Part I: Medicine’s Greatest Folloy
The Emergency Medical Minute proudly presents an educational podcast series produced by the Colorado Hospital Association addressing our the United States’ opioid epidemic.
Part II: Limiting Opioids in the Emergency Department
PRACTICE RECOMMENDATIONS
1. Opioids are inherently dangerous, highly addictive drugs with significant abuse potential, numerous side effects, lethality in overdose, rapid development of tolerance, and debilitating withdrawal symptoms. They should be avoided whenever possible and, in most cases, initiated only after other modalities of pain control have been trialed.
2. Prior to prescribing an opioid, physicians should perform a rapid risk assessment to screen for abuse potential and medical comorbidities. Alternative methods of pain control should be sought for patients at increased risk for abuse, addiction, or adverse reactions.
3. Emergency physicians should frequently consult Colorado’s prescription drug monitoring program (PDMP) to assess a patient’s history of prescription drug abuse, misuse, or diversion.
4. Emergency physician groups should strongly consider tracking, collecting, and sharing individual opioid prescribing patterns with their clinicians to decrease protocol variabilities.
5. Strongly consider removing prepopulated doses of opioids from order sets in computerized provider order entry (CPOE) systems.
6. Opioid alternatives and nonpharmacological therapies should be used to manage patients with acute low back pain, in whom opioids are particularly detrimental. Opioids should be prescribed only after alternative treatments have failed.
7. Potential drug interactions must be evaluated, and opioids should be avoided in patients already taking benzodiazepines, barbiturates, or other narcotics.
8. Patients with chronic pain should receive opioid medications from one practice, preferably their primary care provider or pain specialist. Opioids should be avoided in the emergency department treatment of most chronic conditions. Emergency physicians should coordinate care with a patient’s primary care or pain specialist whenever possible, and previous patient-physician contracts regarding opioid use should be honored.
9. Clinicians should abstain from adjusting opioid dosing regimens for chronic conditions and avoid routinely prescribing opioids for acute exacerbations of chronic noncancer pain.
10. “Long-acting” or “extended-release” opioid products should be avoided for the relief of acute pain.
11. Patients receiving controlled medication prescriptions should be able to verify their identity.
12. Patients who receive opioids should be educated about their side effects and potential for addiction, particularly when being discharged with an opioid prescription.
13. When considering opioids, clinicians should prescribe the lowest possible effective dose in the shortest appropriate duration (eg, <3 days).
14. Emergency departments should refuse to refill lost or stolen opioid prescriptions.
POLICY RECOMMENDATIONS
1. As has been done in other states, the Colorado PDMP should develop an automated query system that can be more readily integrated into electronic health records and accessed by emergency clinicians.
2. Pain control should be removed from patient satisfaction surveys, as they may unfairly penalize physicians for exercising proper medical judgement.
3. Opioid prepacks should be avoided or eliminated in the emergency department if 24-hour pharmacy support is available.
4. Pain should not be considered the “fifth vital sign.”
Part III: Alternatives to Opioids
PRACTICE RECOMMENDATIONS
1. All emergency departments should implement ALTO programs and provide opioid-free pain treatment pathways for
the following conditions:
a. Acute on chronic opioid-tolerant radicular lower back pain
b. Opioid-naive musculoskeletal pain
c. Migraine or recurrent primary headache
d. Extremity fracture or joint dislocation
e. Gastroparesis-associated or chronic functional abdominal pain
f. Renal colic
2. Emergency departments should integrate ALTO into their computerized physician order entry systems to facilitate a seamless adoption by clinicians.
3. Low-dose, subdissociative ketamine (0.1-0.3 mg/kg) is an effective analgesic that can be opioid-sparing for many acute pain syndromes. Institutional guidelines and policies should be in place to enable clinicians and nurses who administer this agent for pain.
4. For musculoskeletal pain, consider a multimodal treatment approach using acetaminophen, NSAIDs, steroids, topical medications, trigger-point injections, and (for severe pain) ketamine.
5. For headache and migraine, consider a multimodal treatment approach that includes the administration of antiemetic agents, NSAIDs, steroids, valproic acid, magnesium, and triptans. Strongly consider cervical trigger-point injection.
6. For pain with a neuropathic component, consider gabapentin.
7. For pain with a tension component, consider a muscle relaxant.
8. For pain caused by renal colic, consider an NSAID, lidocaine infusion, and desmopressin nasal spray.
9. For chronic abdominal pain, consider low doses of haloperidol, diphenhydramine, and lidocaine infusion.
10. For extremity fracture or joint dislocation, consider the immediate use of nitrous oxide and low-dose ketamine while setting up for ultrasound-guided regional anesthesia.
11. For arthritic or tendinitis pain, consider an intra-articular steroid/anesthetic injection.
POLICY RECOMMENDATIONS
1. Hospitals should update institutional guidelines and put policies in place that enable clinicians to order and nurses to administer dose-dependent ketamine and IV lidocaine in non-ICU areas.
2. Emergency departments are encouraged to assemble an interdisciplinary pain management team that includes clinicians, nurses, pharmacists, physical therapists, social workers, and case managers.
3. Reimbursement should be available for any service directly correlated to pain management, the reduction of opioid use, and treatment of drug-addicted patients.
Part IV: Harm Reduction
PRACTICE RECOMMENDATIONS
1. Patients who abuse opioids should be managed without judgement; addiction is a medical condition and not a moral failing. Caregivers should endeavor to meet patients “where they are,” infusing empathy and understanding into the patient/medical provider relationship.
2. Every emergency clinician should be well-versed in the safe injection of heroin and other intravenous (IV) drugs, and understand the practical steps for minimizing the dangers of overdose, infection, and other complications. When treating patients with complications of IV drug use, injection habits should be discussed and instruction should be given about safe practices.
3. Emergency department patients who inject drugs should be referred to local syringe access programs, where they can obtain sterile injection materials and support services such as counseling, HIV/hepatitis testing, and referrals.
4. Emergency departments should provide naloxone to high-risk patients at discharge. If the drug is unavailable at the time of release, patients should receive a prescription and be informed about the over-the-counter availability of the drug in most Colorado pharmacies.
5. Emergency clinicians should be familiar with Colorado’s regulations pertaining to naloxone. State laws eliminate liability risk for prescribing the drug, encourage good samaritan reporting of overdose, and make naloxone legal and readily available over the counter in most pharmacies.
6. Emergency department patients who receive prescriptions for opioids should be educated on their risks, safe storage methods, and the proper disposal of leftover medications.
POLICY RECOMMENDATIONS
1. Harm reduction agencies and community programs that provide resources for people who inject drugs (PWID) should be made readily available.
2. When local programs are unavailable for PWID, emergency departments should establish their own programs to provide services such as safe syringe exchanges.