1. The Pendulum Swings: A Rational Approach to Narcotic Prescribing in the ED
May 1, 2014
David J. Adinaro MD, MAEd, FACEP
Chief, Emergency Medicine, SJRMC
President, NJ-ACEP

2. SOCIAL MEDIA @NJACEP (#NJACEP2014) Facebook (NJ-ACEP Page)
NJEmergencyDocs.com (blog)

3. 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

4. Disclosures/Background
I have no financial relationships to report regarding the medications discussed (or any medications for that matter)
HOWEVER….

5. 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)

6. Disclosures/Background

7. Disclosures/Background
Higher Potency/Longer Acting
30mg Oxycodone (2)
Morphine 15mg (1)
Dilaudid 2mg (2)
Oxycontin 20mg (1)

8. Disclosures/Background
AND a patient who has received narcotic pain medication…
Winter of
MVC
Femur Fracture
Surgery x 4

9. Disclosures/Background
Demerol
Morphine (Yuck)
Percocet

10. Disclosures/Background
Summer of 2013
“El Diablo”
4mm distal UVJ stone
Oxycodone 5mg/ 325mg APAP (#20)

11. Prescription Drug Abuse

12. Prescription Drug Abuse

13. Prescription Drug Abuse

14. Culture of Treating Pain
Cure Sometimes. Treat Often. Comfort Always.
- Hippocrates

15. Culture of Treating Pain
The 5th Vital Sign
Term introduced in the mid-90s
Codified by Joint Commission to be routinely measured

16. 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

17. Culture of Treating Pain
The 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

19. Culture of Treating Pain
And still….Concerns of Oligoanesthesia in the ED persist.
Racial disparities
Age disparities (elderly)
CMS timing of pain meds for long bone fractures

20. Culture of Treating Pain
Is this an ED Problem?
We make up 2-5% of all narcotics prescribed and filled
We generally prescribe only doses of the lowest strengths

21. Culture of Treating Pain
Is 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

22. “I Have a Peep”

23. 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!

24. 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

25. 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

26. 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

27. Drug-Seeking Spectrum
At-Risk
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

28. 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

29. I Have a Peep

30. 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

31. The ED Challenge Life saving care to the critically ill and injured.
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!

32. 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

33. 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

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

35. PMP
180 patients
Excluded those with acute injuries or appeared acutely ill or injured
Probable bias in enrollment

36. 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

37. 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

38. 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

39. 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

41. PMP
NO!

42. 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

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

44. A RATIONAL GUIDE
If pseudo addiction suspected coordinate closely with PMD
Arrange appropriate follow up
Use best judgment in terms of prescribing CDS

45. A RATIONAL GUIDE When prescribing narcotics:
Screen for substance abuse as needed
Emphasize risks to patient
Encourage safe disposal of left over medication

46. 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

47. 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

48. 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

49. QUESTIONS?

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