedipine scare. A tempest in a teapot.
 
Long term use of injectable and po narcotics for patients lacking the care of a physician who coordinates all of the disease and mental health issues(over 80% of current physicians), will lead to a small number of unnecessary tragedies. These will be widely publicized by single issue profiteers and well intentioned reductionists.
 
ADDITIONAL DEMEROL TOXICITY OPINION IS ATTACHED BELOW. I THINK THAT THESE DANGERS ARE OVERSTATED, BUT HAVE NO DISAGREEMENT WITH THOSE WHO CHOOSE TO USE FENTANYL OR MORPHINE OR DILAUDID. PETHIDINE(see below) IS THE BRITISH NAME FOR MEPERIDINE--WMR
Pennsylvania Patient Safety Authority says...

“Demerol is an old, lumbering dinosaur which must be taken out of use in order that effective pain control can become a reality.”

Dr. J. Davis Daniels
The Passing of Demerol

I have attached the thorough article talking about this medication.
=======================================

http://en.wikipedia.org/wiki/Meperidine

Pethidine is quickly hydrolysed in the liver to pethidinic acid and is also demethylated to norpethidine, which has half the analgesic activity of pethidine but a longer elimination half-life (8-12 hours[14]); accumulating with regular administration, or in renal failure.

Norpethidine is toxic and has convulsant and hallucinogenic effects.

The toxic effects mediated by the metabolites cannot be countered with opioid receptor antagonists such as naloxone or naltrexone and are probably primarily due to norpethidine's anticholinergic activity probably due to its structural similarity to atropine though its pharmacology has not been thoroughly explored.

The neurotoxicity of pethidine's metabolites is a unique feature of pethidine compared to other opioids.

Interactions
Pethidine has serious interactions that can be dangerous with MAOIs (e.g., furazolidone, isocarboxazid, moclobemide, phenelzine, procarbazine, selegiline, tranylcypromine). Such patients may suffer agitation, delirium, headache, convulsions, and/or hyperthermia. Fatal interactions have been reported including the death of Libby Zion.[15] It is thought to be caused by an increase in cerebral serotonin concentrations. It is possible that Pethidine can also interact with a number of other medications, including muscle relaxants, some antidepressants, benzodiazepines, and alcohol.

Pethidine is also relatively contraindicated for use when a patient is suffering from liver, or kidney disease, has a history of seizures or epilepsy, has an enlarged prostate or urinary retention problems, or suffers from hypothyroidism, asthma, or Addison's disease.

Index--sedation/analgesia, office surgery, demerol, numerator news

Hospital Charges

Major issue is different observation codes for patients discharged from the hsopital on the same day versus the next day.
 
Medicos major use 2008 has been for the many women who are sent or self refer to the hospital for false labor. If the physician signed the chart and accepted the medicolegal responisility for the caree of that patient, that physician is entitled to bill an observatioin code and a service for intepreting the fetal monitor strip.
 
Research study--Hypothesis--For every 100 deliveries, there are ten of these observation admissions which go unbilled. How much money is that, and would you like to have it in support of your mission?

Alternative hyspothesis--Every week Medicos has at least two of these patients or 100 a year. this is a common but predictable source of underperfromance andlost revenue.

With best wishes for your professional success.
 

 
Index--charges, hospital,nonoffice

Pelvic exams: Gyn Ultrasound

I have a quandary.  Now a days, if a woman is monogamous and has had 3 normal PAPs and no hx of abnormal PAPs and you might even do an HPV and if negative can be more confident that  you only need to do PAPs q 3 years.

My question is, is there any reason to be doing pelvic exams (in asymptomatic women) in between those 3 year  periods, or really, at all?

I can’t find any official recommendations on pelvic exams.  Most patients are obese and you can’t feel anything anyway, so I am really beginning to wonder why we bother doing them at all but the question is, are we supposed to do them every year even though not doing PAPs every year.Thoughts? 

Kathy Saradarian, MD

Branchville, NJ  www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90; Practice Partner 5/03

This quandary has been mostly resolved among family physicians in the Medicos project 1999-2009. Steve Goldstein MD ACOG has previously published his strong opinions regarding the poor sensitivity and specificity of the pelvic examination. I agree that we should be teaching pelvic ultrasound to every physician who would care for women.
 
Pelvic pain women are diagnostic orphans in the current system of generic primary care. I find no physicians who have received accountable training in the bimanual pelvic examination.  Residency trained physicians cannnot detect the common causes of pevic pain--PID with TOA, PID with free fluid, PID with pyosalpinx, Missed Ab, degenerated fibroids, ovarian cysts, Polycystic Ovarian Syndrome, probable ovarian Ca.
.
These are examples of cases diagnosed in our family medicine office this month. By keeping the faith with OB ultrasound in the FP office, we have gone on to offer point of service immediate ultrasound for our  patients. Worse yet these women frequently need another appointment, another care trip, another stranger who is not a physician, another inconvenience to obtain the most sensitve and specific examination available. Ultrasound.
 
No radiation and unrestricted physicians can do it in their office at the time of service.
It's natural win-win. Where is the advocacy on this issue?
 
Pelvic exams are only useful for visual inspections and acquistion of secretions/ biopsies.Paps, HPV, discharges, colposcopy, and surface anatomy problems.
 
Note the silent disappearance of the rectovaginal exam after years of "insisting" that it was useful. Medicos will  try to organize a "teach the teachers" conference for Gyn ultrasound as we did in 1992 when we were at at UT in Memphis. Any interested collaborators?
 
 
With best wishes for your professional success,

Wm. MacMillan Rodney MD, FAAFP, FACEP
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville, rural, and international
www.psot.com
Practice Partner EMR since 1999

For what it’s worth, here’s what just came out of ACOG.

John L. Pfenninger, MD

Hi…let me know when this class is….I am comfortable with basic L and D U/S…..I need GYN and dating U/S skills…..JMS

Juliemarie M Sicilia MD
Associate Director Alaska WWAMI
Alaska Family Medicine Residency

Index--pelvic exam, gyn ultrasound

Cesarean Training By-laws Reform

 
Methodist Hospital system is one of the largest in the South. For years Family Medicine privileges have been effecrtively road blocked by a "poison pill" in the delineation of prvileges document. Although privileges were allowed, family physicians were required to obtain written backup for guaranteed Cesarean coverage 24/7/365 from at least two obstetricians.
 
Secondly, although fellowship  trained family physicians could be granted Cesarean privileges, the by-laws required that they have an obstetrician or another Cesarean capable physician scrub the case with them. FP's without Cesarean privileges are not allowed to assist at Cesarean section.
 
Monday June 16, after two years of requests and meetings, I was allowed to present the family medicine case for reform to the Methodist cross specialty task force. Although, it needs confirmation by the credentials committee and Medical staff executive, the following is encouraging. The  previous and continuing support of the medical community is appreciated.
 
With best wishes for your professional success,
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Medicos para la Familia
Memphis, Nashville and rural

Dr. Rodney:
 
The cross-specialty task force will make several recommendations to the Credentials Committee: 
 
1)  Remove the requirement for a surgical second assist for FP to perform c-sections
2)  Remove the requirement for written obstetrical back up for FP
3)  Redefine FP OB Core privileges to include c-sections defining the criteria to grant the privilege (one year in a FP OB training program which included 50 c-sections, documentation of current clinical competence (case log for previous 24 months, including 20 c-sections per year average)  Maintenance:  current clinical competence and average of 20 c-sections per year) 
4)  Define criteria for required obstetrical consultation
 
Dr. Dormois or Dr. Handorf would be glad to discuss these recommendations with you if you need any other information.
 
Thanks,
 
Pat
Pat Busbey, CPMSM
Corporate Director, Medical Staff Services
Methodist LeBonheur Healthcare

www.psot.com
Index--privileges OB, Cesarean training, bylaws reform
 

OB Fellowship Vs. P4

Family Medicine Leader and Tn rural physician for 19 years, David McRay MD is currently director of the Maternity care curriculum at JPS in Ft.Worth.

He writes:

I am concerned.... that we appear to be moving toward a requirement/expectation that family physicians must do an additional year of training to be qualified to perform cesareans.  I do not think this should become the norm.
 
I completed a three-year residency (at JPSH), before fellowships were available. I performed 67 cesareans as a primary surgeon.  I then practiced for 19 years in a small community, leading a group practice performing 250 deliveries per year.  I have since been granted unrestricted cesarean privileges at JPS, a tertiary care center delivering 7000 babies per year.  However, if I understand correctly the decision at Methodist, I would not be eligible for cesarean privileges there.  Or, can one read the new requirement (one year in an FM-OB program performing 50 cesareans) to include a traditional 3-year FM residency with a high-volume OB experience?  I certainly believe my training and career experience equal or eclipse that of most fellowship-trained family physicians.
 
What do you see happening around the country?  My residents are asking if they will be required to complete a fellowship, if our P4 program will be viewed as equivalent to a fellowship, and how many cesareans they must perform during their training (residency and/or fellowship) in order to be eligible for privileges.  What is your take on where we are heading?

REPLY-(WMR):

Completing residency, and adding a fellowship year is the credential most likely to succeed. You should "brand" your fourth year as a fellowship.
 
Regarding the promise of complete training withing the 3 year FM residency, nobody was more hopeful than I. But maternity care FP's were undercut by the majority of residencies who could not support adequate training. Last year a residency director from Va. wrote my hospitals telling them that he could not recommend his resident for normal delivery privileges!
 
The logic of this residency director was that, since none of his faculty currently held privileges for normal deliveries, none of his faculty could make a recommendation on delivery privileges for any of their graduates. These residencies have not demanded that the by-laws of their hospitals encourage Family Medicine Obstetrics. Despite the AAFP-ACOG[Harr-Bagley] agreement, specialty neutral credentialing for OB rarely occurs in places where tomorrow's family physicians train.
 
The fourth year fellowship was a necessary political device which allowed Family Medicine to regain access to privileges. Memphis is recognized as a major urban market and an academic medical  center. This precedent was one of my administration's major goals 1989-1999. Rural communities downstream were depending on us hold the fort and wave the flag.
 
Some university departments have succeeded in this area-- Boston, Portland-Oregon, USC under Ric Hahn[now retired], Colorado, etc. Credit to Tuscaloosa, Tacoma, Rochester, and Spokane who were the original pioneers. Kudos to them.
 
Family Medicine fellowships have grown, because they reliably produce the desired outcome. The curriculum is more than surgery. The curriculum maintains a Family Medicine identity while addiing skills in  ultrasound, neonatal resusciation, office surgery, mission medicine, etc. During the fellowship year, our fellows obtained valid medical licenses in Nigeria and obtained operating room privileges. Residents could never do this.
 
Because of the credentials barrier, we have created a valid certification examination through the American Board of Family Medicine Obstetrics. I urge you to consider taking the exam and obtaining this credential. You would qualify on the basis of your equivalent training, documented experience, and proven ability.
 
Family Medicine as a member of the American Board of Medical Specialties(ABMS) cannot create a CAQ in Obstetrics or Emergency Medicine. This is viewed as conflicting with an already established specialty in another area. ACGME bylaws prohibit this.
 
As I said to Dan Casey, the fellowship credential(not a fourth residency year), is the most likely to succeed. Few are contesting the rural positions where deliveries are low in volume, and doctors take call every other night if not every night.
 
The problem is that these hospitals are dropping their OB services. Lexington, Huntingdon, Camden, Portland, LaFollett are small town hospitals in Tennessee that have dropped their OB. These job opportunities are shrinking and many of the small town opportunities are not viable. Small town doctors pay big city malpractice premiums.
 
The residency directors through their organization ARDFM, have not required "fairplay" on OB privileges for their graduates. Most residencies cannot win Cesarean privileges for any graduate at any hospital. Theoretically RRC guidelines required that this training be made available to all residents who requested it, but look at the data. JPS and a few others did provide this training within residency, but very few others did. In my six years, RRC site visitors never once cited this.
 
Family Medicine leaders will have to convince its own members in the AAFP, STFM and RRC-FM about the importance of this issue. When I served on the RRC, the AAFP did not instruct its delegates to vote for the mandatory OB rule. On the other hand, they were not instructed to vote against it. We won 5-4. Its up for vote again.
 
The current leadership of the Tennessee AAFP disagrees with me on the need to REQUIRE RRC regulation on this issue. One of my previous fellows dropped OB, and feels it is misguided to make this a priority. He has opposed my efforts in this area. As President of the Tn. AAFP, he has influence.
 
Therefore, the prevailing political reality REQUIRES graduating from residency before fellowship begins. Graduation from residency means that fellows will have full hospital privileges, a valid medical license, malpractice insurance, and be ABFM eligible before beginning their fellowship. This is not possible if they are still considered  "residents". In the university all of my fellows served simultaneously as junior faculty, and we could bill for all of their activities without cosigning their charts. The fellowship is financially self supporting.
 
I encourage you and your colleagues to engineer your systems accordingly. With best wishes for your professional success, 
  
Wm. MacMillan Rodney MD, FAAFP, FACEP
Chair, Academic Affairs
Medicos para la Familia
Memphis, Nashville and rural

John Gibson MD JPS writes:

It really seems to be that until we can win the battle of COMPETENCY based credentialling vs arbitrary "fellowship" issues, we are all at risk in this fight. Competency should be based on scope and breadth of training AND continuing experience backed up by good record keeping, peer review, and evaluation along with a reasonable process to document current competency (proctoring).  I am not sure how a "fellowship" adds more to competency as compared with P4 program with good OB curriculum and experience spread out during the entire training period with a final result of knowledge and procedure experience that meets the same requirements of a fellowship.  Perhaps at JPS we will need to adjust terminology for our trainees when they finish, but I am very sure they will have good evidence of competency from their P4 experience.
 
John Gibson, MD
OB Fellowship Faculty Member
Director of Global Health Education
JPS Dept of Family Medicine

John, this is about the currently brutal reality of American Hospital credentialing. Rightly or wrongly, the fellowship sells the perception of "additional training". Graduating from a 4 year residency does not.
 
Then there is the issue of trying to bill for a 4th-year resident. You cannot. Keep up the good work. Your graduates will have an easier time of it if they leave with a "fellowship" certificate.
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Clinical Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural
www.psot.com

DepoProvera Follow-up

 Medicos has struggled with the growth in its responsibilities for women's health care. Adding Cesarean services was not easy, and family planning services are central to the mission. The request for tubal ligation was frequently impossible to fulfill. Reasons were many. Lost sterilization permits. Transportation and language barriers led to missed appointments with the only OB service in town accepting medicaid patients for stand-alone tubal ligation.
 
Uninsured patients were even more difficult given the need to pay hospital charges for OR, anesthesia, and the full physician's fee. Our only source for referral was the OB-Gyn residency downtown.

These charges usually were more than $2500. The no show rate for referrals sent by  Medicos was more than 50%. This created friction in the already tense arena of OB-Gyn care for the underserved. Rodney WM, Martinez C, Chiu WK, et al. Prenatal Patients Who don't Deliver: Unplanned Events, Uncounted Services, Risks. Am J Clin Med 2009 in press.
 
Essure in the office has been a Godsend, but the materials for each procedure must be paid by the physician up front. The cost is $1415, and Medicos is concerned about providing these services without incurring a loss.
 
TOPIC DEPOPROVERA--There was little response to the DepoProvera conundrum of medicaid reimbursements set at $55 while one "wholesale" dealer charged $62 for the 150 mg medroxyprogesterone. Women come to the office, go to the drugstore, return to the office, then, and only then, do they receive these family planning services.This is common and not necessary.
 
The answer--Medicos has located a licensed pharmacist who will compound injectable DepoProvera for less than half this price.

Index--Essure, Family Planning, DepoProvera, surgery in office, charges