Misuse and addiction to opioids, including prescription pain relievers and synthetic opioids such as fentanyl, have been front and center in the news for several years. Every day, more than 115 Americans lose their lives to opioid overdoses. Some of these deaths are related to abuse of illicit opioids such as heroin, but prescription drug misuse has resulted in a serious national crisis impacting public health, as well as the social and economic welfare of this country. The number of opioid-related overdose deaths increased from an estimated 33,091 in 2015 to 42,249 in 2016, indicating a long road ahead before this complex, tragic epidemic begins to be resolved. The Centers for Disease Control and Prevention cites two distinct but interconnected trends driving America’s opioid overdose epidemic: a 17-year increase in deaths from prescription opioid overdoses, coupled with a recent surge in illicit opioid overdoses, driven mainly by heroin and illegally made fentanyl. It is clear solutions are needed to help address this crisis, while taking into account the needs of individuals suffering from debilitating pain, whether acute or chronic.
Opioids for Pain in ER Settings
Pain is the most common presenting complaint in emergency rooms (ERs), with a significant number of visits resulting in administration of opioid pain prescriptions. A recent cross-sectional study reported individuals visiting ERs for pain received an average of 17 pills of short-acting pain medications per prescription. When ibuprofen or acetaminophen are ineffective, Percocet and Vicodin are often the go-to drugs for people presenting with pain at ERs. Among more than 1.7 million veterans presenting at VA medical center ERs, the most frequently prescribed medication was hydrocodone/acetaminophen (471,221 or 7.5%), followed by ibuprofen (247,460 or 4.0%) and prednisone (245,990 or 3.9%). In response to the prescription opioid epidemic, many agencies and experts now advocate for changes in opioid-prescribing policies, especially in ERs.
Opioid Reduction Efforts
Several research projects have focused on reducing opioid use in individuals seeking treatment for pain at ERs. A 6-month pilot project called the Colorado Opioid Safety Collaborative, aimed at cutting the use of the prescription painkillers, is likely the first in the nation with so many participating hospitals (10). At the onset, the goal was to reduce prescription opioid use by 15%, however, institutions fared much better, cutting the use of these drugs by 36%, on average. The overall decrease resulted in 35,000 fewer opioid doses than prescribed during the same period in 2016. Instead of opioids (e.g., oxycodone, hydrocodone or fentanyl), safer, less addictive options such as ketamine and lidocaine were used.
- The use of lidocaine increased 451%, while ketamine use rose 144%.
- Estimated reductions in specific drugs included methadone (51%), oxycodone (43%), codeine (35%) and fentanyl (11%).
Claire Duncan, a clinical nurse coordinator at Swedish Medical Center was surprised by the pushback of individuals being treated for pain. She attributed this to individuals relying on the power of narcotics to treat pain because they have not experienced multifaceted pain management. Peter Bakes, an ER medicine doctor at the same facility, said the project changed many minds, empowering healthcare professionals to combat an opioid crisis they unwittingly helped create.
Other ER Studies
A randomized clinical trial conducted from July 2015 to August 2016 at two urban ERs in the Bronx, New York, analyzed data on 416 individuals, ages 21-64 with moderate to severe acute extremity pain. Participants (104 per each combination analgesic group) received 400 mg of ibuprofen and 1000 mg of acetaminophen, 5 mg of oxycodone and 325 mg of acetaminophen, 5 mg of hydrocodone and 300 mg of acetaminophen or 30 mg of codeine and 300 mg of acetaminophen. Researchers found no statistically significant or clinically important differences in pain reduction (after two hours) among single-dose treatment with ibuprofen and acetaminophen or the three different opioid and acetaminophen combination analgesics. In response to significant mortalities from unintentional overdoses in the NYC area, Staten Island University Hospital adopted a policy focused on decreasing prescriptions of controlled substances in 2013. This resulted in a decrease in total prescriptions from 1,756 to 1,128 in each of the three-month periods analyzed, although the average number of pills remained virtually unchanged (12.78 vs. 12.44). They also noted sizable reductions in opioid prescriptions written for arthralgias/myalgias, dental pain, soft tissue injuries and headaches. Researchers concluded similar policies may be the key to reducing the opioid epidemic and saving lives from unintentional overdoses. All of these studies show promise for reducing opioid prescriptions as well as reducing associated misuse and addiction, while addressing the valid need for pain management strategies among the thousands of people presenting at ERs across the U.S. every day.