QA Reviews: Lessons from the Sharp End

May 1, 2014The Pendulum Swings: A Rational Approach to Narcotic Prescribing in the EDDavid J. Adinaro MD, MAEd, FACEPChief, Emergency Medicine, SJRMCPresident, NJ-ACEP

SOCIAL MEDIA@NJACEP (#NJACEP2014)

Facebook (NJ-ACEP Page)

NJEmergencyDocs.com (blog)

Goals and ObjectivesReview 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/BackgroundI have no financial relationships to report regarding the medications discussed (or any medications for that matter)

HOWEVER.

Disclosures/BackgroundI am a prescriber of narcotics.

One year thru March 2014Cared for 2,700 patients318 scripts for CDS (down from 390 year prior)Averaged 18 pills per script (19 year prior)

Disclosures/Background

Disclosures/BackgroundHigher Potency/Longer Acting30mg Oxycodone (2)Morphine 15mg (1)Dilaudid 2mg (2)Oxycontin 20mg (1)

Disclosures/BackgroundAND a patient who has received narcotic pain medication

Winter of 1988-1989MVC Femur FractureSurgery x 4

Disclosures/BackgroundDemerolMorphine (Yuck)Percocet

Disclosures/BackgroundSummer of 2013El Diablo4mm distal UVJ stone

Oxycodone 5mg/ 325mg APAP (#20)

Prescription Drug Abuse

Prescription Drug Abuse

Prescription Drug Abuse

Culture of Treating PainCure Sometimes. Treat Often. Comfort Always.

- Hippocrates

Culture of Treating PainThe 5th Vital Sign

Term introduced in the mid-90sCodified by Joint Commission to be routinely measured

Culture of Treating PainThe 5th Vital Sign

Term introduced in the mid-90sCodified 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 disparitiesAge disparities (elderly)CMS timing of pain meds for long bone fracturesCulture 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 strengthsCulture 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 drugsI Have a Peep

The Holy Grail of EMUsed to be which chest pain patient can be sent home safely

Now it is who really needs pain medication!Drug-Seeking Spectrum DiversionFalse names, false addresses, no actual medical complaintMultiple Visits for Acute ConditionsToothaches, traumatic injuries, visceral organ painChronic Pain from non-specific conditionsMigraines, Low Back Pain, Fibromyalgia, Chronic Lyme disease, etc.C1-Esterase DeficiencyChronic Pain 2nd to specific medical conditionGamut from SCD, Gastroparesis, Chronic pain after surgeryHeadaches 2nd to Brain Aneurysm, Recurrent Renal ColicPseudo-AddictedAddicted

Drug-Seeking SpectrumPseudo-AddictionA 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 SpectrumLogan et al. Medical Care. August 2013

Survey of 400,000 insurance enrollees who received a narcotic prescription in the ED10.3% had indicators putting patient at-riskMajority had high daily dose (> 100 MME)5mg oxycodone = 7.5 MME 5mg hydrocodone = 5MMEDrug-Seeking SpectrumLogan et al. Medical Care. August 2013

Survey of 400,000 insurance enrollees who received a narcotic prescription in the ED10.3% had indicators putting patient at-riskMajority had high daily dose (> 100 MME)5mg oxycodone = 7.5 MME 5mg hydrocodone = 5MMEAt-RiskAt-Risk SpectrumWilsey 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 abuseI Have a Peep

The ED ChallengeBalance 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 patientsThe ED ChallengeWhile 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!PMP544 patients, 38 EPsFair agreement between clinical impression and PMPDefined drug seeking by PMP data as:4 or greater prescriptions from4 or greater providersOver 12 months

PMPAssociated with drug seeking by PMP data:Requesting meds by nameMultiple visits for same complaint Suspicious historySymptoms out of proportion to examNOT AGE, GENDER, SPECIFIC ETHNICITY

PMPPMP changed management in 9.5%6.5% received unplanned narcotics3.0% did not receive planned narcotics

PMP180 patientsExcluded those with acute injuries or appeared acutely ill or injuredProbable bias in enrollment

PMPMost 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 decreased1/3 it increased

Institutional GuidelinesEffect 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 scriptAssociated decrease in dental pain visits

Institutional Guidelines15 patients averaging 19 visits per year without significant comorbities (cancer, renal colic, SCD)All had PCPsEmphasis was on more appropriate rescue meds from PCPs

Institutional GuidelinesDid not receive parenteral narcotics in EDDecreased to average of 2 visits per year7 weaned off narcotics4 converted to methadone1 to fentanyl patchPCP visits also markedly decreased

PMP

NO!A RATIONAL GUIDEUse the PMP consistently to screen for at-risk behavior when:

Multiple recent ED visits Exacerbation of chronic painPatient requests medications by nameAllergies to multiple alternative medicinesNot from typical catchment areaPrescribing LA opioids for non-cancerous pain

A RATIONAL GUIDEWhen PMP data suggests at-risk behavior share concerns with patient and negotiate no CDS prescription vs. smallest amount possible

A RATIONAL GUIDEIf pseudo addiction suspected coordinate closely with PMD

Arrange appropriate follow up

Use best judgment in terms of prescribing CDSA RATIONAL GUIDEWhen prescribing narcotics:

Screen for substance abuse as neededEmphasize risks to patientEncourage safe disposal of left over medicationA RATIONAL GUIDEWhen prescribing narcotics:

Continue to use short-acting formulationsGenerally limit amounts to five daysStrongly consider alternatives in patients already taking benzodiazepines A RATIONAL GUIDEWhen prescribing narcotics:

When practical avoid parenteral medications for exacerbations of chronic pain

Have a higher threshold for certain conditions including dental pain, sprainA RATIONAL GUIDEWhen prescribing narcotics:

Establish intra-departmental protocols for the most common conditionsAdd tools to your tool boxAlternative therapiesDental blocks

QUESTIONS?

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

TWITTER:@PatersonER

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