Effect of opioid analgesics on emergency department length of stay among low back pain patients in the United States

ObjectivesThe objective of this study was to compare emergency department (ED) length of stay (LOS) between patients treated with opioid analgesia versus non-opioid analgesia for low back pain (LBP) in the ED.MethodsWe conducted a secondary analysis of National Hospital Ambulatory Medical Care Survey (NHAMCS) data (2014–2015). Adults (age ≥18 years) who presented to the ED with a reason for visit or primary diagnosis of LBP were included in the final study sample. Patient visits were categorized into two groups based on whether they received opioid analgesia (with or without non-opioid analgesia) or non-opioid analgesia only in the ED. The primary outcome measure was ED LOS, which was log-transformed (as ED LOS was not normally distributed) for analysis. A multivariable linear regression analysis was used to evaluate the association between opioid use and ED LOS.ResultsThe study sample consisted of a national estimate of approximately 8.6 million ED visits for LBP (during 2014–2015), of which 60.1% received opioids and 39.9% received non-opioids only. The geometric mean ED LOS for patient visits who received opioids was longer than patient visits who received non-opioids (142 versus 92 min, respectively; p < 0.001). After adjusting for confounders in the multivariable analysis, patient visits that received opioids had a significantly longer ED LOS (coefficient 0.25; 95% CI 0.11 to 0.38; p < 0.001).ConclusionsIn a nationally representative sample of patient visits to ED due to LBP in the US, use of opioids in the ED was associated with an increased ED LOS.     

Predictors for opioid analgesia administration in children with abdominal pain presenting to the emergency department

OBJECTIVES: Abdominal pain is one of the most common symptoms in children. The aim of this study was to determine the rate of opioid analgesia in children with abdominal pain presenting to the pediatric Emergency Department (ED) and to identify factors associated with administration of opioids. METHODS: We retrospectively reviewed all charts of patients with abdominal pain < 7 days presenting to the ED of a tertiary pediatric hospital over a 3-month period. Demographic and illness-related variables were recorded, and the primary outcome variable was whether opioid analgesia was used to relieve abdominal pain. We analyzed the data with a univariate analysis and a multivariate stepwise regression analysis to determine independent influences on the rate of opioid prescribing. RESULTS: Of 582 children included in the analysis, 53 (9%) received opioid analgesia. Pain in the right lower quadrant on examination, documentation of a pain score in triage, and the level of acuity as determined by the triage nurse were predictors of administration of opioids by the physician. Thirty-four (77%) of the opioids given were below the recommended dose for the child. CONCLUSIONS: Few pediatric patients with abdominal pain are treated with pain medications. The decision to use opioid analgesia for acute abdominal pain in the pediatric ED is influenced by acuity level, pain score documentation in triage, and location of abdominal pain. Efforts should be made to educate physicians on the appropriate administration and dose of opioids in children with abdominal pain in the ED.     

Long-term Success With Diminished Opioid Prescribing After Implementation of Standardized Postoperative Opioid Prescribing Guidelines: An Interrupted Time Series Analysis

ObjectiveTo assess longitudinal prescribing patterns for patients undergoing urologic surgery in the nearly 2-year time frame before and after implementation of an evidence-based opioid prescribing guideline to accurately characterize the impact on postoperative departmental practices.Patients and MethodsHistorical prescribing data for adults who underwent 21 urologic procedures at 3 academic institutions were used to derive a 4-tiered guideline for postoperative opioid prescribing. The guideline was implemented on January 16, 2018, and prescribing patterns including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid-naïve patients undergoing urologic surgery before (January 1, 2016, through January 15, 2018; N=10,649) and after (January 16, 2018, through September 30, 2019; N=9422) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and χ² tests. Cochran-Armitage trend tests and interrupted time series analysis were used to test for significance in the change in OMEs prescribed before vs after guideline implementation.ResultsThe median quantity of opioids decreased from 150 OMEs (interquartile range, 0-225) before guideline implementation to 0 OMEs (interquartile range, 0-90) after guideline implementation (P<.001). Median OMEs decreased significantly in each tier and each of 21 individual procedures. Overall guideline adherence was 90.7% (n=8547). Despite this decrease in OMEs prescribed, post–guideline implementation patients obtained fewer refills than the pre–guideline implementation group (614 [6.5%] vs 999 [9.4%]; P<.001).ConclusionIn a multi-institutional follow-up prospective study of adult urologic surgery–specific evidence-based guidelines for postoperative prescribing, we demonstrate sustained reduction in OMEs prescribed secondary to guideline implementation and adherence by our providers.     

The effects of a morphine shortage on emergency department pain control

ObjectiveIn 2018, due to a national morphine shortage, our two study emergency departments (EDs) were unable to administer intravenous (IV) morphine for over six months. We evaluated the effects of this shortage on analgesia and patient disposition.MethodsThis was a retrospective study in two academic EDs. Our control period (with morphine) was 4/1/17–6/30/17 and our study period (without morphine) was 4/1/18–6/30/18. We included all adult patients with a chief complaint of pain, initial pain score ≥4, and ≥2 recorded pain scores. The primary outcome was delta pain score. Secondary outcomes included final pain score, proportion of ED visits with opioids vs. non-opioids administered, and ED disposition.ResultsWe identified 6296 patients during our control period and 5816 during our study period. There was no significant difference in mean final pain score (study 4.45, control 4.44, p = 0.802), delta pain score (study −3.30, control −3.32, p = 0.556), nor admission rates (study 18.8%, control 17.8%, p = 0.131). We saw a decrease in opioid use (study 47.4%, control 60.0%, p < 0.01) and an increased use of non-opioid analgesics (study 27.3%, control 18.44%, p < 0.01).ConclusionsRemoving IV morphine in the ED, without a compensatory rise in alternative opioids, does not appear to significantly impact analgesia or disposition. These data favor a more limited opioid use strategy in the ED.     

Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department

BackgroundThe use of ABCD3-I score for Transient ischemic attack (TIA) evaluation has not been widely investigated in the ED. We aim to determine the performance and cost-effectiveness of an ABCD3-I based pathway for expedited evaluation of TIA patients in the ED.MethodsWe conducted a single-center, pre- and post-intervention study among ED patients with possible TIA. Accrual occurred for seven months before (Oct. 2016–April 2017) and after (Oct. 2017–April 2018) implementing the ABCD3-I algorithm with a five-month wash-in period (May–Sept. 2017). Total ED length of stay (LOS), admissions to the hospital, healthcare cost, and 90-day ED returns with subsequent stroke were analyzed and compared.ResultsPre-implementation and post-implementation cohorts included 143 and 118 patients respectively. A total of 132 (92%) patients were admitted to the hospital in the pre-implementation cohort in comparison to 28 (24%) patients admitted in the post-implementation cohort (p < 0.001) with similar 90-day post-discharge stroke occurrence (2 in pre-implementation versus 1 in post-implementation groups, p > 0.05). The mean ABCD2 scores were 4.5 (1.4) in pre- and 4.1 (1.3) in post-implementation cohorts (p = 0.01). The mean ABCD3-I scores were 4.5 (1.8) in post-implementation cohorts. Total ED LOS was 310 min (201, 420) in pre- and 275 min (222, 342) in post-implementation cohorts (p > 0.05). Utilization of the ABCD3-I algorithm saved an average of over 40% of total healthcare cost per patient in the post-implementation cohort.ConclusionsThe initiation of an ABCD3-I based pathway for TIA evaluation in the ED significantly decreased hospital admissions and cost with similar 90-day neurological outcomes.     

Impact of high-sensitivity cardiac troponin implementation on emergency department length of stay,testing, admissions,and diagnoses

ObjectiveWhile high-sensitivity (hs) troponin (cTn) has been associated with shorter emergency department (ED) length of stay (LOS) and decreased hospital admissions outside the United States (US), concerns have been raised that it will have opposite effects in the US. In this study, we aimed to compare ED LOS, admissions, and acute coronary syndrome (ACS) diagnoses before and after the implementation of hs-cTn.MethodsWe conducted a single-institution, retrospective study of two temporally matched six-month study periods before and after the implementation of hs-cTn. We included consecutive adults presenting with chest pain. The primary outcome was ED LOS, which was log transformed and analyzed using multiple linear regression. Binary secondary outcomes of admissions, cardiac testing, cardiology consultation, and ACS diagnoses were analyzed using multiple logistic regression.ResultsWe studied 1589 visits before and 1616 visits after implementation of hs-cTn. Median age and sex ratios were similar between study periods. Median ED LOS was longer in the post-implementation period [post: 384 (interquartile range, IQR 260–577) minutes; pre: 374 (IQR 250–564) minutes; adjusted geometric mean ratio 1.05; 95% confidence interval, CI 1.01–1.10)]. Admissions were lower in the post-implementation period [post: 24% (385/1616) vs. pre: 28% (447/1589); adjusted odds ratio, aOR 0.75 (95% CI 0.64–0.88)]. Cardiac risk stratification testing [pre: 9% (142/1589) vs post: 9% (144/1616); aOR 0.95 (95% CI 0.74–1.22)], cardiology consultation [pre: 13% (208/1589) vs post: 13% (207/1616); aOR 0.91 (95% CI 0.73–1.12)], and ACS diagnoses [pre: 7% (116/1589) vs post: 7% (120/1616); aOR 0.94 (95% CI 0.72–1.24)] were similar between the two study periods.ConclusionIn this single-center study, transition to hs-cTn was associated with an increased ED LOS, decreased admissions, and no substantial change in cardiac risk stratification testing, cardiology consultation, or ACS diagnoses.     

Reduction of Parenteral Opioid Use in Community Emergency Departments Following Implementation of Treatment Guidelines

Objective

Opioid prescribing guidelines are commonly seen as part of the solution to America's opioid epidemic. However, the effectiveness of specific treatment guidelines on altering opioid prescribing in the emergency department (ED) is unclear. We examined provider ordering patterns before and after implementation of opioid use guidelines for ED patients overall and the specific subsets of ED patients with either chronic opioid use or fracture.

Methods

We conducted a pre–post interrupted time series analysis of adult (≥18 years old) ED encounters in 14 integrated community EDs before (2013) and after (2014) the implementation of opioid prescribing guidelines. We compared opioid use pre‐ and postintervention using segmented logistic regression for primary and secondary analyses. The primary outcome was parenteral opioid use in the ED, with additional subgroup analysis of chronic pain and fracture cohorts. We also examined ED oral opioid use and discharge prescribing.

Results

There were 508,337 pre‐ and 531,620 postintervention encounters. The intervention was associated with an initial reduction in the odds of parenteral opioids ordered (odds ratio [OR] = 0.89, 95% CI = 0.87–0.91) and a decrease in the monthly trend compared to the preintervention period (OR = 0.99, 95% CI = 0.99–0.99). The immediate reduction in parenteral opioid use was significantly larger in the cohort of patients with chronic pain (OR = 0.81, 95% CI = 0.72–0.91), whereas the fracture cohort showed no change (OR = 1.10, 95% CI = 0.97–1.25).

Conclusion

The use of an opioid ordering guideline was associated with significant reduction in parenteral opioid use in the ED and as intended subgroup comparisons suggest that acute fractures were not affected and chronic pain visits were associated with larger decreases in opioid use.

     

Evaluation of Chronic,Noncancer Pain Management Initiative in a Multidisciplinary Pain Clinic

BackgroundChronic pain management is a major challenge for primary care providers (PCPs). PCPs manage many patients with chronic pain and other comorbidities including mental health problems like post-traumatic stress disorder (PTSD) and depression. Chronic pain and opioid problems are a national crisis, particularly among veterans (U.S. Department of Veterans Affairs, 2019). There are many veterans with chronic non-cancer pain who are being treated with opioids. Chronic opioid use has contributed to an epidemic of opioid-related adverse events (VA, 2017). Opioids not only result in poor pain control, but have associated risks such as misuse, overdose, and diversion which may be fatal (Frieden & Houry, 2016).AimsThe aim of this project was to evaluate chronic non-cancer pain management of veterans using an advanced practice registered nurse (APRN)-led multidisciplinary team approach to incorporate non-opioid and non-pharmacologic modalities to affect self-reported pain and use of prescribed opioids.MethodsA retrospective quality improvement (QI) project was conducted in the multidisciplinary pain (MDP) clinic. The APRN used a biopsychosocial approach for chronic pain management guided by the Plan, Do, Study, Act (PDSA) cycle framework. Thirty-four patients who were utilizing opioids for pain management were included using convenience sampling from the MDP clinic. The APRN educated and treated patients with non-opioid medications and non-pharmacolog therapies. A 10-point pain scale and morphine equivalent daily dose (MEDD) were utilized pre- and post-intervention to evaluate the MDP clinic.ResultsParticipants were predominantly male (91.8%), with a mean age of 63.18 ± 15.39 years, and 36.4% of whom were retired. Only 20.6% of the participants reported the use of opioids for <12 months. Low back pain (93%) was the most common pain location. The mean baseline MEDD was 41.04 and the post tapered MEDD was 23.05; this revealed a significant decline in MEDD (p < .0001). A decline was also found between pre- and post-pain scores (ranges 0-8). There was a significant reported decline in pain scores with a baseline of 6.11 to post tapering pain of 3.1 (t = 4.99, df = 28, p < .0001). Participants preferred non-opioid medications 94% and non-pharmacologic therapy 86%, like physical therapy, yoga, and acupuncture. Fifty-one percent of patients were referred for injections and 46% were referred to primary care behavior health, which includes pain school, sleep hygiene classes, and cognitive behavior therapy.ConclusionsAPRNs are in a key position to assess and treat patients based on current evidence while facilitating opioid titration. This initiative highlights that safe tapering of opioids is possible when utilizing a multidisciplinary approach for chronic pain management. Findings support the use of non-pharmacologic and non-opioid therapy for chronic pain management which can result in reduced patient-reported pain. Further research is warranted to examine both pharmacologic (non-opioid) and non-pharmacologic strategies that promote pain management while tapering opioids.     

Evaluation of sex disparities in opioid use among ED patients with sickle cell disease, 2006–2015

BackgroundAcute pain from a vaso-occlusive crisis (VOC) is a leading reason patients with sickle cell disease (SCD) visit the emergency department (ED). Prior studies suggest that women and men receive disparate ED treatment for acute pain in EDs. We aim to determine sex differences in analgesic use among patients with SCD presenting to the ED.MethodsThis cross-sectional study uses data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2006–2015. We identified ED patients with a primary diagnosis of SCD. Among patients with SCD, we evaluated sex differences in the use of opioid analgesia using logistic regression (adjusting for patient and visit characteristics). Analyses accounted for survey design and weighting.ResultsWhen evaluating the effect of sex on any opioid medication use in this population, though not significant, the odds that male patients were prescribed opioids was 1.5 (95% CI 0.8–2.8) times that of female patients after adjusting for age, the reason for visit, region, insurance status, and pain score. There was no significant difference in pain scores between male patients, 8.1 (95% CI 7.55–8.68) compared to female patients, 7.4 (95% CI 6.7–8.12).ConclusionsIn this nationally representative sample of ED visits among patients with SCD, there was no conclusive evidence of sex disparities in opioid prescribing. Though there is evidence of a trend signaling that male patients with SCD were more likely than female patients to be prescribed an opioid.     

Comparison of intravenous lidocaine/ketorolac combination to either analgesic alone for suspected renal colic pain in the ED

Study objectiveTo compare analgesic efficacy and safety of intravenous lidocaine and ketorolac combination to each analgesic alone for ED patients with suspected renal colic.MethodsWe conducted a randomized, double-blind trial comparing analgesic efficacy of a combination of intravenous lidocaine (1.5 mg/kg) and ketorolac (30 mg), to ketorolac (30 mg), and to lidocaine (1.5 mg/kg) in patients aged 18–64 presenting to the ED with suspected renal colic. Primary outcome included difference in pain scores between the groups at 30 min. Secondary outcomes included a comparative reduction in pain scores in each group from baseline to 30 and 60 min as well as rates of adverse events and need for rescue analgesia at 30 and 60 min.ResultsWe enrolled 150 subjects (50 per group). The difference in mean pain scores at 30 min between Lidocaine and Lidocaine/Ketorolac groups was −2.89 (95% CI: −4.39 to −1.39); between Ketorolac and Lidocaine/Ketorolac group was −0.92 (95% CI: −2.44 to 0.61); and between Ketorolac and Lidocaine was −1.98 (95% CI: −3.69 to −0.27). A comparative percentage of subjects in each group required rescue analgesia at 30 and 60 min. No clinically concerning changes in vital signs were observed. No serious adverse events occurred in either group. Commonly reported adverse effects were dizziness, nausea, and headache.ConclusionThe administration of intravenous lidocaine/ketorolac combination to ED patients with suspected renal colic results in better analgesia in comparison to lidocaine alone but provides no analgesic advantages over ketorolac alone.Clinicaltrials.gov Registration: NCT02902770.