Practical strategies for handling chronic pain and opioid/heroin abuse when they come to a head in the emergency department
Practical strategies for handling chronic pain and opioid/heroin abuse when they come to a head in the emergency department
A recent CDC report covering 28 states from 2010 to 2012 found a 5% decline in the number of deaths related to opioid pain reliever (OPR) use. That seems like good news. But the same report noted an increase in the number of people using OPRs, and increase in heroin use among frequent OPR users, and a doubling of heroin overdose deaths. In other words, OPR deaths might be down, but we’re still in the midst of an opioid overdose epidemic fueled by the rise in availability of prescription opioids . About a third of Americans report being afflicted by chronic pain  and 5 million people report non-medical use of OPRs . And emergency medicine is on the front lines of this epidemic – EDs treated 420,040 OPR poisonings and 258,482 heroin-related poisonings in 2011 alone .
One possible answer to this epidemic is to expand the availability of naloxone . Several ED approaches have been proposed: 1) distribute and/or prescribe naloxone in the ED; 2) identify and refer ED patients with OPR disorder to treatment; and 3) improve the practice of safe opioid prescribing in the ED.
Pros and cons of distributing and/or prescribing naloxone in the ED
Naloxone has been in use since 1970 in the ED and is a safe and effective opioid antidote. Putting this antidote directly in the hands of opioid users and their social networks can be effective as these are the people who are the highest risk of overdose, are more likely to witness an overdose, and can provide timely rescue breathing and naloxone administration. Evizio, an autoinjected intramuscular naloxone formulation with voice instructions, was approved by the FDA last year. Other commonly used preparations include a standard Intramuscular (IM) and a Intranasal (N) Naloxone, available in many states, which are both organized into aftermarket naloxone rescue kits .
From 1999 to 2010, 118 US communities educated and distributed naloxone to 53,032 individuals at risk or likely to witness an opioid overdose. During that period they reported 10,171 overdose reversals . In Massachusetts, a state-supported community-based program that includes several EDs has been distributing the Intranasal (IN) Naloxone formulation since 2007. They’ve seen lower opioid mortality rates than those areas without rescue kits. As a public health pilot, the program includes a standing order which allows distribution by community health workers directly to people at risk and their friends and families without a prescription. The rescue kits are similar to those distributed in other states and include instructions for recognizing and responding to an opioid overdose, rescue breathing, calling 911 and administrating naloxone .
Community efforts have begun to involve prescribers and pharmacists . Project Lazarus, a North Carolina community-based overdose prevention program in which primary care physicians distributed naloxone reported a significant decrease of opioid deaths . Also a 2013 North Carolina state law (90-106.2) allowed physicians to prescribe an opioid antagonist to not only a person at risk, but also anyone who might be in a position to assist a person at risk.5 Federal policy currently promotes and supports expanding access to naloxone . Twenty-seven US states and the District of Columbia have amended their laws to allow non-medical administration of the drug without legal consequences .
But there remain many challenges buy-in from pharmacies, ED nurses and physicians, law enforcement, and opioid users and their families. Personnel are needed to conduct training. Current payment mechanisms vary widely by state and insurance carrier9. (The FDA approved EvzioR naloxone auto injector cost about $600 for two injectors while the nasal atomized naloxone kits cost $75) .
Identifying ED patients at risk for opioid overdose and referring them to treatment
Try this simple question, “How many times in the past year have you used a prescription or illegal drug for nonmedical reasons, for instance, for the experience or feeling it gives you?” . Other questions should assess: 1) previous or recent opioid overdose, 2) recent release from jail or prison or abstinence treatment program; 3) taking opioid doses at levels >50 mg/day morphine equivalent; 4) currently taking methadone or suboxone; 5) chronic diseases such as HIV, COPD, sleep apnea, asthma; and 5) consuming alcohol or taking benzodiazepines.9 Such patients could be candidates for overdose education, prescription for naloxone rescue kits and, possibly further referral.
For those patients with chronic opioid pain reliever addiction buprenorphine/Suboxone is a promising treatment owing to its partial agonist effects which reduces pain and blocks craving . However, due to its antagonist effects, it can precipitate withdrawal. So patients must be abstinent or in moderate withdrawal before initiating treatment. Engagement in counseling and social support groups increases the chances of successful withdrawal.
Safe opioid prescription practices in the ED
From 2001 to 2010, ED prescriptions for Schedule II opioid analgesics rose from 7.6% to 14.5%, with hydromorphine and oxycodone showing the largest increase. NSAID prescriptions also increased 26%. During this period the percent of patients whose ED visits was pain related increased by only 4%, from 47.1% in 2001 to 51% in 2010. Some worry that patient satisfaction metrics may be pressuring emergency physicians to prescribe opioid pain relievers even though not indicated .
So how are EDs addressing safe management of chronic pain patients? A number of State ACEP chapters have developed opioid prescribing guidelines [17,18] The North Carolina College of Emergency Physicians partnered with Community Care of North Carolina and Project Lazarus to develop an ED toolkit  which makes the following recommendations:
- Avoid prescribing controlled substances for pain that is chronic, and therefore more appropriately addressed with the patient’s primary care provider.
- Do not provide refills for chronic pain medications (lost prescriptions, need for after hours or weekend refills, etc.)
- Check the North Carolina Controlled Substance Reporting System (Prescription Drug Monitoring Program) before prescribing a controlled medication for pain.
- Limit the number of doses of controlled meds dispensed or prescribed. For example, set a default number for computerized prescriptions for opiate at #10 or less for chronic pain.
- For patients with pain complaints who have no primary care provider, identify staff who can help connect to a regular provider.
The North Carolina ACEP guidelines are not meant to take the place of physician clinical judgment of an individual patient. Rather, the guidelines provide an opportunity to cite a system-wide policy rather than engage in time consuming negotiations with the patient.
Of course, as the pendulum swings away from trying to make each patient pain free on the 1-10 scale, there is a danger that patients may be denied appropriate opioid medications. When other non-opioids have been tried and failed in patients with moderate to severe acute pain, cautious use of a short course and limited number of low dose opioids in synergy with (NSAIDS or Acetaminophen) may be indicated after risk assessment and patient education. Emergency physicians have been cautioned not to initiate ED treatment with long acting extended release opioids . There is no easy solution to this challenging clinical encounter and limited evidence to guide and support our ED practice [21,22]
Edward Bernstein, MD is a Professor and Vice Chair for Academic Affairs, Emergency Medicine, Boston University School of Medicine
Photo by Of R. Nial Bradshaw
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2. NIH Draft Executive Report: Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Available at https://prevention.nih.gov/docs/programs/p2p/ODPPainPanelStatementDraft_10-02-14.pdf accessed 12/1/14
3. Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.
4. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD.
5. ACEP Now. 2014 ACEP Council Meeting Highlights. Available at http://www.acepnow.com/article/2014-acep-council-meeting-highlights-resolutions-summary
6. Food and Drug Administration. FDA approves new hand-held auto-injector to reverse opioid overdose. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm accessed 12/1/15
7. Centers for Disease Control and Prevention (CDC). Community-based opioid overdose prevention programs providing naloxone—United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61:101-5. [PMID: 22337174]
8. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ. 2013;346:f174.
9. Prescribe to Prevent. Available at http://prescribetoprevent.org/ accessed on 12/29/14
10. Albert S, Branson FW, Sanford CK, Dasgupta N, Graham J, Lovette B. Project Lazarus: Community-based overdose prevention in rural North Carolina. Pain Medicine 2011; 12: S77–S85.
11. ONDCP and ACEP Trauma and Injury Section sponsored webinar. Naloxone distribution from the ED for patients at risk for opioid overdose. ” Available at http://www.acep.org/uploadedFiles/ACEP/memberCenter/SectionsofMembership/trauma/ACEP_ONDCP%20Naloxone%20Distribution%20Webinar.pdf Accessed on 12/1/14
12. Network for public health law. Legal interventions to reduce overdose mortality: Naloxone access and Overdose Good Samaritan Laws. Available at https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf. Accessed 12/1/14
13. GoodRX Available at http://www.goodrx.com/evzio accessed 12/1/14
14. Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., & Saitz, R. (2010). A single-question screening test for drug use in primary care. Archives of Internal Medicine. 2010; 170: 1155–1160.
15. Becker WC, Ganoczy D, Fiellin DA, Bohnert AS. Buprenorphine/Naloxone Dose and Pain Intensity Among Individuals Initiating Treatment for Opioid Use Disorder. J Subst Abuse Treat. 2015 Jan;48(1):128-131.
16. Mazer-Amirshahi M, Mullins PM, Rasooly I, van den Anker J, Pines JM. Rising opioid prescribing in adult U.S. emergency department visits: 2001-2010. Acad Emerg Med. 2014 Mar;21(3):236-43. doi: 10.1111/acem.12328. PubMed PMID: 24628748.
17. New York State Department of Health. New York’s Medical Conduct Program. Pain Management: A Guide for Physicians. Available at http://www.health.ny.gov/publications/4179.pdf
18. Neven DE, Sabel JC, Howell DN, et al. The development of the Washington State emergency department opioid abuse predictors and strategies to curb opioid abuse. Pain Physician 2012;15:ES67–92.
19. The Project Lazarus Toolkit: Emergency Department is available at https://www.communitycarenc.org/media/related-downloads/pl-toolkit-eds.pdf accessed 12/1/14
20. New York City Emergency Department Opioid Prescribing Guidelines. Available at http://www.nyc.gov/html/doh/downloads/pdf/basas/opioid-prescribing-guidelines.pdf Accessed on 12/11/14
21. Cantrill SV, Brown MD, Carlisle RJ et al; American College of Emergency Physicians Opioid Guideline Writing Panel. Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med 2012 Oct; 60(4):499-525. PMID 23010181
22. Musey PI Jr, Linnstaedt SD, Platts-Mills TF et al ‘Gender differences in acute and chronic pain in the emergency department: results of the 2014 academic emergency medicine consensus conference pain section. Acad Emerg Med 2014 Dec; 21(12):1421-30 doi: 10.1111/acem.12529.Epub2014Nov24 PMID 25422152
Additional web resources: Safe and effective opioid prescribing for chronic pain. Available at http://www.opioidprescribing.com/overview. Accessed on 12/11/14