For the safety of our patients, in the management of emergency department patients with acute or chronic non-cancer pain,

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1 BACKGROUND Overdose deaths involving prescription opioid analgesics are rising at a startling rate in the United States. Between 1999 and 2010, reported deaths involving opioid analgesics quadrupled (4,030 to 16,651) 1,2. Over the same period, the yearly number of opioid prescriptions dispensed by retail pharmacies in the U.S. increased from 120 to 210 million and evidence suggests that the increased number of prescriptions has directly contributed to the number of opioid related deaths 3,4. Data specific to Hawaii is limited. However, according to records from the Medical Examiner s Office in the City & County of Honolulu, prescription opioid medications were involved in 36 of 106 drug-related deaths on Oahu in The CDC estimates 5% of Hawaii s population over the age of 11 used prescription opioids for non-medical reasons in Nationally, emergency physicians provide less than 5% of the total number of opioid prescriptions 5,6. However, we witness the effects of opioid misuse on a daily basis as we care for patients who have intentionally or unintentionally overdosed on opioid medications. We are also acutely aware that many use the emergency department as a place to inappropriately obtain prescription opioid medications for diversion or misuse. In response to the epidemic of prescription opioid abuse, multiple government and nongovernment organizations have issued opioid prescribing guidelines Early evidence suggests that such guidelines may reduce the number of opioid prescriptions and inappropriate emergency department visits 11,12. The Hawaii Chapter of the American College of Emergency Physicians created these guidelines to ensure and protect the appropriate use of prescription opioid medications, while attempting to reduce opioid abuse and diversion in the state of Hawaii. Our guidelines are not intended for patients in palliative care programs or for patients with cancer pain, nor do they replace clinical judgment in the care of the individual patient. These guidelines were adopted and modified for Hawaii primarily from the Washington Emergency Department Opioid Prescribing Guidelines published by the Washington Chapter of the American College of Emergency Physicians and the New York City Emergency Department Discharge Opioid Prescribing Guidelines 7,9.

2 RECOMMENDATIONS For the safety of our patients, in the management of emergency department patients with acute or chronic non-cancer pain, 1. Consider short-acting opioid analgesics for the treatment of acute pain only when the severity of the pain is reasonably assumed to warrant their use. Opioid analgesics should not necessarily be considered the primary approach to pain management. With consideration to their inherent risks, alternative and effective pharmacological interventions for acute pain include non-steroidal antiinflammatory drugs (NSAIDs), acetaminophen, and nerve blocks (e.g. for dental pain). Non-pharmacological therapies, such as fracture immobilization and proper elevation of injured extremities, may obviate the need for additional pain medications. Short-acting opioid analgesics such as hydrocodone, immediaterelease oxycodone, and hydromorphone may be considered as adjuncts to relieve acute pain when the severity of the pain warrants their use or when non-opioid medications have not provided adequate relief from pain. 2. If opioid analgesics are prescribed, use the lowest possible safe and effective dose. Higher doses of opioid medications and long-acting opioid medications increase the risk of unintentional overdose and death The risks of opioid use and addiction should be discussed with patients when opioids are prescribed as the initiation of prescription opioid therapy in itself is a risk factor for long term use of narcotic medications Prescribe short courses of opioid analgesics for acute pain. Most patients require no more than three days of medication. Excessive quantities of opioid medications increase the risk of misuse, abuse, and diversion. When prescribed, patients should receive only enough opioid medication from the emergency department (ED) to last them until they are able to see a physician for follow-up care. Further assessment of the patient s pain and appropriate treatment can be made at that time. Some acute conditions in which severe pain is expected to last an extended period of time (e.g. rib fractures) or other extenuating circumstances (e.g. travel, prolonged time to follow-up care) may warrant prescriptions of greater quantities. However, in most cases if the patient s severe pain outlasts an initial three-day prescription, further medical evaluation is warranted to exclude serious complications or the need for further treatment.

3 4. Avoid prescribing long-acting or controlled-release opioid analgesics. Long-acting or controlled-release opioid should only rarely be prescribed from the emergency department, and only in close collaboration with the patient s primary opioid provider. Long-acting and controlled release opioid analgesics are not indicated in the management of acute or intermittent pain. This class of opioid medications may cause fatal respiratory depression when administered to patients not previously exposed to opioids, even when used as directed. Patients being treated with long-acting or controlled-release opioid analgesics for the treatment of pain require close follow-up that cannot be reasonably provided by emergency medical providers. Exceptions may be appropriate for patients in consultation with the patient s primary opioid provider. 5. Consider accessing Hawaii s Prescription Monitoring Program for information on the patient s controlled substance prescription history before providing opioid prescriptions. To assess for opioid abuse or addiction, consider using targeted history or validated screening tools. Patients with a history of substance abuse are at increased risk for developing opioid addiction when prescribed opioid analgesics for acute pain 17,18. Numerous validated screening tools are available, including the DAST-10 (Drug Abuse Screening Test) and the Opioid Risk Tool 19,20. Alternatively, the single question, How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons? was found to be 100% sensitive and 74% specific for the detection of a drug use disorder compared to DAST A history of substance abuse in itself should not exclude a patient from prescription opioid medications. However, it should prompt a discussion about the increased risk of addiction. Providers may consider offering non-opioid therapy or reducing the amount of opioid medications prescribed. Referral information for opioid dependence or addiction may also be considered. Hawaii s prescription monitoring database, accessed at the above website, became available to providers in February All prescriptions for controlled substances filled at non-military pharmacies in the state of Hawaii are logged in the database. Currently, prescriptions filled at military facilities are not entered. Providers involved in the patient s care do not need patient permission to access Hawaii s Prescription Monitoring Program. All emergency providers are encouraged to apply to and use the state s monitoring program as a means to gain information regarding a patient s history of controlled substance use before writing prescriptions for opioid medications. An observational study of emergency physician use of the Ohio Automated Rx Reporting System

4 found that physicians changed their opioid prescription plan for 41% of patients after reviewing a patient s prescription history. Among patients whose prescriptions were changed, 61% received fewer or no opioids and 39% received more opioids than originally planned Consider risk factors for respiratory depression and use caution when prescribing opioid analgesics to patients being treated with benzodiazepines or other opioids. More than half of all overdose deaths involving opioid analgesics involve other drugs. Benzodiazepines are the most common class of drug identified with opioid related deaths and are found in 20% of cases 23. Opioid analgesics, when combined with other central nervous system depressants or given to patients with certain underlying medical conditions, can increase the risk for overdose, especially in older patients. Carefully consider the risks and benefits when patients are being treated with both benzodiazepine and opioid medications. The CDC estimates that patients receiving opioids who were prescribed a combination of 100 or more morphine equivalents per day account for 80% of opioid overdoses 24. Opioid analgesics should be used with caution in older patients and those with sleep-disordered breathing, such as sleep apnea, congestive heart failure, or obesity 9. Doses may need to be adjusted in patients with renal or hepatic dysfunction due to decreased clearance. 7. Avoid administering intravenous or intramuscular opioid analgesics for acute exacerbations of chronic pain. Parenteral opioids should generally be avoided for the treatment of chronic pain in the ED because of their short duration of action and potential for addictive euphoria. Generally, oral opioids are superior to parenteral opioids in duration of action and provide a gradual decrease in pain. Parenteral opioids may be appropriate when there is evidence or reasonable suspicion of an acute pathological process causing the acute exacerbation of chronic pain. Under special circumstances some patients may receive intravenous or intramuscular opioids in the ED when an ED care plan is coordinated with the patient s primary care provider. 8. One medical provider should provide all opioid medications to treat a patient s chronic pain. The emergency physician s one-time patient relationship does not allow for proper monitoring of the patient s response to chronic opioid therapy (COT). The American Pain Society states that, Regular monitoring of patients once COT is initiated is critical because therapeutic risks and benefits do not remain static and can be affected by changes in the underlying pain condition, presence of coexisting disease,

5 or changes in psychological or social circumstances. 14 Adding to or changing a patient s COT without contacting the patient s primary opioid provider may place the patient at risk for harm and should be avoided. Opioid prescriptions from the emergency department for exacerbations or progression of chronic pain are discouraged. Patients who require opioid analgesics should obtain opioid prescriptions from a single provider who monitors the patient s pain relief and function. Prescribing opioid analgesics from the emergency department for chronic pain is a form of unmonitored therapy and is not optimal for patient care. Changing a patient s opioid regimen or adding further opioid medications may place the patient at risk and should be avoided. If changes or additions are made, they should be made in consultation with the patient s primary opioid provider. 9. Avoid providing replacement prescriptions for controlled substances that were lost, destroyed, or stolen. Replacement doses of methadone should not be provided in the emergency department. Patients misusing controlled substances frequently report their prescriptions were lost or stolen. Pain specialists routinely stipulate in pain agreements with patients that lost or stolen controlled substances will not be replaced. Emergency departments should maintain a policy to not replace prescriptions for narcotic medications that are lost, stolen, or destroyed. Methadone should not be prescribed or administered as opioid substitution therapy from the ED. Methadone has a long half-life and patients who are part of a daily methadone treatment program and miss a single dose will not go into opioid withdrawal for 48 hours. Furthermore, opioid withdrawal is not an emergency medical condition. The emergency medical provider should consider the patient may have been discharged from a methadone treatment program for noncompliance or is not enrolled. If the patient is admitted to the hospital, the emergency medical provider or admitting physician should call the methadone treatment program to verify the patient s status in a methadone treatment program before initiating methadone therapy. 10. Attempt to coordinate the care of patients who frequently seek care in the ED among emergency, primary care, and specialty providers. Primary care and pain management physicians should make patient pain agreements accessible to local emergency departments and work to include a plan for pain treatment in the ED. Emergency departments should contact the patient s primary provider to notify them of the patient s frequent ED visits and attempt to formulate a care plan. When the patient does not have a primary care provider an ED care plan should be created by an ED physician. This plan should stress the importance of seeing a primary care

6 provider for chronic medical conditions and chronic pain management. The ED care plan should be filed into a dedicated section of the hospital electronic health record. Access to pain management agreements and coordination with the patient s primary opioid provider will help to more safely coordinate the patient s pain management. 11. Provide information about the risks of opioid analgesics, including overdose and addiction, along with information about proper storage and disposal to those receiving a prescription. Patients should be informed of the risks of taking opioid analgesics and be reminded to take them as prescribed. Risks of opioid analgesics include, but are not limited to: overdose that can slow or stop their breathing and lead to death; drowsiness and incoordination leading to injury, especially in those over the age of 60; tolerance; and addiction. Respiratory depression is more common with concurrent use of alcohol, benzodiazepines, antihistamines, and barbiturates. Patients should be reminded to avoid medications that are not part of their treatment plan because they may worsen side effects and increase their risk of overdose. Almost three-quarters (71%) of people aged 12 and older who have used opioid analgesics for nonmedical purposes reported obtaining them free or buying them from family or friends 25. Patients should be instructed how to minimize risks to others by keeping the medication in a secure location, preferably locked, not sharing the medication with anyone, and promptly disposing of unused opioid analgesics by flushing them down the toilet Hospitals are required by law to provide a medical screening examination to determine if a patient has an emergency medical condition. The law does not require physicians to use opioid analgesics to treat pain. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide a medical screening examination to determine whether an individual presenting to the emergency department has an emergency medical condition. EMTALA does not require the use of opioid medication to treat pain. Providers should apply their professional judgment to determine if opioid analgesics are the appropriate treatment for an individual patient. 1. National Center for Health Statistics. National Vital Statistics Reports, Volume 58, Number 19 (05/20/2010). 2010;: Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, JAMA 2013;309(7): National Institute on Drug Abuse. PrescriptionDrugs: Abuse and Addiction. 2011;:1 16.

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