“So, what are you going to give me for the pain, doc?”

“I don’t want to have to come back because of the pain.”

We’ve all heard it before.

After having received any myriad of pain strategies to ensure you didn’t undermanage their pain in the emergency room:

Naturopathic pain remedy

The patient now lies back in their stretcher, post-reduction, with the ankle or wrist immobilized and splinted.

The decision to send a patient home with Acetaminophen (APAP) and Ibuprofen may be easy if they tolerated everything well. While sitting comfortably in their bed, they readily accept the plan to take over-the-counter medications.

For others, they may have only received partial relief from that nerve block, and you know they didn’t tolerate the reduction well. They remember the pain from the fracture-dislocation and they’re worried the pain will come back when the analgesia runs out. Maybe their face says they’re in 3/10 pain, but when you ask they say 9/10. The mantra “APAP/Ibuprofen doesn’t do anything for me,” echoes as the patient scans the “New Medications” section of their discharge paperwork.

How are we going to address their concerns?

Framing the Discussion: The Opioid Epidemic

Most of us heard about the overuse and over-prescribing of opioids while in medical school. It was expected that pain was to be treated like the “5th vital sign”, and the result of that endeavor was roughly 94,000 opioid-related deaths in 2020 and punitive legislation that will stop Johnson & Johnson from producing opioids for the next decade. Most of the patients who would go on to become addicted received their first dose from a physician, and four of five new heroin users got their start from prescription opioid abuse. To date, many professional societies, including ACEP, Colorado ACEP, and AAEM, have published position papers regarding the use of opioids upon discharge from the ED.

How much do they need?

If you’ve concluded that you’re going to prescribe opioids, ACEP and AAEM would suggest 2- to 3-days worth, with the following general rule: the smallest dose and the shortest amount of time. Is this evidence-based or is this dogma?

To better assess the number of opioids used, McCarthy et al published the results of medication diaries for 260 opioid-naive adults for 10 days following discharge from the ED to assess both the quality of pain and the number of pills taken. They looked at patients discharged with back pain, renal colic, fracture/dislocations, musculoskeletal injuries, and “other” reasons (which were never defined or discussed in the supplemental data) for acute pain. Their data regarding 5/325 APAP-Hydrocodone indicated that there was a median need of 8 tablets, with a median requirement of four days of opioid therapy. Additionally, the median number of tablets dispensed fell between 12 to 20 tablets, and 92.5% of the participants had tablets remaining.

There were inherent limitations to the article: only 40% of those enrolled returned their diaries, and they were significantly different than those who didn’t; they were generally older, whiter, more educated, had higher incomes, higher health literacy, and they were more likely to have private insurance. This was also a subanalysis from a larger study, so the intention of the study was not to determine the number of opioids used. This low-quality evidence may not be generalizable to our population given the demographics, but it does suggest that a 2- to 3-day supply (or 18 tablets, assuming every 4-hour dosing) would more than suffice for the median number of patients in this cohort and would have left many with unused medication.

Daoust et al designed a prospective observational study that sought to evaluate the number of opioids that were used and examined a convenience sample of 627 adults with acute pain. They found that the median number of tablets to satisfy 95% of patients over three days was about 15 5mg morphine (or equivalent) tablets, and a median number of 7 tablets were consumed over the 14 days.

The study had several limitations. It was subject to recall bias with 40% of respondents responding to a phone call interview but did not fill out a medication diary. It was also a convenience sample, and non-random selection of patients introduces inherent bias within the study. This low-quality study’s findings also support that 15 tablets, or a 2- to 3-day supply would have sufficed for almost all of the patients.

How Long Will They Have Pain?

It is difficult to predict how long someone will have pain from an acutely painful event, as the duration of pain and need for medication is multifactorial: What was the injury? Does the patient want to take medications? What are their comorbidities? Are their concomitant psychiatric diseases? What about their socioeconomic status?

Daoust et al, to characterize the different pain experiences of patients, evaluated a convenience sample of 372 opioid-naive adult ED patients that presented with an acutely painful condition. They sought to assess the need for outpatient opioid therapy for the 14 days following the visit. The investigators described six different pain trajectories for patients based on the severity at discharge from the ED, and their trajectory over the next 14 days:

Pain Intensity Score v Day After Emergency Department Visit The model with 6 pain trajectories, with the trajectory named according to its initial and final pain intensity combination after ED discharge on day 14. 95% CI reflected by error bars.

The study was limited in that almost 50% of the patients accepted into the study did not return a pain diary. It might be assumed that patients without pain or those who didn’t fulfill their prescription would see no reason to continue the diary and that those who did were more likely to be experiencing more pain.

Daoust et al hoped to illustrate that everyone’s pain experience is not the same and that the solution for one patient in severe pain may not be the solution for another. For most, the pain gets better regardless of opioid therapy, and for a certain subset, the severe pain continues to be severe, irrespective of opioids.

Chapman et al also looked to characterize the resolution of acute pain after discharge from the ED by prospectively studying 513 mostly white, college-educated adults and trending their pain level over six days. The graph for their pain trajectories is below:

Mean acute pain trajectories in 3 subgroups over the course of 5 days after their ED discharge. The upper image shows the pain trajectory for patients whose pain was resolving. The middle image reflects those patients whose pain worsened. The bottom image shows the pain trajectory for those who did not have a change in pain.

They found three different pain trajectories with most individuals improving, but ~20% having either no improvement or worsening pain after discharge.

Both of these reports support what some may have already accepted as a priori: pain usually gets better with time, and we should be prepared to let them know that a small subset of patients will not and that they need to follow up with their primary care provider.

Finding the Balance: Addiction After an Opioid Prescription

Delgado et al performed a retrospective analysis of insurance claims to investigate the risk of persistent opioid use in 30,832 opioid-naive adults between 2011-2015 that received opioids for an acute ankle sprain. Aside from the fact that there was an incredible number of opioid prescriptions for an ankle sprain, they also found that opioid prescriptions for higher amounts (i.e. ≥30 tablets of 5mg oxycodone) were associated with a 6.3% risk of long-term use (defined as filling ≥4 opioid scripts in the next 30-180 days), as opposed to those provided with ≤10 tablets, which was associated with a 1.2% risk of long-term use. While many may shudder at the idea of providing 30 tablets of oxycodone for an ankle sprain, the group at higher risk was prescribed the equivalent of a 5-day supply of “take 1 tab q4-6h prn for pain.”

Friedman et al performed a prospective observational study in 2017 that included 484 opioid-naive adults who presented with acutely painful conditions (i.e. extremity pain, back pain, abdominal pain). This study more closely mirrors the environment that we practice in today: NY State had enacted a law that prevented prescriptions >7 days in 2016, the beginning of mandatory opioid training in NY state was 2017, the HHS declared the opioid epidemic a public health crisis in 2017, and the overall number of opioids prescribed was likely lower than in prior years as a result of both the investigation and the current climate surrounding opioids.
The authors found that 20% of patients filled two prescriptions during the 6-month study period, 1% would go on to fill ≥6 prescriptions in the same period, and 3% were still using opioids at the end of the 6 months. The providers in the study issued a median tablet prescription of <75 Morphine Milligram Equivalents (or ≤10 tablets of oxycodone).

These studies built upon one another with the initial study occurring amid the epidemic and the Friedman et al study occurring after public health interventions had been implemented, and yet they still coming to a similar conclusion: when prescribed ~10 tablets of oxycodone, the risk of persistent use is significantly lower than when oxycodone is prescribed in greater quantities.

Opioids After the ED: Side Effects

The side effects of opioids therapy have been hammered into us since medical school, and the CDC offers a great handout to help educate our patients on what they might expect when taking opioids.

While much of this initial data was gathered on chronic opioid users, Daoust et al’s moderate-quality prospective cohort study assessed the side effects experienced by 386 patients presenting to the ED with acute pain from fractures, other musculoskeletal injuries, renal colic, abdominal pain, and “other” conditions (i.e. burns, abscess, tooth pain). The patients were discharged with a median number of 10 tablets of opioids. These diaries were assessed at the end of 14 days, and the group compared the rates of side effects between those who consumed opioids and those who did not.

Daoust et al’s study may have had selection bias from the lack of randomization, however, the two treatment groups were nearly identical, and the characteristics of those who did not return the diary, while accounting for ~49% of the included participants, were not staggeringly different than those who returned the diary.

Not surprisingly, those who took the opioids experienced more opioid-related side effects, including constipation, nausea/vomiting, dizziness, sweating, drowsiness, and weakness. Of those who used opioids, 80% reported at least one side effect, versus 38% who did not use them. Those who took oxycodone were more likely to have nausea/vomiting and dizziness, but otherwise, there was no other significant association between the opioid selected (hydromorphone, morphine, or oxycodone) and the side effects experienced.

Which Opioid Should You Pick?

Chang et al performed a randomized, double-blinded, prospective trial of 416 adult patients with an acute extremity injury and assessed the degree of pain control with several options for medications: 400/1000 ibuprofen/APAP, 5/300 oxycodone/APAP, 5/300 hydrocodone/APAP, and 30/300 codeine/APAP. Their findings regarding the decrease in pain at both one hour and two hours depicted in Table 1:

Ibuprofen/APAPOxycodone/APAPHydrocodone/APAPCodeine/APAP
Baseline pain8.98.78.68.6
Decline in score at 1 hr (mean)2.93.12.42.7
Decline in score at 2 hr (mean)4.34.43.53.9

This high-quality trial found that there was no statistically significant decrease in their pain score in any of the groups at both one and two hours after administration. There was also no statistically significant difference between the groups with regards to who needed rescue therapy with a 5mg oxycodone dose. So, if you are treating pain in an otherwise healthy adult without hepatic or renal dysfunction and they don’t have a known CYP-450 enzyme defect, it probably doesn’t matter which opioid you choose. Hydrocodone and oxycodone appear to have similar efficacy at low doses.

Take-Aways

1) Advise your opioid-naive patients that their pain will get better with time and that we will prescribe them medication to help them through the first few days. If their symptoms are not improving or getting worse, they should follow up with their primary care doctor , as a minority of patients may have a pain trajectory requiring ongoing care.

2) Explain that there are risks and side effects associated with using opioids, which is why we will be adhering to societal recommendations to limit the number of pills to 2- to 3-day supply.

3) Counsel your patients that APAP/ibuprofen is as effective as routine opioid therapy, and they should not get too caught up in which opioid we prescribe, as the lowest doses are equally effective. Following suit with the AAOS-ASA, it would be appropriate to advise APAP and Ibuprofen throughout the day and an opioid as needed at night.

References:
[1] Ahmad, F., Rossen, L. and Sutton, P., 2021. Provisional Drug Overdose Data. [online] Center for Disease Control and Prevention, CDC.gov.

[2] Lee J. J&J to stop selling opioids for 10 years and will pay $5 billion as part of settlement. MarketWatch. https://www.marketwatch.com/story/jj-to-stop-selling-opioids-for-10-years-and-will-pay-5-billion-as-part-of-settlement-2021-07-21. Published 2021.

[3] ACEP Policy Statement: Optimizing the Treatment of Acute Pain in the Emergency Department. https://www.acep.org/globalassets/new-pdfs/policy-statements/optimizing-the-treatment-of-acute-pain-in-the-ed.pdf. Published 2021.

[4] Motov, MD FAAEM, S., Strayer MD FRCP FAAEM, R., Hayes, PharmD, B., Reiter, MD MBA FAAEM, M., Rosenbaum, MD FAAEM, S., Richman, MD FAAEM, M., Repanshek, MD FAAEM, Z., Taylor, MBBS, S. and Friedman, MD FAAEM, B., 2017. AAEM White Paper on Acute Pain Management in the Emergency Department | AAEM – American Academy of Emergency Medicine. [online] AAEM – American Academy of Emergency Medicine.  https://www.aaem.org/resources/statements/position/white-paper-on-acute-pain-management-in-the-emergency-department.

[5] Strader III, MD, FACEP, D., Duncan, PharmD, R., Verzemnieks, MD, E., Cantrill, MD, FACEP, S., Johnston, MD, FACEP, C., Hoppe, DO, FACEP, J. and Kaucher, PharmD, K., 2017. COLORADO ACEP 2017 Opioid Prescribing & Treatment Guidelines. [ebook] Northglenn, CO: COLORADO CHAPTER, AMERICAN COLLEGE OF EMERGENCY PHYSICIANS. 2017: https://coacep.org/docs/COACEP_Opioid_Guidelines-Final.pdf

[6] McCarthy DM, Kim HS, Hur SI, et al. Patient-Reported Opioid Pill Consumption After an ED Visit: How Many Pills Are People Using?. Pain Med. 2021;22(2):292-302. doi:10.1093/pm/pnaa048

[7] Daoust R, Paquet J, Cournoyer A, et al. Quantity of opioids consumed following an emergency department visit for acute pain: a Canadian prospective cohort study. BMJ Open. 2018;8(9):e022649. Published 2018 Sep 17. doi:10.1136/bmjopen-2018-022649

[8] Daoust R, Paquet J, Cournoyer A, et al. Acute Pain Resolution After an Emergency Department Visit: A 14-Day Trajectory Analysis. Ann Emerg Med. 2019;74(2):224-232. doi:10.1016/j.annemergmed.2019.01.019

[9] Chapman CR, Fosnocht D, Donaldson GW. Resolution of acute pain following discharge from the emergency department: the acute pain trajectory. J Pain. 2012;13(3):235-241. doi:10.1016/j.jpain.2011.11.007

[11] Delgado MK, Huang Y, Meisel Z, et al. National Variation in Opioid Prescribing and Risk of Prolonged Use for Opioid-Naive Patients Treated in the Emergency Department for Ankle Sprains. Ann Emerg Med. 2018;72(4):389-400.e1. doi:10.1016/j.annemergmed.2018.06.003

[12] Friedman BW, Ochoa LA, Naeem F, et al. Opioid Use During the Six Months After an Emergency Department Visit for Acute Pain: A Prospective Cohort Study. Ann Emerg Med. 2020;75(5):578-586. doi:10.1016/j.annemergmed.2019.08.446

[13] Cdc.gov. n.d. PRESCRIPTION OPIOIDS: WHAT YOU NEED TO KNOW. [online]  https://www.cdc.gov/drugoverdose/pdf/AHA-Patient-Opioid-Factsheet-a.pdf.

[14] Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017;318(17):1661-1667. doi:10.1001/jama.2017.16190

[15] n.d. Emergency Department (ED) Pain Relief Strategy for Musculoskeletal Injury: Strategies for relief of musculoskeletal pain in the Emergency Department. [ebook] American Academy of Orthopedic Surgeons.https://www.aaos.org/globalassets/quality-and-practice-resources/patient-safety/pain-alleviation-toolkit/aaos-asa_emergency-department-ed-pain-relief-strategy-for-musculoskeletal-injury.pdf.

[16] Agarwal D, Udoji MA, Trescot A. Genetic Testing for Opioid Pain Management: A Primer. Pain Ther. 2017;6(1):93-105. doi:10.1007/s40122-017-0069-2

The following two tabs change content below.

0 Comments

Leave a Reply

Avatar placeholder

Your email address will not be published. Required fields are marked *

%d bloggers like this: