May 1, 2014

The Pendulum Swings: A Rational Approach to Narcotic

Prescribing in the ED

David J. Adinaro MD, MAEd, FACEPChief, Emergency Medicine, SJRMCPresident, NJ-ACEP

SOCIAL MEDIA

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• NJEmergencyDocs.com (blog)

Goals and Objectives• Review the history and current state of

prescription abuse

• Define some of the patient challenges in pain management in the ED

• Present a rational approach to prescribing narcotics in the ED

Disclosures/Background

• I have no financial relationships to report regarding the medications discussed (or any medications for that matter)

HOWEVER….

Disclosures/Background

• I am a prescriber of narcotics….

• One year thru March 2014• Cared for 2,700 patients• 318 scripts for CDS (down from 390 year

prior)• Averaged 18 pills per script (19 year prior)

Disclosures/Background

5mg Oxy/Hydrocodone89%

Benzos6%

Higher Potency3%

Misc.3%

Disclosures/Background

• Higher Potency/Longer Acting• 30mg Oxycodone (2)• Morphine 15mg (1)• Dilaudid 2mg (2)• Oxycontin 20mg (1)

Disclosures/Background

• AND a patient who has received narcotic pain medication…

• Winter of 1988-1989• MVC • Femur Fracture• Surgery x 4

Disclosures/Background

• Demerol• Morphine (Yuck)• Percocet

Disclosures/Background• Summer of 2013

“El Diablo”4mm distal UVJ stone

• Oxycodone 5mg/ 325mg APAP (#20)

Prescription Drug Abuse

Prescription Drug Abuse

Prescription Drug Abuse

Culture of Treating Pain

Cure Sometimes. Treat Often. Comfort Always.

- Hippocrates

Culture of Treating Pain

The 5th Vital Sign

• Term introduced in the mid-90s• Codified by Joint Commission to

be routinely measured

Culture of Treating Pain

The 5th Vital Sign

• Term introduced in the mid-90s• Codified by Joint Commission to

be routinely measured

• Median Pain Score in ED is 8

Culture of Treating PainThe Pharmaceuticals

• Culminated in heavy advertising by physicians to physicians for Oxycontin

• By 2001 was a $1B drug

• Eventually FDA found manufacturer had engaged in misleading and dangerous advertising

Culture of Treating PainAnd still….Concerns of Oligoanesthesia in the ED persist.

• Racial disparities• Age disparities (elderly)• CMS timing of pain meds for long

bone fractures

Culture of Treating PainIs this an ED Problem?

• We make up 2-5% of all narcotics prescribed and filled

• We generally prescribe only 15-20 doses of the lowest strengths

Culture of Treating PainIs this an ED Problem?

• A significant number of our patients are “at-risk”

• Most EPs feel at least once a shift they are being manipulated for drugs

“I Have a Peep”

The Holy Grail of EM

• Used to be which chest pain patient can be sent home safely

• Now it is who really needs pain medication!

Drug-Seeking Spectrum• Diversion

• False names, false addresses, no actual medical complaint

• Multiple Visits for Acute Conditions• Toothaches, traumatic injuries, visceral organ pain

• Chronic Pain from non-specific conditions• Migraines, Low Back Pain, Fibromyalgia, Chronic Lyme disease, etc.• C1-Esterase Deficiency

• Chronic Pain 2nd to specific medical condition• Gamut from SCD, Gastroparesis, Chronic pain after surgery• Headaches 2nd to Brain Aneurysm, Recurrent Renal Colic

• Pseudo-Addicted• Addicted

Drug-Seeking Spectrum

• Pseudo-Addiction• A drug seeking behavior that simulates

true addiction, which occurs in patients with pain who are receiving inadequate pain medication

• Notoriously hard to distinguish from addiction

Drug-Seeking Spectrum

Logan et al. Medical Care. August 2013

• Survey of 400,000 insurance enrollees who received a narcotic prescription in the ED

• 10.3% had indicators putting patient “at-risk”

• Majority had high daily dose (> 100 MME)• 5mg oxycodone = 7.5 MME • 5mg hydrocodone = 5MME

Drug-Seeking Spectrum

Logan et al. Medical Care. August 2013

• Survey of 400,000 insurance enrollees who received a narcotic prescription in the ED

• 10.3% had indicators putting patient “at-risk”

• Majority had high daily dose (> 100 MME)• 5mg oxycodone = 7.5 MME • 5mg hydrocodone = 5MME

At-Risk

At-Risk Spectrum

Wilsey et al, Pain Medicine 2008

• Psychological Co-morbidities among patients in chronic pain presenting to the ED

• 81% of 113 patients showed propensity for prescription opioid abuse

I Have a Peep

The ED Challenge• Balance benefits of prescribing narcotics with small but

very real risks of abuse and addiction that lead to significant morbidity and mortality

• Use all data available in identifying “at-risk” patients

• Develop institutional guidelines to promote consistent care

• Continue to insist on appropriate access to primary and specialty care for our patients

The ED Challenge• While continuing to provide:

• Life saving care to the critically ill and injured.

• Complex evaluations of high risk patients with undifferentiated complaints.

• Provide access for un-/underinsured patients without alternatives.

• Meet our institutions’ patient satisfaction aspirations!

PMP

• 544 patients, 38 EPs• Fair agreement between clinical impression and PMP• Defined “drug seeking” by PMP data as:

• 4 or greater prescriptions from• 4 or greater providers• Over 12 months

PMP

• Associated with “drug seeking” by PMP data:• Requesting meds by name• Multiple visits for same complaint • Suspicious history• Symptoms out of proportion to exam• NOT AGE, GENDER, SPECIFIC ETHNICITY

PMP

• PMP changed management in 9.5%• 6.5% received unplanned narcotics• 3.0% did not receive planned narcotics

PMP

• 180 patients• Excluded those with acute injuries or

appeared acutely ill or injured• Probable bias in enrollment

PMP

• Most patients high use of narcotics?• 0 – 128 scripts (average 18)

• PMP resulted in change in likelihood of prescribing narcotics in 41%

• 2/3 the likelihood decreased• 1/3 it increased

Institutional Guidelines

• Effect of a ED Guideline (for prescribing Opioids to chronic opioid patients) on visits and CDS prescriptions for dental pain.

• Absolute decrease of 17% in those receiving narcotic script

• Associated decrease in dental pain visits

Institutional Guidelines

• 15 patients averaging 19 visits per year without significant comorbities (cancer, renal colic, SCD)

• All had PCPs• Emphasis was on more appropriate rescue

meds from PCPs

Institutional Guidelines

• Did not receive parenteral narcotics in ED• Decreased to average of 2 visits per year• 7 weaned off narcotics• 4 converted to methadone• 1 to fentanyl patch• PCP visits also markedly decreased

PMP

NO!

A RATIONAL GUIDE• Use the PMP consistently to screen for “at-

risk” behavior when:

• Multiple “recent” ED visits • Exacerbation of chronic pain• Patient requests medications by name• Allergies to multiple alternative medicines• Not from typical catchment area• Prescribing LA opioids for non-cancerous pain

A RATIONAL GUIDE

• When PMP data suggests “at-risk” behavior share concerns with patient and negotiate no CDS prescription vs. smallest amount possible

A RATIONAL GUIDE

• If pseudo addiction suspected coordinate closely with PMD

• Arrange appropriate follow up

• Use best judgment in terms of prescribing CDS

A RATIONAL GUIDE

• When prescribing narcotics:

• Screen for substance abuse as needed• Emphasize risks to patient• Encourage safe disposal of left over

medication

A RATIONAL GUIDE

• When prescribing narcotics:

• Continue to use short-acting formulations

• Generally limit amounts to five days• Strongly consider alternatives in

patients already taking benzodiazepines

A RATIONAL GUIDE• When prescribing narcotics:

• When practical avoid parenteral medications for exacerbations of chronic pain

• Have a higher threshold for certain conditions including dental pain, sprain

A RATIONAL GUIDE

• When prescribing narcotics:

• Establish intra-departmental protocols for the most common conditions

• Add tools to your tool box• Alternative therapies• Dental blocks

QUESTIONS?

Additional Information:

EMAIL: Adinarod@sjhmc.org Adinaromd@hotmail.com

TWITTER: @PatersonER

BLOG: Anatomy of a Super ER (PatersonER.com)