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Temple study: Guidelines help ER docs limit pain meds

Emergency rooms are increasingly a prime spot for patients seeking powerful pain medications, with doctors caught between the desire to help people in pain and the need to discourage addiction and even overdoses.

Outside the emergency room of the Hospital of the University of Pennsylvania.
Outside the emergency room of the Hospital of the University of Pennsylvania.Read moreJoseph Kaczmarek/For The Inquirer

Emergency rooms are increasingly a prime spot for patients seeking powerful pain medications, with doctors caught between the desire to help people in pain and the need to discourage addiction and even overdoses.

Temple University Hospital reported Tuesday that it had found a straightforward way to limit prescriptions of these opioid drugs, such as Percocet, Dilaudid, and Vicodin: a set of guidelines that helps ER doctors determine when to say no.

Among patients with dental, neck, back, or unspecified chronic pain for which opioids are not advised, the number getting prescriptions dropped below 30 percent immediately after the guidance was distributed in January 2013 - down from 52.7 percent beforehand.

These findings, published in the Journal of Emergency Medicine, came from more than 13,000 patient visits to Temple's main location on North Broad Street and its Episcopal Campus on East Lehigh Avenue.

Patients who needed pain medication still got it, said lead study author Daniel A. del Portal, an assistant professor at Temple's Lewis Katz School of Medicine. The guide helped physicians explain to patients why, for certain kinds of pain, they were better off with non-opioid drugs.

"It facilitates the conversation," del Portal said. "It gives us a tool to use."

Nationwide, abuse of opioids has soared in recent years, now accounting for more deaths from overdose than heroin and cocaine combined. And when the overdoses are not fatal, patients often are able to go back to doctors for more, according to another new study this week, led by researchers at Boston Medical Center.

In a national sample of nearly 3,000 patients who suffered a nonfatal opioid overdose, 91 percent were able to get subsequent prescriptions for the drugs, the authors reported in Annals of Internal Medicine.

Temple is not alone in trying to tackle the problem by spelling out when such drugs are a poor choice. Various medical societies and state governments also have weighed in.

But so far, prescribing practices have not changed much in response, said Marc R. Larochelle, the lead author of the study of overdose patients.

The Temple study was unusual in that it saw improvement both immediately after the guidelines were issued and a year later, Larochelle said. From January to July 2014, the opioid prescription rate for patients with dental, back, or other chronic pain was 33.8 percent - well below the original 52.7 percent.

"It's actually pretty impressive," said Larochelle, an assistant professor at Boston University School of Medicine. "It seems that they had a lasting effect. The question is, is this translatable on a large scale?"

Temple's del Portal said guidelines are not enough to get the job done. It is also important to have strong networks of substance-abuse counseling and mental health treatment, among other resources.

Most states also have electronic databases to help physicians tell if patients are filling opioid prescriptions from multiple doctors, though sometimes these programs are designed more for use by law enforcement, he said.

One reason that emergency rooms are a common source of opioid prescriptions is that physicians usually do not know the patients and are less able to tell if the drug is medically necessary. Emergency room physicians also may not be readily able to tell if patients are getting more pills elsewhere.

Some emergency patients ask for opioids by name because they are in severe pain and believe them to be the strongest weapon, del Portal said. Physicians, who are increasingly evaluated through patient satisfaction ratings, may be reluctant to say no.

But for dental pain, a dental block (an injected anesthetic) is a better option. And for back and neck pain, an anti-inflammatory drug like ibuprofen is more effective and safer, del Portal said. In addition to the dangers of addiction and respiratory arrest, opioids also can lead to hallucinations.

The Temple guidelines go beyond listing which conditions are not best treated with opioids. They also state that emergency physicians should not refill prescriptions, leaving that task to primary-care doctors or pain specialists, who can follow the patient over the long term.

Emergency physicians also should not write a new prescription for a patient who says the old one has been lost, the guidelines state.

Inappropriate prescribing of opioids has consequences for others beside the patient, del Portal said.

Every time someone seeks an opioid refill in the emergency room, other patients have to wait longer to be treated, he said.

In addition, opioids can end up in the wrong hands.

"You see kids come in with drug overdoses, and we know we didn't prescribe them a bottle of Percocet," del Portal said.


Temple Guidelines


Here is a recently updated version of the guidelines for prescribing addictive pain medicine (opioids) at Temple University Hospital's emergency department.

Objective: To appropriately relieve pain for patients and attempt to identify those who may be abusing or addicted to opioids and refer them for special assistance.

Guidelines for treating non-cancer pain

1. Opioid analgesics may be appropriate for acute illness or injury when less addictive therapies such as NSAIDs (nonsteroidal anti-inflammatory drugs) or acetaminophen are contraindicated or deemed inadequate to reasonably control pain.

a. Physicians should prescribe the least addictive medications that are expected to provide appropriate analgesia. When appropriate, the physicians should consider prescribing Schedule III or Schedule IV drugs instead of Schedule II drugs (see table).

b. Emergency physicians should not prescribe long-acting opioids such as OxyContin, extended release morphine or methadone.

2. Discharge prescriptions are limited to the amount needed until follow up and should not exceed 7 days' worth.

3. The patient should not receive opioid prescriptions from multiple doctors. Emergency physicians should not prescribe additional opioids for a condition previously treated in our ED, in another ED, or by another physician.

4. Emergency physicians should not replace lost or stolen prescriptions for controlled substances.

5. Emergency physicians should not prescribe opioids to patients who have run out of pain medications. Refills are to be arranged with the primary or specialty prescribing physician.

6. Opioids are discouraged for dental and back pain, whether acute or chronic.

a. Non-opioid alternatives such as dental block or NSAIDs may be offered.

7. Opioids should not be used to treat migraines, gastroparesis, or chronic abdominal/pelvic pain.

8. Patients with chronic non-cancer pain should not receive injections of opioid analgesics in the ED.

9. Physicians may consider drug screening as needed to guide treatment decisions.

10. Patients with suspected addictive behavior may be referred to detoxification resources.

Opioids by DEA Drug Schedule

The U.S. Drug Enforcement Agency classifies opioid drugs by their potential for abuse and psychological/physical dependence.

Schedule I (highest potential). Includes heroin and other illegal drugs.

Schedule II (high potential for abuse, severe dependence potential). Includes Hydromorphone (Dilaudid), Oxycodone (Percocet), Hydrocodone (Vicodin) and Fentanyl.

Schedule III (lower potential for abuse than II, still high potential psychological dependence). Includes Tylenol with codeine (Tylenol 3).

Schedule IV (lowest potential for abuse/dependence). Includes Tramadol (Ultram).

SOURCE: Temple University HospitalEndText