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Community Medicine Rants - Opioids

Al Sacchetti, MD
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EMRAP 2018 08 August Vol.18 Written Summary 658 KB - PDF

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brendanC -

Al Sacchetti, Jerry Hoffman, Billy Mallon. Three legends of emergency medicine who all feel the opioid free ED is a crock of S...
OR ED Docs can believe a paper (about opioid addiction being initiated by prescription from the ED) written by a guy from Harvard who is not an ED doc and has Oboe expertise listed on his CV

I say OG versus OBoe. Why are we listening this ???? Thanks EMRAP for the pushback from the legends of EM.
PS 10 mg of toradol? Based on the ED use of excessive toradol resulting in what harm? IS Harvard gonna say ED docs are accountable for all of the ulcers and renal failure in the US?? more BS

Kevin M., MD -

I agree with this 100%.

Alfred S., M.D. -

Never go wrong listening to Jerry and Billy

Fred L. -

Thanks Al for saying what really needed to be said. Thanks also to Billy and Jerry for speaking out on this. As someone who wrote the first ever chapter on pain management in a textbook of emergency medicine, I've watched our approach to the patient with pain evolve and change over the 40 years Al has been caring for patients in the emergency department. The current hysteria over prescribing opioids for acute pain in the emergency department is the greatest single step backward I have seen in that time. It appears to be based on the fallacious assumption that since the harms of opioids generally outweigh any benefit in the treatment of chronic musculoskeletal pain they just must be bad for everything. In fact, studies have shown that under treatment of acute pain can lead to chronic pain. We can only hope that anyone who believes in an opioid-free ED will be taken to one by ambulance when he or she sustains a femoral fracture in a motor vehicle crash while driving to the hospital for treatment of his or her severe renal colic that did not respond to home NSAIDs. One thing we can reliably do in the emergency department is to reduce patients’ acute pain, regardless of the cause. We can also treat end stage cancer patients’ ongoing pain and help to relieve their suffering. Why would we choose to do otherwise?

Alfred S., M.D. -

Fred: Could not have said better. Thanks for vote of support.

Al

Joseph V. -

I'd love to do rebuttal to the Italian Stallion's rant on opioids this month.
I sit on our department's analgesic committee, so think a lot about pain...
Opioid-only ED (which, at it's extreme, is almost what Al suggests) is not the response to an opioid-free ED.
What we should be doing is the Most painless, most addictionless ED (I know, it doesn't really trip off the tongue).
Which means maximizing non-opioid options where appropriate, and then turning to opioids to help out (not carry all the analgesic burden alone).
So, to summarize:
1) Opioids should rarely be used alone. Combine with acetaminophen/ibuprofen (if using oral) or ketoralac (if parenteral).
2) Increasingly impressive evidence that the best analgesic combination is acetaminophen/ibuprofen. Opioids can always be added if needed.
3) If the patient has moderate pain, and has not taken any analgesic at home, start with non-opioid meds. Add opioids if it isn't enough.
4) Parenteral analgesics don't work better, just faster. And they are titratable. But for moderate, longstanding pain, these factors are less advantageous.
4) If you think the patient is going to be going home (such as sciatica, acute back strain, non-surgical fractures), don't give parenteral analgesics, give oral. Max out your analgesics: Acetaminophen 1 gm, ibuprofen 600mg, hydromorphone 2mg, all at once. It may take a bit longer, but when the patient is going home, you can tell them... "this is the best I can make you feel. Always take the APAP/Ibuprofen, and then you have some narcotics to back you up if you need them. But remember the side effects, addiction, etc..."
5) Maximize non-narcotic, non-nsaids when applicable. Buscopan for GI cramps, nerve blocks for dental pain, finger injuries, etc. And always use more bupivicaine than lidocaine when suturing, because who wants their pain to come back in 30 mins?
6) Don't use crappy po opioids. Skip the Tramadol and Codeine, go straight for morphine and hydromorphone. The only things the crappy drugs give you is more side effects and less beneficial effects. Use what works.
End of Rant Rebuttal

Alfred S., M.D. -

Thanks Joe V for your comments. You address mild to moderate pain, which everyone agrees can frequently be managed with non-opioid analgesics. Chronic pain is another issue which does require opioid analgesics in some individuals.

However, I have to disagree strongly with the approach in your rebuttal to try anything else first before resorting to an opioid. The idea of titrating up pain relief in someone with moderate to severe pain may be academically appealing but clinically inappropriate. Your statement "Parenteral analgesics don't work better, just faster" is unlikely to be well received by the diaphoretic person rocking on the stretcher with renal colic. For a person in pain, relief in 2 minutes vs 20 minutes is extremely significant.

Along the same lines, I don't understand the rational of making decisions on the route of analgesic administration based on the patient's anticipated disposition or always beginning with the oral route. The 5 year old with the hot soup burn across her chest wall is likely to be more appreciative of atomized fentanyl or Sub Q morphine then of a PO combination of Acetaminophen / Ibuprofen.

No one argues with the concept of treating pain with the most effective medication with the least abuse potential. But these approaches to pain control that withhold opioids until all else has failed really have no place in the delivery of patient care in the ED. If you really look at the pain literature, it is much more supportive of getting a patient's pain under control as rapidly as possible, as this leads to a decreased need for ongoing analgesic usage.

Thanks
Al

Kevin M., MD -

I have been practicing for 25 years now and have seen the ebb and flow of things. I never believed it when I was pressed to give out opiates like candy and I don't believe it when they tell me that opiates are rarely if never to be used. I could rant on and on and never touch the eloquence of Al, Jerry and Billy so I'll just say this.

When I was in my early 20's, I was involved in a motorcycle accident and injured my back. Since then, like clockwork, every 6 months to a year, my back starts to spasm and hurt and when it does, I am absolutely debilitated. I literally have to roll myself out of bed and crawl to the toilet. When that happens, motrin and tylenol don't help one single bit. When this chronic injury flairs up, I can either stay in bed and absolutely not function for 3-5 days, or I can take a norco every 6-8 hours times 3 or 4 doses and function. Now why in the World would I lay there and suffer and more importantly, not function, when I can actually function and with pain that is tolerable? Absolutely no reason at all.

Alfred S., M.D. -

Thanks for sharing and thanks for the rationale approach to patient care.

Colin Kaide, M.D. -

Al, I am so glad you addressed this issue. I have been an attending for 22 years in an academic program, but with enough community, experience to be well-rounded. I see the opiate fear all the time...It is not at the "policy level" but rather in the way we care for patients clinically, driven by both younger attendings and residents. There is a distinct misunderstanding about this issue...There are chronic pain patients; acute minor pain patients; and moderate to severe acute pain patients. It blows my mind that these patients are often, (but not always) lumped together by practitioners. I totally agree with chronic pain being shifted in the ED toward non-opiate solutions. The problem happens when younger practitioners (and some older) lump this population together with the group who has acute moderate to severe pain. Even if I limit this to severe pain, I still see Ibuprofen given to patients with acute (real) kidney stones, patients with significant second-degree burns, fractures and other various painful acute conditions. It drives me "guano-loco" when this happens on my watch and I have to go back and explain to a resident that broken bones hurt like hell...for a finite period of time...The same with many other acute, self-limited conditions. While I am all for not treating my chronic pain patients with opiates, and I will sometimes try escalated therapy with acute minor or early moderate pain...I have no problem escalating rapidly to opiates (IV when it clinically makes sense). In acute severe pain conditions, I default to fentanyl, then a longer-acting IV agent with the transition to oral meds only when it is appropriate. I also, as described above, layer my analgesia with different modalities. I never reserve opiates only when other treatments fail in acute moderate/severe pain. It is a cruel punishment to withhold adequate pain control from a person with acute pain for fear of creating an addict!! My $0.02. Colin

Alfred S., M.D. -

Colin: Thanks for the comments. I particularly like your observation that chronic pain patients, acute minor pain patients and acute moderate to severe patients are frequently lumped together as "pain patients." Seems like you have an extremely realistic approach to this problem. Hope your residents carry it with them when they graduate.

Al

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