Podcast #306: Tramadol Drama

Author: Nick Hatch, M.D.

Educational Pearls

  • Tramadol acts at multiple receptors and is a partial agonist at the mu opioid receptor, but also blocks reuptake of serotonin and norepinephrine throughout the body among others.


  • One major side effect to be aware of is that it lowers the seizure threshold.
  • Useful in setting of pain control in patients with contraindications to NSAIDs who are poor opioid candidates.
  • Use with caution as it potential for abuse.



Hennies HH, Friderichs E, Schneider J (July 1988). “Receptor binding, analgesic and antitussive potency of tramadol and other selected opioids”. Arzneimittel-Forschung. 38 (7): 877?80.

“Tramadol Hydrochloride”. The American Society of Health-System Pharmacists. Retrieved Dec 1, 2014.

“Withdrawal syndrome and dependence: tramadol too”. Prescrire Int. 12 (65): 99?100. 2003

Podcast #305: Stuffers vs. Packers : Drug-Packet Ingestion

Author: Aaron Lessen, M.D.

Educational Pearls

  • A “stuffer” is a term for someone who hastily and conceals a bag of drugs orally/rectally/vaginally in an unplanned situation. A “packer” is someone who is planning to smuggle drugs, and does so in a similar manner.


  • “Stuffers”are more likely to have the drug container open up in their system, while packers tend to have more reliable containment, but typically have larger quantities on-board.
  • Be on look out for symptoms associated with the drug’s exposure (drug dependent) as well as mechanical symptoms (perforation; obstruction).
  • If suspicious, order CT as X-rays underestimate severity.
  • Management: treat symptoms of intoxication appropriately, observe if packets are intact, consider surgery/endoscopy if necessary.



Dueñas-Laita A, Nogué S, Burillo-Putze G (2004). “Body packing”. New England Journal of Medicine. 350 (12): 1260?1

Hergan K, Kofler K, Oser W (2004). “Drug smuggling by body packing: what radiologists should know about it”. Eur Radiology. 14 (4): 736?42.

Traub SJ, Hoffman RS, Nelson LS (2003). “Body packing?the internal concealment of illicit drugs”. New England Journal of Medicine. 349 (26): 2519?26.

Podcast #300: Probiotics

Author: Peter Bakes, M.D.

Educational Pearls

  • Probiotics are living bacteria that are taken as an oral supplement.
  • Most of the data to support their use is in the prevention of antibiotic-related diarrhea and the reduction of the symptoms of ulcerative colitis (UC).
  • Some studies have some a reduction of the incidence of antibiotic-related diarrhea in children of up to 12% with the use of probiotics.
  • There may be a reduction of up to 60% in the incidence of antibiotic-related C. diff infection in adults with probiotic use
  • Studies have shown a 10% or more reduction in the duration and severity of the symptoms of UC with probiotic use.
  • Proposed mechanisms of probiotics include a decrease in gut permeability and a decrease in pathogenic gut bacteria due to resource competition.

References: http://www.cochrane.org/CD006095/IBD_use-probiotics-prevent-clostridium-difficile-diarrhea-associated-antibiotic-use

Podcast #297: Truvada

Educational Pearls

  • Truvada (Emtricitabine/tenofovir) is a combination nucleotide reverse transcriptase inhibitor that can be used as pre-exposure prophylaxis (PrEP) for HIV. It has been shown to dramatically reduce the risk of contracting HIV.
  • It is used in high-risk patients, like the MSM community or those who are in a relationship with someone with HIV.
  • Side effects include nausea, vomiting, headache, and liver damage.
  • HIV testing should be performed every 3 months while taking it, since it is not meant to fight an actual infection.
  • Since 2012, there have only been 3 confirmed cases of transmission while using Truvada.
  • It costs between 50-60$ dollars per pill, but it is covered by most insurances, including Medicaid.
  • Generic version has recently been FDA approved.

References: https://www.cdc.gov/hiv/pdf/prep_gl_patient_factsheet_truvada_english.pdf

Podcast #296: Synthetic Cannabinoids

Author: Rachael Duncan, PharmD

Educational Pearls

  • A NEJM study report in July 2016 discussed a situation in New York during which 30 people became “zombie-like” after ingesting synthetic cannabinoids (aka “Spice).
  • The ER managed to coordinate with the CDC to evaluate  blood samples from 18 patients who were transported to the hospital.
  • Of those who went to the ER, the mean age was 36.8, many  of them were homeless, all of them were male. Mass spectrometry was used to confirm the presence of synthetic cannabinoid in their blood.
  • Compared to normal THC, synthetic cannabinoids have a much lower EC50 and LD50.
  • Spice intoxication presents in a variety of ways -patients may be hyperthermic, combative, delirious and/or seizing.
  • Treatment  is supportive, including fluids, cooling, electrolyte management, and sedatives.

References: Adams, A. J., Banister, S. D., Irizarry, L., Trecki, J., Schwartz, M., & Gerona, R. (2017). “Zombie” Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York. New England Journal of Medicine, 376(3), 235-242. doi:10.1056/nejmoa1610300

Podcast #289: Cannabinoid Hyperemesis

Author: Dylan Luyten, M.D.

Educational Pearls

  • Cannabinoid Hyperemesis syndrome is a relatively new diagnosis that presents with vomiting and abdominal pain without a clear etiology in the setting of daily marijuana use.
  • The pathophysiology is not well-understood well, but may involve cannabinoid receptors in the gut.
  • Treatment is abstinence from marijuana, fluids, dextrose, and antiemetics (haldol, ondansetron, etc). Opioids should be avoided.
  • Capsaicin cream on the abdomen may be helpful, as it can distract from the pain and vomiting. Milk can be used to reverse its effects.

References:  Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid Hyperemesis Syndrome. Current drug abuse reviews. 2011;4(4):241-249.

Podcast #265: The 2017 Flu Vaccine

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist – Emergency Medicine

Educational Pearls

  • CDC recommends using the inactivated, injectable flu vaccine in those 6 months and older. The live attenuated vaccine is not used because of low efficacy.
  • Pregnant women should be vaccinated, and can receive the vaccine at any stage of their pregnancy.
  • The vaccine is contraindicated ONLY in those with a history of a severe anaphylactic reaction to the injection in the past.
  • Antivirals (oseltamivir, zanamivir) are useful for Flu A and B. Their dosing needs to be adjusted for renal function, and it is contraindicated in those with ESRD who are not receiving dialysis. It should be used for prophylaxis in those with exposure and/or for the very young, very old, morbidly obese, nursing home residents, and those who are immunocompromised. They may be effective as long as 72 hours after symptom onset.

References: https://www.cdc.gov/flu/professionals/index.htm

Podcast #263: Early Antibiotics in Sepsis

Author: JP Brewer, M.D.

Educational Pearls

  • After the first hour, every 1 hour delay in antibiotics in a patient with septic shock patient is associated with a 4% increase in mortality.
  • In patients with high suspicion for septic shock (fever and hypotension), antibiotics should be initiated ASAP. Rocephin (ceftriaxone) should be used for those with community-acquired sepsis, zosyn for nosocomial or IV-associated sepsis.

References: https://lifeinthefastlane.com/ccc/antibiotic-timing/

Podcast #261: Icatibant

Author: Aaron Lessen, M.D.

Educational Pearls

  • Icatibant was introduced to treat ACE-inhibitor induced angioendema.
  • This type of angioedema is refractory to epinephrine and antihistamines, and is likely mediated by elevated bradykinin.(which is inactivated by ATII and ACE).
  • Icatibant initially was shown to reduce facial swelling and airway obstruction in the setting of ACE-I angioedema, but later, better-powered studies showed that it had no benefit compared to standard treatment.

References: Sinert R et al. Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema. J Allergy Clin Immunol Pract 2017. PMID: 28552382

Podcast #256: Fentanyl Ingestion


Don Stader, M.D & Rachael Duncan, PharmD BCPS BCCCP

Educational Pearls

  • Fentanyl patches may be abused in many ways, including changing the patches more frequently, chewing them, extracting the fentanyl in a tea, and administering them rectally.
  • Fentanyl is very lipophilic and has a fast onset, but it has a very low bioavailability when given enterally, because it does not survive the stomach and 1st pass metabolism. It can be given IV, intranasal, through the buccal mucosa, or transdermal.
  • When patients present with fentanyl overdose due to ingestion of a patch, it is more important to find out how long the patient had the patch in their mouth, since that is the principal form of absorption.

References: http://www.medscape.org/viewarticle/518441_3