The woman presents as an emergency patient with severe tooth pain and the underlying condition of diverticulitis. The patient’s own reporting uncovers a welter of inconsistencies—as well as complications--with regard to prescribing. She says she’s allergic to morphine and codeine. Other comments suggest patterns of drug-seeking behavior. Should I treat this patient, and if so, under what circumstances?
A member of DOCS Education writes:
My new emergency patient complains of severe tooth pain. She has been referred for RCT.
The woman indicates an allergy to morphine/codeine--thus no Tylenol 3™.
Her diverticulitis rules out NSAIDs.
Finally, the patient says she cannot take amoxicillin/penicillin because of previous poor reactions.
Dr. Anthony Feck, Dean of DOCS Education faculty, responds:
You should pursue whether the patient’s claims represent true allergies. Very often these assertions turn out not to be allergies at all but rather GI disturbances or some sort of idiosyncratic reaction. If the evidence does, however, point to true allergies, the patient should be tested for allergies to antibiotics and opiates.
DOCS Education member responds:
Red flags are beginning to emerge. This patient didn't report her codeine allergy until after leaving the office. Also, she still picked up the Tylenol 3™ prescription and solicited advice from an acquaintance who “used to own a drugstore.”
The woman says she took the medication at night and supplemented it with Benadryl™. The combination resulted in a mild rash but not the full-blown hives that afflicted her before. I am beginning to be suspicious of drug-seeking behavior.
1. In any future contact with this patient, I'm prepared to say I cannot treat her further due to the many inconsistencies in her comments as well as lack of compliance.
2. With regard to future patients who report similar allergies and history, do you advise referral to an allergist and/or their treating MD for pain management to address the diverticulitis? Will I receive medication advice following the allergy consultation, or just the test results?
3. Also, it appears the stronger NSAIDs (Celebrex™, ketorolac) carry serious life- threatening side effects. Besides the previously recommended combination of ibuprofen and acetaminophen, is there a preferred "go to" for this class?
4. I typically use Tylenol 3™ as the moderate-to-severe pain drug of choice. When should tramadol, i.e., ultram or ultracet, (synthetic opiate) be considered instead?
Dr. Anthony Feck, Dean of DOCS Education faculty, responds:
Has this patient asked for medication? The woman’s characteristics link to almost every analgesic option, and she doesn’t appear to be a typical drug-seeker. I admit that it is somewhat troubling she took a prescription for a medication she professed to be allergic to, and then complemented the mixture with Benadryl™.
Does your state have a prescription drug monitoring program (PDMP) permitting access to the patient's prior prescription drug history? When all is said and done, you should never treat or prescribe medication to someone you suspect isn’t being forthright and/or who is likely to procure drugs for illicit purposes.
The reason I recommended testing by an allergist is to determine which analgesics/antibiotics the patient can and cannot take. If the patient is truly allergic to morphine and codeine, she may still be able to take other opioids, including tramadol. Even if the woman is allergic to penicillin, she may still be able to take cephalexin. Clindamycin is always an option, but in a patient with this many allergies, I would want to have a test run before risking an allergic reaction that has the potential to be life-threatening.
As far as the diverticulitis goes, the degree of severity shows wide variation. Consult with her treating physician to obtain guidance in determining what, if any, NSAIDs or other analgesics are suitable.
The bottom line with this patient is that you need more information from her treating physician and possibly an allergist before you prescribe any more antibiotics or analgesics. I would get the medical consult before prescribing acetaminophen as well.
