BackgroundThe crisis of prescription opioid addiction in the USA is well-documented. Though opioid consumption per capita is lower in the UK, prescribing has increased dramatically in recent decades with an associated increase in deaths from prescription opioid overdose. At one Scottish Emergency Department high rates of prescribing of take-home co-codamol (30/500 mg) were observed, including for conditions where opioids are not recommended by national guidelines. An Implementation Science approach was adopted to investigate this.MethodsA Behaviour Change Wheel analysis suggested several factors contributing to high opioid prescribing: poor awareness of codeine addiction risk, poor knowledge of NICE (National Institute for Health and Care Excellence) guidelines on common painful conditions, mistaken assumptions about patient expectations and ready access to a large stock of take-home co-codamol. Based on this analysis a combined Education/Persuasion intervention was implemented over a 1-month period (January 2019) reaching 93% of prescribers. An Environmental Restructuring intervention was introduced at 4 months, and co-codamol prescriptions were monitored over a 12-month follow-up period. Unplanned re-attendances and complaints related to analgesia were monitored as balancing measures.ResultsThe Education/Persuasion intervention was associated with a 59% reduction in co-codamol prescribing that was maintained over 12 months. The Environmental Restructuring intervention was not associated with any further reduction in prescribing. No increase in unplanned re-attendances occurred during the study period and no complaints were received relating to pain control.ConclusionsThe increasing incidence of prescription opioid addiction in the UK suggests the need for all clinicians who write opioid prescriptions to re-evaluate their practice. This study suggests that knowledge of addiction risk and prescribing guidelines is poor among Emergency Department prescribers. We show that a rapid and sustained reduction in prescribing of take-home opioids is feasible in a UK Emergency Department, and that this reduction was not associated with any increase in unplanned re-attendances or complaints related to analgesia.
Ciguatera is a common but underreported tropical disease caused by the consumption of coral reef fish contaminated by ciguatoxins. Gastrointestinal and neurological symptoms predominate, but may be accompanied by cardiovascular features such as hypotension and sinus bradycardia. Here, we report an unusual case of junctional bradycardia caused by ciguatera in the Caribbean; to our knowledge, the first such report from the region. An increase in global sea temperatures is predicted to lead to the spread of ciguatera beyond traditional endemic areas, and the globalisation of trade in coral reef fish has resulted in sporadic cases occurring in developed countries far away from endemic areas. This case serves as a reminder to consider environmental intoxications such as ciguatera within the differential diagnosis of bradycardias.
The misuse of highly potent benzodiazepines is increasing in the UK, particularly among the opioid-using population in Scotland. Differentiating opioid from benzodiazepine toxicity is not always straightforward in patients with reduced level of consciousness following drug overdose. Patients on long-term opioid substitution who present with acute benzodiazepine intoxication and are given naloxone may develop severe opioid withdrawal while still obtunded from benzodiazepines. This situation can be difficult to manage, and these patients may be at increased risk of vomiting while still unable to protect their airway. Fortunately, the short half-life of naloxone means that the situation is generally short-lived. Naloxone should never be withheld from patients with life-threatening respiratory depression where opioids may be contributing, particularly in community and prehospital settings; however, where appropriate clinical experience exists, naloxone should ideally be administered in small incremental intravenous doses with close monitoring of respiratory function. Increased awareness of the potential risks of naloxone in opioid-dependent patients acutely intoxicated with benzodiazepines may reduce the risk of iatrogenic harm in an already very vulnerable population.
An audit at a Scottish DGH found that large numbers of Emergency Department (ED) patients were being sent home with ‘To Take Out’ (TTO) boxes of Co-Codamol (30/500 mg) – a concerning finding given rising rates of prescription opioid addiction in the UK. Informal conversations suggested that many clinicians were prescribing high-dose codeine because ‘patients expect to be given something they can’t buy over the counter’. A survey-based study was therefore designed to explore this assumption.A short survey (figure 1) was developed to explore ED patients’ expectations of analgesia and knowledge of common painkillers. In the first stage of the study, the survey was circulated among 25 ED prescribers who were asked how they thought ‘most patients’ with mild to moderate pain would answer these questions. In the second stage, 50 ED patients with mild to moderate pain were asked to complete the survey. Prescribers’ and patients’ answers were then compared.Abstract 046 Figure 1There was a significant difference between how prescribers thought ‘most patients’ would answer and how most patients actually answered the questions. Fewer patients expected to be sent home with painkillers than the prescribers predicted (figure 2), and patients were prepared to tolerate significantly more pain than prescribers expected (figure 3). A relatively high number of patients were aware of the addictive potential of codeine, yet some were unaware of the addictive potential of morphine, while others thought that paracetamol and ibuprofen were also addictive. Almost all patients indicated that if a painkiller could lead to addiction, they would expect their ED doctor to inform them of this risk.Abstract 046 Figure 2Abstract 046 Figure 3These results suggest that strong painkillers are sometimes given out on the mistaken assumption that this is what patients expect. Involving patients in shared decision making about TTO analgesia may be a useful strategy to reduce ED opioid dispensing.
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