Sunday, June 5, 2016

Relevance of New CDC Opiate Guidelines for Emergency Physicians

Author: Samuel Bergin, MSIV, Uniformed Services University of the Health Sciences
Chad Roberts, MSII and Scott Pew, MPH Candidate
University of Utah
Originally Published: Modern Resident April/May 2016

Epidemiology
While the CDC was compiling data from 1999 to 2014, more than 165,000 people in the US died from overdoses linked to prescription opioids.[1] The opioids most commonly prescribed include methadone, oxycodone and hydrocodone. From 2004 to 2010, ED visits due to abuse of prescription drugs increased 115% while visits due to illicit drugs increased 18%.[2] Currently up to 1,000 people per day are treated in emergency departments for misusing prescription opioids. While emergency physicians are responsible for less than 5% of immediate and extended-release opiate prescriptions, they prescribe opiates for 17% of ED discharges.[4] Reasons for ED opioid prescriptions most commonly include back pain, abdominal pain and fractures/sprains.[4] We are in a position to help play a pivotal role in prescriptions, addictions and treating overdoses.[3]

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CDC Recommendations
The new CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 are generally directed at primary care physicians and evaluates three broad categories: (1) when to initiate and continue opioids for chronic pain, (2) opioid selection, dosage, duration, follow up and discontinuation, and (3) assessing risk and addressing harms. Spanning these broad categories are 12 recommendations to guide appropriate opioid prescription. These recommendations include:
  1. Starting with non-pharmaceutical & non-opioid management for chronic pain
  2. Setting & keeping goals
  3. Patient education of risks & benefits
  4. Immediate-release formulations instead of extended release
  5. Lowest effective dose & taking care to assess the morphine milligram equivalents
  6. Acute pain treated with lowest effective dose for three to seven days
  7. Frequent follow up
  8. Evaluating risk factors for abuse and harm
  9. Using state Prescription Drug Monitoring Programs (PDMP’s)
  10. Using urine drug screens to assess compliance
  11. Avoiding co-prescribing opioids and benzodiazepines
  12. Use of evidence-based medicine for opioid use disorder
Two recommendations are particularly applicable to emergency medicine.

Recommendation #6 states: “When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.” The authors note that “just in case” opioids should not be prescribed.

Recommendation #9 states: “Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose…” Application of these two recommendations may help reduce the likelihood of opioid-na├»ve patients becoming dependent and can help prompt intervention for opioid-dependent patients.

Reference:

  1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. doi:10.1001/jama.2016.1464.
  2. Drug Abuse Fact Sheet. ACEP News. American College of Emergency Physicians. http://newsroom.acep.org/fact_sheets?item=30034. Accessed on 22 March 2016.
  3. Governale L. Outpatient prescription opioid utilization in the U.S., Years 2000–2009. Presented at the Joint Meeting of the Anesthetic and Life Support Advisory Committee and the Drug Safety and Risk Management Advisory Committee, Adelphi, Maryland, 22–23 July 2010. Accessed at www.fda.gov/downloads/AdvisoryCommitteesMeetingMaterials/Drugs/AnestheticAndLifeSupportDrugsAdvisoryCommittee/UCM220950.pdf (slide 16) on 22 March 2016.
  4. Hoppe JA, Nelson LS, Perrone J, et al. Opioid prescribing in a cross section of US emergency departments. Ann Emerg Med. 2015;6:253–259.
  5. Phillips DM. Joint Commission on Accreditation of Healthcare Organizations. JCAHO pain management standards are unveiled. JAMA. 2000;284(4):428-429.

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