(Last Updated On: October 7, 2015)

Welcome to the first entry in an ongoing series called the Knowledge Bomb!

Description

These entries will contain a short, quick-hitting summary of a recently published piece of literature with major take-home points including the writers (resident) opinion on how it influences their practice, plus an attending response/perspective.

Motivation

Keeping up with the literature while completing residency is challenging.  It is unreasonable to stay up to date with all published resources but there are times that certain articles or subjects stand out for you.  Often it is tied to patient care, medical decisions and/or discussions/conflicts with an Attending about the best choice for patient care.  The Knowledge Bomb provides an opportunity to present an article pertaining to a topic of interest with the goal to spread recent literature and discussion among the residency.  It also offers a chance to give a personal opinion on the literature and the perspective of the Attending (maybe the one with the initial discussion).

The blog entry will be a summary of the conference presentation with the chance for further discussion through the comment section.

Papers chosen for the Knowledge Bomb can hit a wide variety of topics, examples might be procedural decisions to outpatient treatment management to acute interventions.  Let us hear what motivates you!!!!!


Knowledge Bomb #1

Bomb3Bomb Article

Hoppe JA, Kim H, Heard K. Association of Emergency Department Opioid Initiation With Recurrent Opioid Use. Annals of Emergency Medicine. 2015;65(5):493-499.e4. doi:10.1016/j.annemergmed.2014.11.015.

Background

Patients presenting to the ED with acute pain is a frequently encountered issue. Treatment strategies used by attendings varies remarkably and finding the method most comfortable for me is part of the residency process.  While caring for a patient with acute lower back pain with one of my attendings, he described his strategy of aggressive initial pain control with IV hydromorphone followed with oral opioid and a short course of oral opioids to continue with pain control at home.  In his experience, oral/IV NSAIDs have offered limited relief and tend to prolong the hospital stay.  He then challenged me to find evidence that discharging the patient with short course of opioids is harmful to the patients.  Due to this conversation the article caught my eye.

Article Study/Results

Retrospective study of patients presenting to Denver area hospital system for an acute painful event.  Study looked at patients that were opioid naive (defined as no opioid prescription filled one year prior to event) whether discharge with an opioid prescription increased the odds of recurrent opioid use one year post-event (10-14 month post-event anniversary).

Patients that were discharged with opioid prescription that was subsequently filled were at 1.78 (95% CI 1.33-2.34) increased odds of recurrent opioid use compared to those not given a script.  Patients discharged with opioid prescription but unfilled were at similar odds (0.84 – 95% CI 0.51-1.32) to patients not given prescription.

Study Concerns

It is a retrospective study; cannot control for possible biases. The study did not look at patient centered outcome such as morbidity/mortality, e.g. does it matter that patients are getting more opioids?

Personal Influence from paper

The results showed an increased odds of recurrent use of opioids for patients who were given, and subsequently filled, opioid prescriptions from the ED.  Chronic opioid use is tied to increased long-term abuse and harm to the patient.  These two items show a discouraging trend for prescriptions that I provide to the patient, which I do so with the intention of improving patient comfort.

The downstream effects of my prescribing practice are important to realize and contemplate when they are initiated.  I will be more hesitant to discharge patients with a short prescription of opioids, and believe that a longer patient discussion about opioid use is essential when choosing to initiate these medicines from the ED.  I will continue to perform aggressive pain control within the emergency department with IV/oral narcotics when indicated, but will limit my use of prescriptions.

Thoughts? Please let us know below…






Here is the Attending Response from Dr. Peder Lindberg, LGH Faculty:

I’m grateful to George for emphasizing this paper and I’m excited to see this work.  Apparently, this is the beginning of a body of work to better define the use of opioid pain medicine.  The study was well-designed and carefully implemented, and I think its results are important for all emergency physicians to know to educate their patients.

I’m not sure that it changes my practice-yet.

Dr Hughes raised 2 points of contention regarding the treatment of the patient that raised the subject in the ED. As I remember, the first point of disagreement was with regard to choosing an agent for acute pain control.  The second subject is then with regard to longer-term pain control, and I think that this is the subject better addressed by the study at hand.

I would estimate that I see as many patients who are suffering the effects of insufficient pain control as those who have suffered too much.  Back pain is a good example and I encourage most of my friends to start non-narcotic pain medicine early-especially when suffering back pain.  In my practice I frequently encounter patients on their 3rd day of back pain after they have tried only sweat and white knuckles for pain control first.

By the time these people get to me, they are usually in severe pain and unless they are given potent narcotics, they are unable to ambulate to the bathroom and unfit for discharge.  If these patients are admitted, I have no expectation that they will avoid narcotics.  When these patients are discharged, they typically leave with a sophisticated understanding of non-narcotic pain meds and instructions to use them-and a script for about 24 hydrocodone tabs.

This leads to the point of contention addressed by the paper.  The specter raised by this paper is that this last practice may be the first step towards drug dependence for my patients and this would be a serious concern.  The paper does not (indeed cannot) prove that the prescription CAUSES dependence, but it does show the association that is necessary to consider such a link.  Of course such an association can be explained by other factors: the most obvious being that folks who get one prescription are more likely to have pain, or have injuries, or have a condition that would require narcotic treatment.

Drs Heard and Hoppe have extended their evidence in the most recent issue of Annals of Emergency Medicine to describe typical prescribing practices in the U.S.

Back pain seems to be an excellent test case for this issue.

My current practice for severe back pain is to pursue rapid opioid pain control after maximizing acetaminophen and NSAID treatment, then to provide instructions to continue aggressive pain treatment at home starting with NSAIDs (if tolerable of course) and acetaminophen.  If this is insufficient, I do provide opioids with driving restrictions and instructions to use stool softeners.  I educate patients on the correct use of non-narcotic meds and encourage them to remove the opioids first.  When I put myself in my patients’ shoes, I believe that I would want the option of using opioids in the acute phase, coupled with my knowledge of their risks and other choices.

This paper has changed my practice in that: I will re-consider the number of tabs of my typical script, based in part by Drs Heard and Hoppe’s new work.  I also have considered printing a complete set of instructions for non-narcotic pain medicine.  Typically I give this speech orally, but it takes a while and it may be incomplete if I’m in a rush.  I find that many patients are uninformed when it comes to non-narcotic meds and I think that we doctors do a poor job educating folks, perhaps because we consider non-narcotics out of our typical area of responsibility or even expertise. They should be neither.

I still consider aggressive opioid pain control in the ED to be a key part of treatment of acute back pain (after an examination of the prescription monitoring program every time.)  If a patient has more than 90 tabs of prescribed narcotic, the conversation is much different and too long for this venue (HA! as if this isn’t too long already).