Opioid free Emergency Department?

Opioids Free ED

Hassan Zahoor

Concept Of Opiate Free Ed

Dr Sergey Motov MD, with particular interest in Pain management in ED, ran ED shift without prescribing single opiate as part of research work, also and website painfree.com with lectures and resources.

Swedish Ed physicians in most medical centres have taken initiative of oxy fee ED based on risks associated with opiates prescription

2

http://painfree.com/

Areas To Cover

Concept and rationale of opiate free ED: Why do we need alternatives to opioids in ED

Different analgesic options depending upon patient population

Choosing right opioids if you have to

Need Of Alternative to Opiates ( Problems with opiate prescribing)

1. Severe Side effects esp. elderly patients

http://www.ncbi.nlm.nih.gov/pubmed/24033733


2. Addiction and Misuse ( non medical use)

Clear Evidence of overdose, injection related harms, and dependance

Data from the United States FDA Adverse Event Reporting System shows that oxycodone contributed to the largest number (5548) of all drug-related deaths in North America during the period 1998 to 2005 (morphine ranked fourth, contributing to 1616 deaths).11

In another study investigating North American accidental pharmaceutical overdose deaths, non-medical use of pharmaceuticals was involved in 63%.



3. No consensus on optimum opioid doses (weight-based, fixed, nurse initiated?)


4. Poor Titration Practices


5. Regulatory Concerns of prescribing opiates? Concerns from AHPRA? only consultants will be authorised to prescribe oxycodone.

Pain Team at SCGH

Acute pain service will support any measures to reduce oxycodone prescription in this hospital, as it is too addictive, and there are equally efficacious analgesics which do not cause social carnage and hyperalgesic consequences.

Focus is on avoiding oxycodone prescribing except in elderly people.

Practical Consideration

Dual/tripple analgesia combination

Different classes of analgesia together provide synergistic effect

small doses of each agent result in decreased potential of adverse effects

less sedation, early mobilisation and decreased LOS with opioid free analgesia

Multimodal Receptor Targeted analgesiaNSAIDS COX1-2 eg celecoxib, naproxen, meloxicam

NMDA receptors eg ketamine, NO

Central Ca receptors eg pregabalin, gabapentin

Less Addictive opioids

Alpha 2 central agonists eg clonidine

Choosing opioids

What options we have

Tramadol :

Centrally acting , atypical opioid analgesic

Serotinine and NA reuptake inhibitor

Active metabolites similar to opioids

Oral or IV 50-100 mg 4/24 PRN

BuprenorphinePartial Mu opioid agonist ( Ceiling Effect)

High receptor affinity

SL route, transdermal patch onset 12-24 hours

Minimal gut effect

Primary site of action is spine not brain, less

abuse potential

Gabapentinoids

Inhibit presynaptic ca channels

Also inhibit NMDA receptors

Modulate pain and inhibit central sensitisation

Antihyperalgesic

Reduce opioid requirements

Gabapentinoids

Reduce opioids side effects

Reduce post operative ch pain by 50-90 percent

No pharmacokinetic drug interactions

Not lethal in overdose

Easily dialiasable

22 years old male, BIBA , involved in motor bike accident, sustaining right open tib-fib fracture, splinted by SJA. haemodynamically stable, nil active bleeding, crying with pain. What will you give??or what have you used in past??

45 years old male, presented to Ed with left sided renal colicky pain, previous h/o same side kidney stone, pain feels the same. What will you use??/what have you used in past??? What will you give on discharge??


http://www.ncbi.nlm.nih.gov/pubmed

/24381620

50 year old female, known ch back pain , recent acute exacerbation with radiculopathy signs left side , nil motor weakness or red flags, nil infection or tumor signs. What are the options??or what have you used in past?? What will you give on discharge??


Opioid free Emergency Department?

Health & Medicine

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