Prescribing Narcotics in the ED: A Rational Approach in a Changing World

“Cure Sometimes. Treat Often. Comfort Always”  - Hippocrates (400-ish BC)

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What is doctor to do?  We have a mandate to treat pain and relieve suffering, but some of the best medications available have high abuse potential and are involved in an epidemic of unintended morbidity and mortality.

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Do we as physicians prescribe too many narcotics?  Specifically do we emergency physicians prescribe more than we should? As with much else in medicine the evidence is complex and at times contradictory.  Some examples of the argument that we are not aggressive enough in the treatment of pain are the following (click on them to access links):

If you have spent any time looking at the news or proposed state legislation the answer would clearly be yes. There is an epidemic of deaths related to prescription drug use and misuse. The problem is stark both in terms of the individual tragedies and sheer numbers.

 

drug deaths

 

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My goal in this piece is to lay out the problem from an emergency medicine perspective and to suggest a set of guidelines that might help my colleagues in their daily struggle to figure out what the right thing to do is for each patient. This is based on a lecture I delivered at NJ-ACEP Scientific Assembly in May 2014 (Click here for slides: The Pendulum Swings).

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To start out let me disclose the following to understand my perspective:

one year of prescribing
I am a prescriber of narcotics….

  • One year thru March 2014
  • Cared for 2,700 patients
  • 318 filled prescriptions for CDS (down from 390 year prior)
  • Averaged 18 pills per script (19 in year prior)

 

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Who rarely prescribes “Higher Potency/Longer Acting” formulations:high potency

 

  • 30mg Oxycodone (2 scripts)
  • Morphine 15mg (1 script)
  • Dilaudid 2mg (2 script)
  • Oxycontin 20mg (1 script)

 

 

 

 

AND a patient who has received narcotic pain medication…

accident 2
  • Winter of 1988-1989
  • MVC (while as EMT in ambulance)
  • Femur Fracture
  • Surgery x 4
  • Meperidine, Morphine, Oxycodone
Capture

 

 

  • Summer 2014
  • “El Diablo” (kidney stone)
  • 4mm UVJ
  • Toradol and Oxycodone

 

 

 

The Modern Culture of Treating Pain

pain scaleThe introduction of  pain as  “The 5th Vital Sign  in the mid-1990s coincided with an explosion of prescribing of high potency and/or long-acting narcotics. The need to measure pain was codified by the Joint Commission at the start of the 2000′s.

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From an ED point of view pain scales may or may not be useful as the median pain score is an 8.

 

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Heavy advertising especially by physicians to physicians for drugs such as Oxycontin® culminated in this being a block-busting $1Billion drug by 2001.

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Eventually the FDA found the manufacturer had engaged in misleading and dangerous advertising. But by that time an epidemic had begun.

 

 Is this an ED Problem?

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Not surprisingly the answer turns out to be yes and no….

  • We make up 2-5% of all narcotics prescribed and filled.
  • We generally prescribe only 15-20 doses of the lowest strengths
  • However….A significant number of our  patients are “at-risk”
  • AND…. Most EPs feel at least once a shift they are being manipulated for drugs

 

at risk

While it is easy to label certain patients as drug-seekers the reality is much more complex. It is probably more useful to approach this from a RISK perspective.  Data suggests that approximately 10% of those receiving narcotics are “at-risk”.

at risk logan
  • Diversion
    • False names, false addresses, no actual medical complaint
  • Multiple Visits for Acute Conditions
    • Toothaches, traumatic injuries, visceral organ pain
  • Chronic Pain from non-specific conditions
    • Migraines, Low Back Pain, Fibromyalgia, Chronic Lyme disease, etc.
    • C1-Esterase Deficiency
  • Chronic Pain secondary to specific medical condition
    • Gamut from SCD, Gastroparesis, Chronic pain after surgery
    • Headaches secondary to history of Brain Aneurysm, Recurrent Renal Colic
  • Pseudo-Addicted 
    • A drug seeking behavior that simulates true addiction, which occurs in patients with pain who are receiving inadequate pain medication
  • Addicted (hard to distinguish from pseudoaddiction)

 

A Rational Approach to Narcotic Prescribing

in the Emergency Department

 

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The holy grail in emergency medicine has shifted from figuring out which patient with chest pain can be discharged safely to which patient can I safely give narcotics. This, of course, must occur in one of the most complex and information-challenged environments in healthcare. Physicians must balance all this with these other priorities. Here are some guidelines that could be helpful:

 

 When prescribing narcotics:

  • Screen for substance abuse as needed
  • Emphasize risks to patient
  • Encourage safe disposal of left over medication
  • Continue to use short-acting formulations
  • Generally limit amounts to five days
  • Strongly consider alternatives in patients already taking benzodiazepines
  • When practical avoid parenteral medications for exacerbations of chronic pain
  • Have a higher threshold for certain conditions including dental pain, sprain

Use your State’s PMP consistently to screen for “at-risk” behavior when:

  • Multiple “recent” ED visits
  • Exacerbation of chronic pain
  • Patient requests medications by name
  • Allergies to multiple alternative medicines 
  • Not from typical catchment area
  • Before prescribing LA opioids for non-cancerous pain
  • For more on Prescription Monitoring Programs  (PMP) see this blog:
too much too little

When clinical judgement and/or data suggests “at-risk” behavior:

  • Share concerns with patient
  • and negotiate no CDS prescription vs. smallest amount possible
  • If possible speak with primary medical doctor for coordination

If pseudo addiction suspected coordinate closely with PMD:

  • Arrange appropriate follow up
  • Use best judgment in terms of prescribing CDS

Establish intra-departmental protocols for the most common conditions

    • Oral protocols for chronic pain exacerbations
    • Common approach to repeat visits for CDS prescriptions
    • Add tools to your tool box
      • Alternative therapies
      • Dental blocks

As always this is one emergency physicians opinion based on a fair amount of research and discussion. I would love to hear your opinions and questions. 

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professional david adinaroDr. Adinaro is the out-going president of NJ-ACEP and is the Chief of Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. David can be reached via  @PatersonER . This publication represents the personal opinion of the author and does not reflect the policies of his employers.

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The Anatomy of a Super ER – Part One

ER outsideMuch like British naval vessels once considered noon the start of their day,  7 am is the start of the day in the Paterson ER (150,000 visits per year). During the next 24 hours an average of 415 patients will seek care (Monday and Tuesday always being the busiest). They will be cared for by 17 emergency physicians, 4 nurse practicioners, and 45 nurses supported by three dozen scribes, techs, transporters and registration personnel.

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7 clockBut for now only about 30 patients are in the department. It is a busy time of transition. The night shift physicians and most of the nurses have been here since 7pm.  When they came in nine zones were humming along at full power. Now they are turning over only four areas to the day shift.

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Before the new team can begin caring for patients the off-going  Team must sign out. Physician to physician. Clinical nurse to clinical nurse. Charge nurse  (See Inset) to charge nurse. All patients in the emergency department proper are “owned” by someone. This ownership (responsibility) forms the basis of the complex systems that provide medical care.

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Private-ED-Rooms-SJRMC“Ownership” in the Paterson ER is geographical. This very large ER (88 beds with 15-20 additional spaces for overflow) is broken down into nine zones (excluding the Resuscitation bays and Psych area). Each zone is staffed by a set team of one physician and two nurses for 8-10 beds. They are supplemented with a scribe for the doctor, trainees (residents, medical students) and pull from a pool of transporters, registrars and techs.

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CHARGE NURSE – The senior nurse responsible for the immediate operations of the department. Typically all personnel (excluding physicians) work directly for the charge nurse during their shift. The charge nurse generally has the most comprehensive situational awareness from moment to moment and handles  100+ communications per hour. They are traffic controllers, problem solvers, coaches, fixers…. all-knowing and all-important.

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Because of this scale areas have specialties. Zones 1-3 (Main ER) care for adults, are open 24 hours a day and receive the most critical patients. Zones 8 and 9 are pediatric and also never close. Zone 4 (also known as Supertrack) is a hybrid unit taking care of ambulatory patients with low to moderate intensity complaints. Zones 5 and 6 make up the SrED (Senior ED) and specializes in the care of those 65 and older. Finally Zone 7 is an area in transition currently taking care of the excess demand the other units can’t handle.

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ED blueprintAt 7 am with only four zones open (3 in Main ER and one in Peds along with the Psych and Trauma areas), the department can comfortably handle the roughly 8 patients an hour that are arriving. Beginning at 9 am that rate will sharply increase until 20 patients are presenting for care per hour. As demand increases more zones with more beds will come on-line.

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EMERGENCY PHYSICIAN – A physician who practices exclusively in emergency departments after receiving specialized training during their residency (after medical school). Generally certified by the American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine. PatersonER has one such training program that graduates six physicians per year. While residents they are closely supervised by emergency physicians as they learn the art and science of the emergent evaluation of the acutely ill patient.

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The pattern will be much the same for each of those 415 patients. 1)Come in, 2) get triaged (sorted), 3) go into a treatment area (bed), 4) be seen by the doctor and nurse, 5) receive ordered tests and treatments, 6) receive a disposition and 7) leave. Some patients will require this faster, others slower.

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Some will require very intensive care and others just an xray or a prescription. Frequently those who are dying will be saved. Sometimes though a patient will die. All will be touched by multiple people and their care will require the close cooperation of multiple departments and systems during their stay. Compassion amongst organized chaos will be the order of the day

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trackingTechnology plays a big role in modern healthcare but particularly in a SuperER. Without electronic medical record system (EMR) that integrates bed management, medication/test ordering, charting, and disposition planning there is no way this complex system could function. Though paper certainly exists in the ER more and more information is transmitted electronically. It is not unusual for physicians to have 4-5 different program running in order to access their patients’ current information, previous history, lab results, and digital images of radiology tests (CTs, ultraounds, etc).

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ultrasoundBEDSIDE ULTRASONOGRAPHY – Since the 1980s emergency physicians have been making use of bedside ultrasound machines to expedite the care of patients and improve care. Commonly they are used for the evaluation of abdominal pain, complications of pregnancy, and rapid diagnosis of the critically ill (FAST exam – see image). This great, non-invasive technology is also being used to make certain high risk procedures safer including the placement of central venous catheters.

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Next week Anatomy of a SuperER – Part Two will highlight some of the important innovations at PatersonER including Pivot Triage, the SuperTrack, and our astounding evolution of the emergency care of geriatric patients. We will also get in depth into the care of some of the most critical patients including those with major trauma and life threatening heart and brain emergencies. Stay tuned!

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Written by:

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David Adinaro MD, FACEP

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professional david adinaroDr. Adinaro is the president of NJ-ACEP for 2013-14 and is the Chief of the Adult Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. He is also the current editor of the “Year of Confusion…Year of Opportunity: 20 Things Changing Emergency Medicine” blog. Dr. Adinaro can be reached via  @PatersonER .

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This publication represents the personal opinion of the author and does not reflect NJ-ACEP or his employer.


ER 2030: The Future of Emergency Medicine?

SJRMC CRITICAL CARE BUILDING “If only I had a crystal ball…”

I don’t. So I had our residents participate in an exercise where they brainstormed on what the ED of the future will require. I thought as they are part of the future of medicine they would have some great ideas. How right I was!

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I gave them as background the following:

  • That currently EDs account for about 4% of HealthCare costs
  • Control upwards of 15-25% of expenditures (admissions)
  • Patients managed at home will become increasingly complex
  • Expectations are that more acute/chronic treatment will be outside of in-patient hospital units

I then gave them a specific patient in the year 2030:

  • 64 year-old recently retired physician (me in 17 years)
  • Complaining of fever, chills and abdominal pain with a history of diabetes and hypertension
  • Most medical records not at this institution

I then asked then to describe the necessary changes, improvements, technologies, that would be needed to care efficiently for 250,000 patients a year (our current volume 150,000)  and provide proper, coordinated care for the above patient. I asked them to consider the following:

  • Emphasis on coordinated care
  • Integration of technologies
  • Information management
  • Patient flow

technologyTECHNOLOGY

Being a group firmly planted in Generation Y they were very comfortable and specific on the need in terms of technology. They wanted healthcare technology to be as universal, easy to operate and intuitively obvious as what the make use of on a daily basis now.

A number of their suggestions were focused on electronic medical records and the need for them to be more portable, multimedia, and interactive.  Aside from the obvious need for a universal medical record they also suggested:

  • Incorporation of photos especially of wounds for comparison
  • Fingerprint ID
  • Personalized electronic discharge instructions (to phone/email, etc)
  • Personalized charting software
  • Improved dictation systems
  • System integration (one screen for all records – ED, past hospitalizations, Radiology, Lab, PMPs)

Their other technology improvements were focused on very specific patients issues:

  • I-Cloud Microblood Chip (implanted blood analyzer)
  • Affordable Pad-based ultrasounds
  • Advanced, non-radioactive cardiac imaging
  • Video-Chat for prehospital calls and communicating with other physicians
  • At-home telemetry
  • Universal health care provider communications (eliminate answering services)
  • Virtual Translation services
  • Wireless EKG
  • Jetpacks for patient transport (my favorite!)

health care system

SYSTEMS

To be clear systems are not all about computers but rather the structures humans create to accomplish specific tasks. Health Care systems are by nature complex, dynamic and tightly coupled (See posts on High Reliability ED). For many physicians in training this is not a well understood concept. Residents, to be honest, spend most of their time mastering the medical parts of health care and do not generally look at the systems they work in. However, our residents did a great job suggesting needed additions to our current systems to improve the efficiency and coordination of care.

  • Expanded use of observation units
  • Telephone triage (prior to arrival)
  • On-site access to primary care (directly from triage)
  • In-house pharmacies in EDs
  • Shuttle systems for getting patients from ED directly to primary care sites
  • Kiosks for patient entered medical data (chief complaint, meds, allergies, review of systems)
  • Multidisciplinary facilities (coupling primary and specialty care closer to EDs)
  • Personnel Optimization
    • Increased specialization of different roles of health care providers
    • More systematic assignment of personnel to meet flow demands
  • Improved safety checks prior to discharge to reduce bounce-backs

case23_fig1CULTURE

Finally, the residents brainstormed on what other changes in the culture of both Medicine and being a Patient. Almost universally the group agreed that patient accountability (the flip side of the medical coin) was the number one concern. Their desire was for patients to feel more ownership and responsibility in their own care.  This seemed to be in response to the increased expectations placed on physicians in improving the value of care.

Other areas they sought improvement included:

  • Better integration between community/schools and the health care system
  • Palliative Care  teams available in the ED
  • Improved communication between Private physicians and the ED (both directions)
  • “Super Gyms” – integration between wellness facilities and hospitals
    • to improve life-style modifications.
  • Informative health videos in ER waiting rooms
  • Outpatient pain management referred directly from ED

This exercise was hugely entertaining and enjoyable for all who participated. If you would like to share your views please feel free to add a comment!

David

 


PALLIATIVE CARE IN THE ED – A WISE CHOICE

Originally posted on NJEmergencyDocs:

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You have probably heard the term “palliative medicine” a lot lately. At least I hope you have! But what does this type of medicine have to do with the Emergency Department?

Let’s start with some basic questions…How often do you ask yourself :

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  • Why am I doing this tube/line/CPR/futile procedure on the poor person who will not get any benefit, and most likely get worse?”
  • How many patients do you see per week that you do a full work-up and management that you would NOT be surprised if they died within the next 6 months?
  • How often are you coding a patient that has obviously been declining for a while with a chronic/terminal condition such as CHF/COPD/dementia and the family has no conception of what is happening?

If you identify with any of these scenarios then read on…

Just as many serious public health questions have ended…

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In the ER: Too Much or Too Little Pain Medication?

Originally posted on NJEmergencyDocs:

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Do we as physicians prescribe too many narcotics?  Specifically do we emergency physicians prescribe more than we should? As with much else in medicine the evidence is complex and at times contradictory.  Some examples of the argument that we are not aggressive enough in the treatment of pain are the following (click on them to access links):

If you have spent any time looking at the news or proposed state legislation the answer would clearly be yes. There is an epidemic of deaths related to prescription drug use and misuse. The problem is stark both in terms of the individual tragedies and sheer numbers.

The CDC has some great graphics that…

View original 583 more words


Exit Only! How to reduce CA-UTIs

” A  finger or tube in every orifice” – Old School emergency medicine motto

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exit onlyIn my humble opinion foley catheters are the work of the devil.  Yes I know that in the right circumstances they are important in the care of patients and are a god send to those in acute urinary retention.

white spaceTrust me I know (See The Day I Almost Died…).  But everyone also knows many are placed for reasons that do not obviously benefit the patient. (perhaps up to half of those placed).

white spaceAnd to boot they cause infections.  Nasty multi-drug resistant infections. Close to 2,000 to 9,000 deaths per year are attributed to CAUTI (catheter associated urinary tract infections).

white spaceAnd, of course, there is a financial cost.  Estimates are $400M in 2007 dollars (http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf)

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white spaceThe good news is that there is help out there to help us break our habit!

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This is a great initiative that is working on the state level to help emergency departments bring change to their systems and culture. ( OnTheCusp).  They give you all the tools you need to implement change and produce real results. We will be focusing on the inappropriate reasons that catheters get placed (particularly in the ER):

  • Incontinence (without additional indication)
  • Diuresis (think non-ICU CHF exacerbations)
  • Frequent, nonessential measurement of UOP
  • Nurse’s concern about patient comfort
  • Diarrhea (without additional indication)
  • Patient’s preference (without additional indication)

SJRMC CRITICAL CARE BUILDING

PatersonER will be participating in this initiative and looking forward to increasing the safety of our patients.  We will rely on the systems we have already developed (See previous posts on Collaborative Leadership in the ED and EDQA).

white spaceBelow is a link to a slide set related to how physician leadership plays a vital role.

David

PS:  Let me know if you will be at MEMC VII this September in Marseille. This is going to be my first trip out there!

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Quality Initiatives: Physician Leadership in the Emergency Department