Opioid‐related Policies in New England Emergency Departments

Weiner, Scott G.; Raja, Ali S.; Bittner, Jane C.; Curtis, Kevin M.; Weimersheimer, Peter; Hasegawa, Kohei; Espinola, Janice A.; Camargo, Carlos A.

doi:10.1111/acem.12992

Cited by 17 publications

(13 citation statements)

References 5 publications

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“…However, the implementation of institutional policies varies widely. In a study of New England hospitals, policies recommending use of screening tools and prescribing naloxone for at-risk patients are uncommon, but policies regarding utilization of PDMPs and referral of patients with opioid use disorders to recovery resources are more prevalent [10]. The presence of an opioid prescribing policy has shown divergent results on practice, both reducing [11][12][13] and having no effect on [14] the amount and strength of prescribed OA.…”

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confidence: 99%

Opioid Prescribing: How Well Do We Know Ourselves?

Wightman

Nelson

2016

J. Med. Toxicol.

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Get your facts first, then you can distort them as you please.-Mark Twain BI would rather over-prescribe and risk some medication diversion or non-medical use, than under-prescribe and not treat a patient's pain.^This statement, taken from a survey published in the current issue of JMT by Pomerleau et al. 2016 [1], was used to assess clinicians' self-reported attitude about the challenge in meeting individual patient needs while balancing public health risk. The statement essentially pinpoints the current dilemma in the ED: alleviation of suffering in an individual may expose that patient or others (through misuse or diversion) to the risk of opioid analgesic (OA) abuse, addiction, overdose, and death. Pain-related complaints are the most common reason for Emergency Department (ED) visits [2,3], and ED providers are among the top five medical specialist groups writing prescriptions for OAs in patients under 40 years of age [4]. However, only 17 % of ED patients are given a prescription for an OA on discharge and the majority of prescriptions dispensed are for a small number of immediate release pills [5,6]. Still, iatrogenic opioid abuse and addiction remain a concern, because half of ED patients with opioid-use disorders were first exposed to an opioid by a prescription from a medical provider [7].Responsible opioid analgesic prescribing is paramount in our efforts to combat the epidemic of opioid abuse and promote safe opioid use, but little is currently known about which factors drive decision-making among emergency department (ED) prescribers of OAs. Pomerleau et al. highlights the complexity of the decision-making process and brings forth a number of interesting issues. Through a series of queries, the study explores the factors providers believe affect their OA prescribing practices, as well as their attitudes toward OA prescribing. Of course, individual provider opinions and attitudes cannot provide the complete picture. Patient age, race, type of insurance, provider training and experience, functionality of PDMPs, and geographic location are a few of the many factors highlighted in the literature to affect OA prescribing decisions.Whether to prescribe an OA for any given patient not only depends on the aforementioned patient and provider factors and the culture of the work environment, but also on the quality and type of patient doctor communication. One study showed that when faced with identical hypothetical case scenarios, ED physicians' decisions whether to prescribe an OA varied greatly [14]. For the same clinical scenario, subtle differences in the patient-doctor interaction (for example, a patient requesting a specific drug or an additional dose of pain medication) could change the likelihood of prescribing substantially [18]. To support this unconscious bias, Pomerleau, et al. uncovered some interesting paradoxes. For example, survey respondents report that they would be less likely to write a prescription for a patient with an opioid use disorder, but they also state their skills to identify pat...

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confidence: 99%

Opioid Prescribing: How Well Do We Know Ourselves?

Wightman

Nelson

2016

J. Med. Toxicol.

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“…While the concept of “self-reported pain” has generated considerable debate, the increasingly negative consequences associated with analgesics (pain killers) have necessitated intervention at multiple levels including hospital emergency departments where misuse and diversion are common (14). There is an urgent need for health care professionals to educate and realign patient expectations regarding pain management (15). By far the most common acute and chronic pain medications are opioid analgesics which include codeine, hydrocodone, oxycodone, morphine, and fentanyl, and others.…”

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A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health

Wiss

2019

Front. Public Health

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The opioid crisis has reached epidemic proportions in the United States with rising overdose death rates. Identifying the underlying factors that contribute to addiction vulnerability may lead to more effective prevention strategies. Supply side environmental factors are a major contributing component. Psychosocial factors such as stress, trauma, and adverse childhood experiences have been linked to emotional pain leading to self-medication. Genetic and epigenetic factors associated with brain reward pathways and impulsivity are known predictors of addiction vulnerability. This review attempts to present a biopsychosocial approach that connects various social and biological theories related to the addiction crisis. The emerging role of nutrition therapy with an emphasis on gastrointestinal health in the treatment of opioid use disorder is presented. The biopsychosocial model integrates concepts from several disciplines, emphasizing multicausality rather than a reductionist approach. Potential solutions at multiple levels are presented, considering individual as well as population health. This single cohesive framework is based on the interdependency of the entire system, identifying risk and protective factors that may influence substance-seeking behavior. Nutrition should be included as one facet of a multidisciplinary approach toward improved recovery outcomes. Cross-disciplinary collaborative efforts, new ideas, and fiscal resources will be critical to address the epidemic.

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“…This situation potentially contributes to opioid overuse 4,5. Competing efforts focus on reducing inappropriate ED opioid prescribing6,7 as well as on reducing ED barriers and inequities in the effective treatment of pain 8–10. Despite this attention to ED pain treatment, few studies examine individualized pain treatment for emergency patients 11…”

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confidence: 99%

Quantitative sensory testing measures individual pain responses in emergency department patients

Duffy

Flickinger

Kristan

et al. 2017

JPR

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BackgroundRefining and individualizing treatment of acute pain in the emergency department (ED) is a high priority, given that painful complaints are the most common reasons for ED visits. Few tools exist to objectively measure pain perception in the ED setting. We speculated that variation in perception of fixed painful stimuli would explain individual variation in reported pain and response to treatment among ED patients.Materials and methodsIn three studies, we 1) describe performance characteristics of brief quantitative sensory testing (QST) in 50 healthy volunteers, 2) test effects of 10 mg oxycodone versus placebo on QST measures in 18 healthy volunteers, and 3) measure interindividual differences in nociception and treatment responses in 198 ED patients with a painful complaint during ED treatment. QST measures adapted for use in the ED included pressure sensation threshold, pressure pain threshold (PPT), pressure pain response (PPR), and cold pain tolerance (CPT) tests.ResultsFirst, all QST measures had high inter-rater reliability and test–retest reproducibility. Second, 10 mg oxycodone reduced PPR, increased PPT, and prolonged CPT. Third, baseline PPT and PPR revealed hyperalgesia in 31 (16%) ED subjects relative to healthy volunteers. In 173 (88%) ED subjects who completed repeat testing 30 minutes after pain treatment, PPT increased and PPR decreased (Cohen’s dz 0.10–0.19). Verbal pain scores (0–10) for the ED complaint decreased by 2.2 (95% confidence intervals [CI]: 1.9, 2.6) (Cohen’s dz 0.97) but did not covary with the changes in PPT and PPR (r=0.05–0.13). Treatment effects were greatest in ED subjects with a history of treatment for anxiety or depression (Cohen’s dz 0.26–0.43) or with baseline hyperalgesia (Cohen’s dz 0.40–0.88).ConclusionQST reveals individual differences in perception of fixed painful stimuli in ED patients, including hyperalgesia. Subgroups of ED patients with hyperalgesia and psychiatric history report larger treatment effects on ED pain and QST measures.

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Opioid‐related Policies in New England Emergency Departments

Cited by 17 publications

References 5 publications

Opioid Prescribing: How Well Do We Know Ourselves?

Opioid Prescribing: How Well Do We Know Ourselves?

A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health

Quantitative sensory testing measures individual pain responses in emergency department patients

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