1) The document discusses critical issues in prescribing opioids for adult patients in the emergency department. It provides recommendations on 4 critical questions related to opioid prescribing based on a review of the available medical literature.
2) The first critical question addresses whether prescription drug monitoring programs can help identify patients at high risk for opioid abuse. The recommendation is that PDMPs may help with this.
3) The second critical question discusses whether opioids are more effective than other medications for acute low back pain. The recommendations are to consider non-opioid options first and avoid routine opioid prescribing.
4) The third and fourth critical questions and recommendations address appropriate opioid selection and prescribing considerations on discharge for acute pain patients.
1. American College of Emergency Physicians
Clinical Policy:
http://www.acep.org/clinicalpolicies/
Critical Issues in the Prescribing of Opioids for Adult
Patients in the Emergency Department
Created by Danielle S. Campbell, Project Coordinator
Subject Expert: Knox Todd, MD
2. *This photo is used as a courtesy from Johns Hopkins Medicine.7/24/2013
High Pain Prevalence
Press Ganey
Prescription Opioid Abuse
The Joint Commission
Pain Management in the Emergency Department
5. 0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Proportionreceivingopioids
White
Black
Hispanic
Asian/Other
Non-White
*Pletcher MJ, et al.
Differential opioid prescribing to Non-Hispanic Whites in the Emergency Department
JAMA 2008;299(1):70-78.
Emergency Department Opioid Trends by Ethnicity
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Proportionreceivingopioids
White
Black
Hispanic
Asian/Other
Non-White
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Proportionreceivingopioids
White
Black
Hispanic
Asian/Other
Non-White
6. *Slide used as a curtsey
from pinterest
7% 4%
5%
12%
17%
55%
Prescription Medication
Other source
Drug dealer or
stranger
Took from friend or
relative without asking
Bought from a friend
or relative
Prescribed by a doctor
Obtained free from
friend or relative
In 2010, 2 million people reported taking prescription
painkillers nonmedically for the first time
8. Emergency Department Opioid Prescribing
http://www.acep.org/clinicalpolicies/
Emergency Physicians, as a specialty, are higher
prescribers of opioids for patients between the ages of
10 to 40 years.
9. PROPERTIES
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10. Stephen V. Cantrill, MD
Michael D. Brown, MD, MSC
Russell J. Carlisle, MD
Kathleen A. Delaney, MD
Lewis S. Nelson, MD
Robert E. O’Connor, MD, MPH
Ann Marie Papa, DNP, RN, CEN, NE-BC
Karl A. Sporer, MD
Knox H. Todd, MD, MPH
Rhonda R. Whitson, RHIA
Daniel P. Hays, PharmD
Leonard J. Paulozzi, MD, MPH
National Center for Injury Prevention and
Control, CDC
Chet Pogostin, DMV, MPH
National Center for Injury Prevention and
Control, CDC
Bob A. Rappaport, MD
Center for Drug Evaluation and Research, FDA
Jacqueline Spaulding, MD
Center for Drug Evaluation and Research, FDA
Writing Panel Technical Panel
American College of Emergency Physicians
Opioid Guideline Writing Panel
11. 2. Expert review
3. PICO format
Development of Recommendations
1. Literature review
patient
intervention
comparison
outcome
What does PICO stand for?
13. Disclaimer:
This policy is not intended to be a complete manual on the
evaluation and management of adult ED patients with painful
conditions where prescriptions for opioids are being considered, but
rather a focused examination of critical issues that have particular
relevance to the current practice of emergency medicine.
It is the goal of the ACEP Opioid Guideline Panel to provide an
evidence-based recommendation when the medical literature
provides enough quality information to answer a critical
question. When the medical literature does not contain enough
quality information to answer a critical question, the members of
the ACEP Opioid Guideline Panel believe that it is equally
important to alert emergency physicians to this fact.
Recommendations offered in this policy are not intended to represent the
only management options that the emergency physician should consider.
ACEP clearly recognizes the importance of the individual physician’s
judgment. Rather, this guideline defines for the physician those strategies
for which medical literature exists to provide support for answers to the
critical questions addressed in this policy.
Limited
Evidence based
Judgment
14. 1. Compare prescription drug monitoring programs.
2. Describe an ideal prescription monitoring program.
3. Register for the prescription monitoring program (PAT) in Texas.
4. Obtain opioid risk screening tools.
5. Recognize the need for quality research.
OBJECTIVES
“A mature person is one who does not think only in absolutes,
who is able to be objective even when deeply stirred emotionally,
who has learned that there is both good and bad in all people and in all things,
and who walks humbly and deals charitably with the circumstances of life,
knowing that in this world no one is all knowing and therefore all of us need both
love and charity.”
-Eleanor Roosevelt, It seems to Me: Selected Letters
www.goodreads.com
16. In the adult ED patient with non cancer pain for whom opioid
prescriptions are considered, what is the utility of state prescription
drug monitoring programs in identifying patients who are at high risk
for opioid abuse?
Level A: None specified.
Level B: None specified.
Recommendations:
Level C: The use of a state prescription monitoring
program may help identify patients who are at high risk
for prescription opioid diversion or doctor shopping.
critical question #1
PDMPS may help identify high risk patients
17. Is this statement True or False?
“Only Physicians can access data from
the prescription monitoring program.”
TRUE FALSE
18. “Most states allow health care providers and
pharmacists to access the programs for patients under
their care. Other groups such as law enforcement and
regulatory boards may also have access. One program
tracks only schedule II drug prescriptions, whereas most
track drug prescriptions of schedule II to IV or II to V
drugs.”
http://www.acep.org/clinicalpolicies/
19. Prescription Drug Monitoring Programs (PDMP)
2011
2005
National All Schedules Prescription
Electronic Reporting Act (NASPER)
Prescription Drug Abuse Prevention Plan
released by the Office of National Drug
Control Policy (ONDCP)
20. Evolution of State Prescription Monitoring Programs
Purdue Pharma L.P.,Stamford, CT
2007
2008
2012
2013
National Conference of State Legislation
National Conference of State Legislation
Alliance of States with Prescription Monitoring Programs
21. Specialty Nonoutlier
Prescribers
Outlier
Prescribers
No. of Outlier
Prescribers
1 Pain medicine 3813 8811 1
2 Anesthesiology 1749 8128 1
3 Physical medicine 916 5599 1
4 Preventive medicine 662 44,397 1
5 Family practice 575 12903 8
6 Geriatric medicine 493 15544 1
7 General practice 462 24502 1
8 Internal medicine 422 11314 12
9 Sports medicine 387 7025 1
10 Psychiatry 213 18757 3
11 Emergency medicine 203 7935 2
12 Obstetrics and gynecology 110 11096 3
13 Pediatrics 31 5524 2
Average Monthly Doses of High-Risk Drugs Prescribed
Mitch Betses RPh., and Troyen Brennan, MD MPH
N Engl J Med 2013; 369:989-991September 12, 2013 DOI: 10.1056/NEJMp1308222
http://www.nejm.org/doi/pdf/10.1056/NEJMp1308222
22. Help identify patients who engage in doctor
shopping.
May identify providers or pharmacists who
engage in diversion of controlled substances.
Provide information about prescribing trends
for surveillance and evaluation purposes.
Functions of PDMPs
32. Recommendations:
Level C: (1) Physicians should avoid the routine prescribing of outpatient
opioids for a patient with an acute exacerbation of chronic noncancer pain seen
in the ED.
(2) If opioids are prescribed on discharge, the prescription should be for the
lowest practical dose for a limited duration (eg,< 1 week), and the prescriber
should consider the patient’s risk for opioid misuse, abuse, or diversion.
(3) The clinician should, if practicable, honor existing patient-physician pain
contracts/treatment agreements and consider past prescribing patterns from
information sources such as prescription drug monitoring programs.
In the adult ED patient with an acute exacerbation of noncancer
chronic pain, do the benefits of prescribing opioids on
discharge from the ED outweigh the potential harms?
Level A: None specified.
Level B: None specified.
critical question #4
1. Avoid routine prescriptions
2. Limited dose
3. Seek additional information
37. In the adult ED patient for whom opioid prescription is
considered appropriate for treatment of new-onset acute pain,
are short-acting schedule II opioids more effective than short-
acting schedule III opioids?
Level C: Research evidence to support superior pain relief for
short-acting schedule II over schedule III opioids is
inadequate.
Level B: For the short-term relief of acute musculoskeletal pain,
emergency physicians may prescribe short-acting opioids such as
oxycodone or hydrocodone products while considering the benefits
and risks for the individual patient.
Level A: None specified.
critical question #3
1.Two studies
Recommendations:
2. No differences found
38. Schedule II Opioids:
1. oxycodone combination products
2. hydromorphone (eg, Dilaudid
3. oxycodone (eg, Roxicodone) and
oxycodone combination products
4. morphine (eg, MS Contin),
oxymorphone (eg, Opana),
morphine (eg, MS Contin),
oxycodone (eg, Roxicodone)
oxycodone combination products
(eg, Percocet, Percodan),
and fentanyl (eg, Duragesic patch,
Actiq).
Schedule III Opioids:
1. hydrocodone combination
products
2. codeine combination products
Controlled Substance Scheduling
What are the schedule II and schedule III
opioids?
39. Calls to Reclassify Hydrocodone
http://www.fda.gov/drugs/drugsafety/ucm372089.htm
41. In the adult ED patient with acute low back pain, are
prescriptions for opioids more effective during the acute
phase than other medications?
Level A: None specified.
Level B: None specified.
Level C: (1) For the patient being discharged from the ED with acute low back pain, the
emergency physician should ascertain whether nonopioid analgesics and
nonpharmacologic therapies will be adequate for initial pain management.
(2) Given a lack of demonstrated evidence of superior efficacy of either opioid or nonopioid
analgesics and the individual and community risks associated with opioid use, misuse,
and abuse, opioids should be reserved for more severe pain or pain refractory to other
analgesics rather than routinely prescribed.
(3) If opioids are indicated, the prescription should be for the lowest practical dose for a
limited duration (eg, <1 week), and the prescriber should consider the patient’s risk for
opioid misuse, abuse, or diversion.
Recommendations:
critical question #2
1. Consider nonpharmacologic and nonopioid therapies
2. Avoid routine opioid prescribing
3. Lowest dose and duration
43. 19% reported opioid use at 3 month follow up
Reoccurrence Rate of Low Back Pain
50-80%Symptoms
44. Opioids
Low Back Pain
Abuse
Reference:
42. United States Government Accountability Office
Instances of Questionable Access to Prescription Drugs.
GAO-11-699.Washington, DC: Government Accountability Office;2011.
Questionable Access to Prescription Drugs
45. • Federal Guidelines on Proper Disposal of Prescriptions:
www.fda.gov/forconsumers/consumerupdates
• Office of National Drug Control Policy: www.whitehouse.gov/nidamed
• NIDA: The National Institute on Drug Abuse: www.drigabuse.gov
• SAMHSA: The Substance Abuse and Mental Health Services Administration
www.samhsa.gov
• DAWN: Drug Abuse Warning Network: www.dawn.gov
Additional Resources
46. Baehren DF, Marco CA, Droz DE, et al.
A statewide prescription monitoring program affects emergency department prescribing behaviors.
Ann Emerg Med. 2010;56:19-23.
Cantrill SV, et al
Clinical Policy-Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department
Ann Emerg Med. 2012;60:499-525.
Devulder J, Jacobs A, Richarz U, et al.
Impact of opioid rescue medication for breakthrough pain on the efficacy and tolerability of long-acting opioids in patients
with chronic non-malignant pain.
Br J Anaesth. 2009;103:576-585.
Friedman BW, Chilstrom M, Bijur PE, et al.
Diagnostic testing and treatment of low back pain in US emergency departments. A national perspective.
Spine. 2010;35:E1406-E1411.
Hall AJ, Logan JE, Toblin RL, et al.
Patterns of abuse among unintentional pharmaceutical overdose fatalities.
JAMA. 2008;300:2613-2620.
Holmes CP, Gatchel RJ, Adams LL, et al.
An opioid screening instrument: long-term evaluation of the utility of the Pain Medication Questionnaire.
Pain Pract. 2006;6:74-88.
Marco CA, Plewa MC, Buderer N, et al.
Comparison of oxycodone and hydrocodone for the treatment of acute pain associated with fractures:
a double-blind, randomized, controlled trial.
Acad Emerg Med. 2005;12:282-288.
McIntosh G, Hall H.
Low back pain (acute).
Clin Evid (Online).2011;05:1102.
References
47. Palangio M, Morris E, Doyle RT Jr., et al.
Combination hydrocodone and ibuprofen versus combination oxycodone and
acetaminophen in the treatment of moderate or severe acute low back pain.
Clin Ther. 2002;24:87-99
Passik SD, Kirsh KL, Casper D.
Addiction-related assessment tools and pain management: instruments for screening, treatment
planning, and monitoring compliance.
Pain Med. 2008;9(suppl2):S145-S166
Pradel V, Frauger E, Thirion X, et al.
Impact of a prescriptionmonitoring program on doctor-shopping for high dose buprenorphine.
Pharmacoepidemiol Drug Saf. 2009;18:36-43.
Rockett IRH, Putnam SL, Jia H, et al.
Assessing substance abuse treatment need: a statewide hospital emergency department study.
Ann Emerg Med. 2003;41:802-813.
Roelofs PDDM, Deyo RA, Koes BW, et al.
Non-steroidal anti-inflammatory drugs for low back pain.
Cochrane Database Syst
Rev. 2008;(1):CD000396. doi:10.1002/14651858.CD000396.pub3.
Simpson DM, Messina J, Xie F, et al.
Fentanyl buccal tablet for the relief of breakthrough pain in opioid-tolerant adult patients with
chronic neuropathic pain: a multicenter, randomized, double-blind,placebo-controlled study.
Clin Ther. 2007;29:588-601.
Tamayo-Sarver JH, Dawson NV, Cydulka RK, et al.
Variability in emergency physician decision making about prescribing opioid analgesics.
Ann Emerg Med. 2004;43:483-493.
References
48. Email us:
Knox H. Todd, MD, MPH
Professor and Chair
Department of Emergency Medicine
MD Anderson
khtodd@mdanderson.org
Danielle S. Campbell
Program Coordinator
Department of Emergency Medicine
MD Anderson
dscampbell@mdanderson.org
Zeena Shelal
Research Interviewer
Department of Emergency Medicine
MD Anderson
zshelal@mdanderson.org
Questions
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