SGEM#55: Drugs in My Pocket (Opioids in the Emergency Department)

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Date: November 28, 2013

Guest Skeptic: Dr. Damon Atrie and Dr. Amy McCulloch

Case Scenario: 33 year-old man presents to the emergency department at 2AM complaining of a infected tooth. At triage he requests that “oxy” stuff that worked really well last time.

Question: Can a departmental guideline on controlled substance prescriptions reduce opioid abuse?

Background: In 2001, the Joint Commission made pain “the fifth vital sign” and raised the awareness of oligoanalgesia in the ED. In the US, ED physicians started being evaluated and compensated by means of patient satisfaction with ED pain control. This provided a misguided incentives for giving out opioids. The threat of oligoanalgesia has become so large that many practitioners liberally prescribe opioids in spite of the risks.

ED physicians are among the most frequent prescribers of opioids. (Volkow et al. JAMA 2011). Attempting to eliminate pain is certainly well-intentioned but you have to ask yourself how many patients are being harmed by the addictive feeling of euphoria and respiratory depressant effect that opioids provide, all in trying to attain a pain score of zero. Somehow many of us have been trained that all pain must be eliminated. We all know that this is unrealistic in many cases of severe and refractory pain.

Do patients want their pain to be eliminated at the expense of their level of awareness and understanding why they are in pain? We all have had patients who surprisingly refuse opioids. The literature supports that. It seems that educated patients would rather live with some pain. Platts-Mills et al showed that after an MVC, educated patients receive less opioids compared to less educated patients. (Platts-Mills TF, et al. Pain 2012).

Perhaps our biggest failure in pain management is not explaining to patients the cause of their pain and the potential risks of opioid use. Writing a script for Percocet is much easier than having that discussion. Nonetheless, although ED physicians had little to do with causing the problem, we have witnessed a public health crisis in the past decade by way of prescription drug abuse – namely oxycodone. The Dhalla CMAJ study in 2009 raised some serious issues with the way opioids are prescribed. In Ontario alone, opioid-related deaths doubled between 1991 and 2004. This has been attributed to the release of long-acting oxycodone. The addition of long-acting oxycodone to the drug formulary was associated with a five-fold increase in oxycodone-related mortality. Most of these deaths were deemed unintentional. In more than half of these patients, a prescription for oxycodone was filled in the month prior to death. Could these deaths have been prevented?

This disturbing situation with opioids has also been observed in America (Manchikanti L et al. Pain Physician 2012). In October 2012, ACEP published practice guidelines regarding opioids. They suggest that opioid use be carefully individualized and time-limited; that opioids best left for patients with severe or refractory acute pain; and that exacerbations of chronic pain not be treated with opioids.

Dr. Atrie’s approach to patients in severe acute pain:

Explain that the pain will not go away completely.
Explain what’s causing the pain, the natural history of the condition.
Multimodal approach to medications.
Acetaminophen and NSAID (if able to tolerate) regularly around the clock.
Small doses of pure opioids as last resort, emphasizing the side effects of opioids (constipation, drowsiness, delirium, addiction) and to minimize use as much as possible.
My opioid of choice is hydromorphone which seems to cause less delirium in the elderly, synergy with acetaminophen.
I completely avoid combination opioids (i.e. Percocet, Tylenol with codeine) completely.
In dealing with dental pain, my litmus test is whether the patient accepts a nerve block. It they do, I prescribe an opioid.

Reference: Fox TR et al. A Performance Improvement Prescribing Guideline Reduces Opioid Prescriptions for Emergency Department Dental Pain Patients. Ann Emerg Med. 2013;62:237-240

Population: Adult patients (>16yrs) presenting to two rural emergency departments with dental pain
Intervention: Controlled substance prescribing guideline
Control: One year before new guideline
Outcome: Opioid prescription rate for dental pain and annual dental pain ED visits

Result: Decrease from 59% (302/515) to 42% (65/153) representing an absolute decrease of 17% (95% CI 7%-25%). Decrease in dental pain ED visits from 26 to 21 per 1,000 (95% CI 2-9/1000)

Authors’ Conclusion: “A performance improvement program involving a departmental prescribing guideline was associated with a reduction in the rate of opioid prescriptions and visits for ED patients presenting with dental pain.”

EBM Comments: This study looked at the difficulty issue of opioid prescribing in the emergency department. The researchers did not cite the reference standards for performing a chart review as Gilbert et al (Ann Emerg Med 1996) or Worster et al (Ann Emerg Med 2005). There are 12 items considered to be quality indicators when it comes to conducting chart reviews.

Abstract Training – YES, one hour of training.
Case Selection -YES, Inclusion and exclusion criteria were well defined.
Variable Definition – YES, The primary variable recorded was whether or not a patient presenting with dental pain received a prescription for opioid medication at discharge.
Data abstraction – YES, Recorded predefined variables on a standardized spreadsheet.
Performance Monitored – NOT indicated if the abstractors’ performance was monitored.
Binding – NO, The abstractors were not blinded to the objectives of the study.
Inter Rater Reliability (IRR) Mentioned – YES
IRR Tested – YES, They did calculate inter-observere reliability.
Medical Record Identified – YES, The medical database was described.
Sampling Method – YES , Convenience sample – all consecutive cases of computerized ED records with dental pain diagnostic codes .
Missing Data – NO, There was no mention of how they handled missing data.
Ethics – YES, The study was approved by an institutional or ethics review board.

It seemed odd to have a 14 month pre-implementation stage vs. a 5 month post-implementation phase. This study was done in two small rural EDs and the results may not be applicable to large urban areas. Physicians involved in the study were not blinded to what being studied. The ED chairman solicited input from the physician group and was a “champion” of the project. The goals of which were to reduce controlled substance prescriptions. This may have created an observer effect “whereby subjects improve or modify an aspect of their behavior, which is being experimentally measured, in response to the fact that they know that they are being studied”. Therefore, The decrease in controlled substance prescribing found in the results may be secondary not to the actual prescribing guideline, but to several forms of bias including: performance bias, referral bias, and reviewer bias. In addition, there is not good evidence yet to show that reducing prescriptions from the ED actually means you are reducing abuse or opioid mortality. (Gugelman and Perrone. JAMA 2011).

Bottom Line: Opioid prescribing in the ED will continue to be a problem and this study does not provide enough high-quality information to implement this guideline at my hospital.

Case Resolution: The 33 year-old man with dental pain is given a dental block, 600mg ibuprofen, a prescription of amoxicillin 500mg TID and information on accessing a dentist the next morning.

Additional Resource: Here is a video to provide a basic approach to acute pain control. It was created by Dr. Brent Thoma (BoringEM) who will be a guest on next weeks episode of the SGEM. This video discusses oral and intravenous opioids (morphine, fentanyl, hydromorphone and oxycodone) and non-opioids (Acetaminophen and NSAIDS including toradol and naproxen). BoringEM Chalk Talk – Acute Pain Control.

KEENER KONTEST: Last weeks winner was Lauren Shepard from Western University. She knew the song, Baby, It’s Cold Outside on was sung by Anne Murray and Michael Buble. Listen to this weeks podcast for the Keener question. If you know the answer then send your answer to TheSGEM@gmail.com with keener kontest in the subject line. Be the first one with the correct answer and I will send you a cool SGEM skeptical prize.

Some exciting news from the BEEM conference world. We have added PrairieBEEM in Winnipeg, Manitoba, Canada on May 12 & 13, 2014. If you can’t wait that long to meet some of the BEEM Dream Team the registration link is up and working for SweetBEEM in Stockholm, Sweden (March 17-18, 2014).