Emergency Department Prescription Opioids as an Initial Exposure Preceding Addiction

Butler, Megan M.; Ancona, Rachel M.; Beauchamp, Gillian A.; Yamin, Cyrus K.; Winstanley, Erin L.; Hart, Kimberly W.; Ruffner, Andrew H.; Ryan, Shawn W.; Ryan, Richard J.; Lindsell, Christopher J.; Lyons, Michael S.

doi:10.1016/j.annemergmed.2015.11.033

Cited by 153 publications

(122 citation statements)

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“…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.…”

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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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Opioid Prescribing: How Well Do We Know Ourselves?

Wightman

Nelson

2016

J. Med. Toxicol.

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“…8 However, medications have significant side-effects in both the short-and longterm. [9][10][11] Of particular concern is recurrent opioid use, 12 which, in part, can lead to a reluctance to prescribe and administer such medications. 13 Nonsteroidal anti-inflammatory drugs (NSAIDs), another mainstay of ED pain management, also have side-effects especially in the gastrointestinal system and kidneys in the elderly.…”

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Does Ear Acupuncture Have a Role for Pain Relief in the Emergency Setting? A Systematic Review and Meta-Analysis

Jan

Aldridge

Rogers

et al. 2017

Medical Acupuncture

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Objective: Ear acupuncture might be the form of acupuncture best suited to improving acute pain management in the emergency department (ED). The primary aim of this review was to assess the analgesic efficacy of ear acupuncture in the ED. Secondary outcomes included measures of patient satisfaction, adverse effects, cost, administration techniques, and reduction of medication usage. Methods: Seven databases and Google Scholar were searched up to April 27, 2017, using MeSH descriptors for three overarching themes (ear acupuncture, pain management, and emergency medicine). Meta-analyses were performed in 3 comparator groups: (1) ear acupuncture versus sham; (2) ear acupuncture-as-adjunct to standard care; and (3) ear acupuncture (both as sole therapy and adjuvant) versus control to calculate the standardized mean difference (SMD) and weighted mean difference (WMD) for pain scores out of 10. Results: Six randomized controlled trials and 2 observational studies, totaling 458 patients, were retrieved after exclusions. The meta-analysis used data from 4 randomized studies representing 286 patients. The above 3 comparator groups resulted in SMDs of 1.69, 1.68, and 1.66, and WMDs of 2.47, 2.84, and 2.61 respectively, all favoring acupuncture. Battlefield (ear) acupuncture was the most commonly used technique. There were no significant adverse effects and patient satisfaction improved. Results regarding if acupuncture reduced medication use were equivocal. Significant study bias and heterogeneity were found. Conclusions: While study numbers are limited, ear acupuncture, either as stand-alone or as-an-adjunct technique, significantly reduced pain scores and has potential benefits for use in the ED. Further studies will define acupuncture's role and if it reduces use of analgesic medications.

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“…[10][11][12] Although most emergency physicians likely consider opioid medications safe for the relief of acute pain and may therefore regard their role in the current opioid crisis to be limited to preventing diversion, recent reports suggest that opioids prescribed in the emergency department, especially to opioidnaive patients, are associated with substantial morbidity. [13][14][15] In 2014-2015, there were 4779 hospital admissions due to opioid toxicity in Canada, representing a total of 38 405 days of care provided in Canadian hospitals to patients admitted with a diagnosis of opioid toxicity. 16 Patients admitted for opioid toxicity remained in hospital for an average of 8.0 days, longer than the stay for those admitted for a heart attack, pneumonia or hip replacement surgery.…”

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