The College’s new policy lacks a comprehensive perspective and too readily discourages the use of opioids. The dearth of valid evidence should lead EPs to a balanced approach on pain, rather than a restrictive one.
In June, the American College of Emergency Physicians (ACEP) published a new clinical policy entitled: “Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department”. As the opening lines explain, the guidelines were intended, “for adult patients presenting to the ED with acute noncancer pain or an acute exacerbation of chronic noncancer pain.” Unfortunately, despite the panel’s best efforts, the policy falls short in many ways. It is severely limited by a lack of well done studies in this area, most recommendations are Level C recommendations and there were no experts in chronic pain involved in the development of this policy. As a result, the policy, as written, has the potential to encourage physicians to decrease opioids and under-treat pain.
Perhaps the most limiting aspect of this policy is that the recommendations have not been placed within the greater context of all analgesics and the totality of acute pain care, resulting in almost no discussion as to how the prescription of opioids falls within the comprehensive approach to acute pain in the ED. But that is only the first of many problems for this pain policy.
We can all agree that there are very negative points about opioids. First, opioid misuse amongst teenagers is a rising concern with more than 25% of adolescents having misused prescription opioids. The number one source of their drugs is from their parents’ medicine cabinet, because the parents have failed to secure them properly – and we have failed to educate those parents on how to secure them properly. Second, there has been a rise in opioid-associated deaths as the incidence of opioid prescriptions for pain has risen. This is not something to be ignored but should be considered in context of the adverse effects of analgesics that could potentially be prescribed instead of opioids; the amount of morbidity and deaths associated with NSAIDs far surpasses that of opioids, with up to 20% of all new cases of CHF linked to the use of this category of drug. We do not see major national associations decrying NSAIDs – why so much publicity about opioids? The answer is that opioids create an emotional reaction that NSAIDs do not. Third, opioids as a group are can be abused and can lead to criminal behavior. As emergency physicians we are neither agents of law enforcement nor addiction medicine experts - we are patient advocates. Unfortunately as study after study has shown, we do not advocate very well for our patients in pain.
The prescribing of opioids can be both contentious and emotionally charged. Most emergency physicians have not been trained to properly evaluate aberrant drug-related behavior (ADRB), nor how to objectively screen for addiction. ADRB is a term that describes a spectrum of behavior spanning from the mildly problematic (such as hoarding medications to have extra doses during times of more severe pain) to felonies (such as selling medications).
As a result, many physicians distrust any patient that either asks for opioids or manifests ADRB, which is unfortunate given that most victims of oligoanalgesia – the undertreatment of pain – manifest such behavior. Studies of sickle cell patients have demonstrated that 100% of patients in vaso-occlusive crisis have had to use ADRB in an attempt to obtain pain relief.
Contrary to the ACEP statement that pain is associated with 42% of ED visits, actual data show it is closer to 80%. The rate of addiction in society is 10-12% when alcohol is included. Assuming the worse case scenario, that would mean there are 8 times more people in pain coming to our EDs than there are people hoping to divert opioids. So why do we keeping focusing more on the smaller group than on the (much) larger one? A recent Canadian survey showed that the average medical school curriculum spent 1/5 the amount of time on education about pain than did veterinary schools, and almost no time on addiction and aberrant drug-related behaviors. Perhaps the first step should be educating the medical profession in these areas rather than trying to establish inadequate policies for ill-trained physicians.
So let’s look at the four recommendations from the new policy:
1) In the adult ED patient with noncancer 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 C recommendations. The use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shopping.
No one can disagree with state prescription drug monitoring programs, although opioid monitoring is probably one of their lesser utilities. Instant access to medication lists and rapidly identifying drug-drug interactions – the cause of over 10% of all hospital admissions – is an essential part of medical practice today.
2. In the adult ED patient with acute low back pain, are prescriptions for opioids more effective during the acute phase than other medications? Level C recommendations. (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.
There is little evidence to support these recommendations, but absence of evidence is not evidence of absence of effect. It has been demonstrated that of the non-traumatic causes of pain presenting to the ED, back pain and dental pain are the two that consistently score the highest on pain scales. Acute back pain is usually associated with considerable muscle spasm; opioids have several neurobiological reasons why they are the most effective agents for relieving acute painful muscle spasm. ACEP seems to be making two statements with this policy:
- Opioids are not superior to non-opioids for back pain
- Given the risks associated with opioids, they should be used when pain is refractory to other agents. Since we are the first physicians to see these patients, except for very severe cases, this suggests we should not be prescribing opioids for back pain at discharge.
This therefore is a recommendation that states – rare cases excepted – ACEP feels people with back pain, the most painful non-traumatic condition presenting to the ED, should not receive a prescription for opioids at discharge. This also indirectly suggests patients with back pain should not receive opioids while in the ED. Since oral muscle relaxants do not exist (despite what marketing tells you), and rapid access to physiotherapy or chiropractic care is not possible for most ED patients, this essentially means ACEP is recommending acetaminophen or an NSAID as our only options for most people with new onset acute back pain. This comes despite the policy itself stating: “NSAIDs are slightly effective for short-term symptomatic relief in patients with acute and chronic low back pain” This is an unacceptable position for
ACEP to take, and requires much better definition than has been provided.
An excellent part of the recommendation, however, should not be ignored: we need to limit the duration of the prescriptions we provide. Muscle spasm can be controlled within 48 hours with round-the-clock opioids. Patients who continue to have severe pain after 3-4 days should be reassessed, for it would not be expected for most patients to still have severe pain that long, even while recognizing that the pain from a low back problem may last months. It has been documented far too often that emergency physicians provide opioid analgesics in quantities that would last for weeks. Since we do not provide ongoing care, nor the required monitoring for ongoing opioid use, our opioid prescriptions should be of short duration. I would recommend no more than 3-4 days for low back pain, with follow up with a primary care provider by the end of that time period.
3. 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 B recommendations. 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 C recommendations. Research evidence to support superior pain relief for short-acting schedule II over schedule III opioids is inadequate.
As with recommendation #2, this recommendation relies on absence of evidence to state that weaker opioids (Schedule III) are as good as stronger opioids (Schedule II)
Emergency physicians should only initiate short acting opioids, for sustained release preparations and long duration opioids (e.g. methadone) require close monitoring and titration within the first week. The exception to this recommendation is the sustained release oxycodone preparation (OxyNeo®), which does not accumulate over time. The ACEP recommendations again rely on minimal evidence and ignore long standing World Health Organization (WHO) recommendations. The WHO established the ‘Pain Ladder’ for cancer-related pain where it recommends initiation of weaker opioids before using stronger opioids for ongoing pain. This current policy refutes the validity of the WHO position, saying that if given in equianalgesic doses, all opioids are the same. That statement might be valid, if weaker oral opioids could be titrated to the amount required while still being tolerated. That is not true for either codeine or meperidine in patients with severe pain; hydrocodone preparations are usually prescribed in combination preparations, preventing the physician from prescribing the required amount of hydrocodone to provide optimal pain relief. In other words, Schedule III opioids cannot provide equianalgesic results to Schedule II opioids given the adverse effects and dosing limitations.
Surprisingly, ACEP recommends oxycodone instead of morphine as a first line choice despite the former’s recognized high rate of abuse in North America. Morphine induces much less euphoria and is misused to a far lesser degree than most other opioids. Since ACEP says all opioids are equal in equianalgesic doses, why has ACEP not mentioned morphine as a valid option?
One concern from this pain policy is the amount of “creep” that is likely to occur. If ACEP recommends oxycodone or hydrocodone for acute MSK pain after discharge, many physicians are likely to reason that these oral medications will suffice in the ED for patients with severe MSK pain. That is a mindset one would hope that ACEP does not encourage; direction with respect to management of acute severe MSK pain in the ED should have been stated much more clearly in this policy.
4. 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 C recommendations. (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 prescription patterns from information sources such as prescription drug monitoring programs.
Inherent to the prescription of opioids for chronic non-cancer pain (CNCP) is that they come from only one prescriber. The patient with CNCP should also have specific instructions from that prescriber as to how to act when an acute flare up occurs. For neuropathic pain, short acting opioids are not effective; sustained release formulations are effective. Short acting opioids prescribed in the ED for most CNCP conditions result in more rapid tolerance and can create institution dependency – they offer little benefit. For acute worsening of neuropathic pain as seen in complex regional pain syndrome (CRPS), ketamine is far more effective than opioids. Given that it may take a pain physician 3-6 months to identify an effective regimen to control CNCP, there should be no sense of urgency by an emergency physician to get CNCP under control. In patients with fibromyalgia, opioids play no role, and should not be prescribed. Rather, ruling out other causes of the presenting pain and patient education are the two most important requirements of the emergency physician when caring for patient with fibromyalgia. The obvious exceptions to the no-acute-intervention approach are:
- CRPS where a 6-8 hour ketamine infusion can completely stop the acute flare up
- Sickle Cell Disease. Opioids are an integral part of pain management in the acute-on-chronic setting for vaso-occlusive crises and need to be prescribed as part of the routine of controlling each episode.
It may happen that a CNCP patient truly requires more opioids until able to see the primary care provider. Both the previous ACEP policy on pain management and the Canadian Opioid Guideline (http://nationalpaincentre.mcmaster.ca/opioid/) provide excellent recommendations on how to provide opioids for 24-48 hours, until the patient can contact their care giver.
Here’s what is lacking in this 4th recommendation: How is an EP to manage acute severe pain in CNCP patients when that pain does not arise from their chronic pain, as would occur if the patient had a long bone fracture? In such an instance the physician must maintain the usual daily dose of opioids while adding additional opioids for the new problem. The right dose of additional opioids can be estimated by remembering that the recommended prn dose of opioids in a habituated patient is 15-25% of their total daily dose.
It would seem that ACEP’s new opioid policy is not comprehensive in its recommendations and appears to strongly discourage opioid use in many ED patients. There are valid reasons to be concerned about opioids, but fear of diversion should not supersede management of pain in the acute setting. Lack of valid evidence should not lead us to a restrictive approach, but a balanced one. Better physician training and quality research are both required in the very near future if we are to find safe, sustainable solution.
Jim Ducharme, MD, CM, FRCP, is a clinical professor of medicine, McMaster University. He is the Editor-in-Chief, Canadian Journal of Emergency Medicine, Senior VP and Chief Medical Officer at the AIM Health Group, and the Vice-President, International Federation for Emergency Medicine