may 1, 2014 the pendulum swings: a rational approach to narcotic prescribing in the ed david j....
TRANSCRIPT
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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
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SOCIAL MEDIA
• @NJACEP (#NJACEP2014)
• Facebook (NJ-ACEP Page)
• NJEmergencyDocs.com (blog)
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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
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Disclosures/Background
• I have no financial relationships to report regarding the medications discussed (or any medications for that matter)
HOWEVER….
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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)
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Disclosures/Background
5mg Oxy/Hydrocodone89%
Benzos6%
Higher Potency3%
Misc.3%
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Disclosures/Background
• Higher Potency/Longer Acting• 30mg Oxycodone (2)• Morphine 15mg (1)• Dilaudid 2mg (2)• Oxycontin 20mg (1)
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Disclosures/Background
• AND a patient who has received narcotic pain medication…
• Winter of 1988-1989• MVC • Femur Fracture• Surgery x 4
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Disclosures/Background
• Demerol• Morphine (Yuck)• Percocet
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Disclosures/Background• Summer of 2013
“El Diablo”4mm distal UVJ stone
• Oxycodone 5mg/ 325mg APAP (#20)
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Prescription Drug Abuse
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Prescription Drug Abuse
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Prescription Drug Abuse
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Culture of Treating Pain
Cure Sometimes. Treat Often. Comfort Always.
- Hippocrates
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Culture of Treating Pain
The 5th Vital Sign
• Term introduced in the mid-90s• Codified by Joint Commission to
be routinely measured
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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
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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
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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
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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
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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
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“I Have a Peep”
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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!
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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
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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
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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
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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
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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
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I Have a Peep
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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
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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!
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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
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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
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PMP
• PMP changed management in 9.5%• 6.5% received unplanned narcotics• 3.0% did not receive planned narcotics
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PMP
• 180 patients• Excluded those with acute injuries or
appeared acutely ill or injured• Probable bias in enrollment
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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
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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
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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
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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
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PMP
NO!
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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
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A RATIONAL GUIDE
• When PMP data suggests “at-risk” behavior share concerns with patient and negotiate no CDS prescription vs. smallest amount possible
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A RATIONAL GUIDE
• If pseudo addiction suspected coordinate closely with PMD
• Arrange appropriate follow up
• Use best judgment in terms of prescribing CDS
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A RATIONAL GUIDE
• When prescribing narcotics:
• Screen for substance abuse as needed• Emphasize risks to patient• Encourage safe disposal of left over
medication
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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
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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
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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
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QUESTIONS?
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