The Pendulum Swings: A Rational Approach to Narcotic Prescribing in the ED

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 1988-1989 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 15-20 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. At-Risk 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

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. 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! The ED Challenge

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: EMAIL: Adinarod@sjhmc.org Adinaromd@hotmail.com TWITTER: @PatersonER BLOG: Anatomy of a Super ER (PatersonER.com)