Kicking the Habit: Opioid Alternatives for Pain Management in the Emergency Department

Rachel Wilde, Pharm.D.

Zach Henz, Pharm.D., BCPS

Mercy Health – Springfield Regional Medical Center

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Objectives

• Describe national and local trends in opioid use and abuse

• Review adverse effects and therapeutic contraindications

associated with non-opioid analgesics

• Discuss results of a community hospital’s initiative to

reduce opioid prescribing practices for pain management

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The Opioid Epidemic By the Numbers: 2016

116 people die daily from opioid-related overdoses

42,249 deaths from an opioid overdose

19,413 deaths from overdosing on synthetic opioids

11.5 million people misused prescription opioids

2.1 million people misused prescription opioids for the 1st time

170,000 people used heroin for the 1st time

$504 billion in economic costs

2016 National Survey on Drug Use and Health , Mortality in the United States 2016 NCHS Data Brief No. 293, CEA Report: the underestimated costs of the opioid crisis

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52.0 per 100,000

39.1 per 100,000

39.0 per 100,000

37.9 per 100,000

33.5 per 100,000

Death Rates Due to Drug Overdose By State

2016 CDC/NCHS, National Vital Statistics System, Mortality

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Overdose Deaths, United States, 2000-2016

CDC, National Center for Health Statistics. Underlying Cause of Death 2006-2016 on CDC WONDER Online Database, released December, 2017. Accessed at: http://wonder.cdc.gov/ucd-icd10.html

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Overdose Deaths, Ohio, 2000-20016

CDC, National Center for Health Statistics. Underlying Cause of Death 2006-2016 on CDC WONDER Online Database, released December, 2017. Accessed at: http://wonder.cdc.gov/ucd-icd10.html

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Ohio in the National News

• August 2016

• Rapid increase in heroin-related overdoses

• Isolated to Southwest Ohio

• Overdoses in first time users and chronic abusers

• Suspected contaminants

• Fentanyl

• Caffeine

• Carfentanil

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Unintentional Drug Overdose Deaths, Ohio

2016 ODH Ohio Drug Overdose Data, Annual Report

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Unintentional Drug Overdose Death Rate Per 100,000 Population, 2011-2016

2016 ODH Ohio Drug Overdose Data, Annual Report

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Opioid Free Emergency Department (ED)

• Springfield Regional Medical Center ED

• Serving 68,000 patients annually

• Guideline created by ED Medical Staff

• Started Oct 2016

• Goals:

• Reduce narcotic overdoses and diversion

• Optimize treatment of chronic pain

• Improve access to appropriate analgesic use

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Pain Management Guideline

Included Patients

• Multiple presentations to ED for pain-related complaints

• Opioid/ sedative Rx from ≥2 providers in past year

• Discharged from a pain clinic

• Hx of controlled substance abuse or overdose/withdrawal

• Prior controlled substance conviction

• Chronic pain syndrome

Excluded Patients

• Sickle cell

• Cancer or terminal diagnoses

• Acute medical illness, life-threatening condition, or trauma11

Pain Management Guideline

• Lost / stolen / or expired prescriptions will NOT be refilled

• Hydromorphone use

• Cancer pain or palliative care

• End-stage renal disease patients

• Acute exacerbations of chronic pain

• Non-opiate therapy

• No intravenous (IV) or intramuscular (IM) medications

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Clear expectations for providers and patients

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What do we use?

Glycine GlutamateCa+Ca+ Na+Na+

K+K+

Ketamine

Ketamine Mediated Analgesia

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Mercy Health Ketamine for ED Analgesia

Pain?

Apply inclusion/exclusion criteria

Patient meets

inclusion criteria?

Usual care

Low-dose ketamine 0.1-0.3 mg/kg IV (max 20 mg)0.3-0.5 mg/kg IM (max 50 mg)

Dosing/Administration• IV push over 2-5 minutes• Repeat dosing x 1 in 30 min

Monitoring• Telemetry, HR, and Sp02 monitoring• Monitor up to 1 hour post-dose

Exclusion Patient Populations:• < 18 yo• History of psychosis

Relative Contraindications:• Uncontrolled hypertension • Tachycardia

Included Patient Populations:• Musculoskeletal or soft tissue

trauma/pain• Chronic pain• Opioid tolerance or dependence• Burns• Neuropathic pain • Physician discretion

No

Yes

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extracellular fluid

Lidocaine Mediated Analgesia

•Non-selective sodium channel blocker

sodium channel

potassium channel

intracellular fluid

sodium

potassium

Pain Physician. 2013 May-Jun;16(3):231-49.

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Mercy Health Lidocaine for ED Analgesia

• Lidocaine 1-1.5 mg/kg (max 150 mg) in 100 mL 0.9% NaCl

• Administer over 10 minutes

• One-time doseDosing

• Onset: 10-30 min

• Half-Life: 7-30 minKinetics

• Monitor vital signs q15min x 1 hour

• Replete low K and Mg levels prior to administrationMonitoring

• Absolute: Allergy to amides, hx of cardiac arrhythmias, pregnancy, epilepsy

• Relative: heart, renal, or hepatic failureContraindications

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Lidocaine Infusion Toxicity

Think PeripheralMild

• Numbness & tingling in fingers & toes

• Numbness & sensations around mouth

• Metallic taste & ringing in the ears

Think CentralModerate

• Nausea / vomiting

• Dizziness

• Tremors

• Altered mental status (AMS), slurred speech

Think SystemicSevere

• Convulsions

• Cardiac arrhythmias, cardiac arrest

• Muscle twitching

Mnemonic

S-Slurred Speech

A-AMS

M-Muscle Twitching

S-Seizures

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Alternative Analgesics

Abdominal Pain

• Metoclopramide

• Prochlorperazine

• Dicyclomine

• Diphenhydramine

• Capsaicin cream

Renal Colic

• APAP

• NSAIDs

• Ibuprofen

• Ketorolac

• Lidocaine IV

Headache

• APAP

• NSAIDs

• Ibuprofen

• Ketorolac

• Metoclopramide

• Prochlorperazine

• Promethazine

• Valproate IV

• Levetiracetam

• Magnesium IV

• Triptans

Musculoskeletal Pain

• APAP

• NSAIDs

• Ibuprofen

• Ketorolac

• Lidocaine Patch

• Methocarbamol

• Diazepam

• Dexamethasone

• Cyclobenzaprine

APAP= acetaminophen, NSAIDs= non-steroidal anti-inflammatory drugs

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Opioid-Free Initiative Preliminary Outcomes

0

500

1000

1500

2000

2500

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

Opioids Dispensed in the ED

Opioids Dispensed- 2016 Opioids Dispensed- 2017

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0

5

10

15

20

25

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

Pe

rce

nt

ED Outpatient Opioid Prescription TrendNormalized to Department Patient Volume

Opioid Prescriptions- 2016 Opioid Prescriptions- 2017

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0

50

100

150

200

250

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

ED Naloxone Dispenses

Naloxone Dispenses- 2016 Naloxone Dispenses- 2017

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Areas for Improvement

• Mercy Health Opioid Steering Committee

• Creation of system-wide protocols

- Acute Pain

- Chronic Pain

- Palliative Pain

- Pain Management in Patients with Addiction

- Pre / Peri / Post-Operative Pain

• Pain Contracts

• CarePATH Tools- functionality with OARRS/KASPER

• Screening, Brief Intervention, Referral to Treatment (SBIRT)

• Naloxone-To-Go Kits25

Conclusions

• Opioid epidemic plaguing Ohio

• Highest deaths related to heroin and synthetic opioids

• Decrease prescription opioid overdoses

• Ketamine and lidocaine are non-opioid alternatives for

management of acute and chronic pain

• “Opioid Free ED” initiative shows promising progress

• Decrease in opioid use

• Decrease in discharge opioids prescriptions

• Decrease in ED visits

• Unknown effect on patient satisfaction scores

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Kicking the Habit: Opioid Alternatives for Pain Management in the Emergency Department

Rachel Wilde, Pharm.D.

Zach Henz, Pharm.D., BCPS

Mercy Health – Springfield Regional Medical Center

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