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Opioids, Pain and Addiction Management, and the ED Evan Schwarz MD, FACEP, FACMT Associate Professor of Emergency Medicine Washington University School of Medicine
Opioids, Pain and Addiction Management, and the ED
Evan Schwarz MD, FACEP, FACMTAssociate Professor of Emergency MedicineWashington University School of Medicine
DisclosuresPhysician Consultant for the State Targeted ResponseBarnes Jewish Hospital Foundation Grant for Addiction
ManagementACEP Opioid Task Force Member
Thanks to Dr. Eric Ketcham and Dr. Kate Hawk for Use of Some Slides
So We Have 90 Minutes…And That Is A Long Time!
Statistics
Pathophysiology
Treatments
Opioid Alternatives
Opioid Prescribing
Harm Reduction
58,000 Died in Vietnam War51,000 Died from AIDS in ’95
> 70,000 Died in 2017
Life ExpectancyDecreases
For 3rd Year in a Row
What caused the death rate to increase 29% in one year?What contributed to average life expectancy falling 3 years in a row?
Rhode Island 2013-14: 32% of 165 unintentional deaths were fentanyl related
What Happens When We Do Things Poorly
Preliminary 2017 Data:
Opioid overdose deaths increase to ~ 134 Americans per day.
www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
Preliminary 2017 Data:
Fentanyl and fentanyl analogues related overdoses are the most rapidly growing type of opioid overdose deaths
www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
Number and age-adjusted rates of drug OD deaths, 2017
https://www.cdc.gov/drugoverdose/data/statedeaths.html
MO Dept of Health and Human Services
Heroin
Non Heroin Opioids
Year 2001-2016
# D
eath
s
Kg of fentanyl: $1.3 millionKg of heroin: $271,000
Kg of fentanyl: $1.3 millionKg of heroin: $271,000
ADDICTION
A MEDICAL DISEASE DRUG SEEKING IS COMPULSIVE. DIFFICULT TO CONTROL.
ADDICTION > CONSEQUENCE.
RELAPSING & REMITTING.
ENDORPHINS
DYNORPHINS
DOPAMINE
REWARD
SYSTEM
MALFUNCTION
Patient’s suffering
with O.U.D. USE TO:
GET HIGH
NORMAL
NOT FEEL SICK
Chemical Receptor Imbalance – an organic
brain disease
Voluntary Action
Behavioral Change
Impulsive Action
NeuroadaptationsNEJM 2016;374:363.
WITHDRAWAL AND NEGATIVE AFFECT
Kakko, et al, Lancet. 2003 Feb 22;361(9358):662-8.
bupe taper, thenplacebo (+ counseling)
dailybuprenorphine (+counseling)
Swedish Study:• 40 patients randomized • Daily supervised med
administration for the first 6 months
Retention at 1 year:75% in the bup group0% in the placebo group
1 year Mortality:0% in the bup group20% in the taper group
Opioid Agonist Therapy is Much More Effective than Drug Counseling!!
Buprenorphine
Methadone
Naltrexone
Buprenorphine
Methadone
Naltrexone
Methadone
NaltrexoneAbstinence Based Care: About 5%
Naltrexone
Adverse Events Tough To StartDelirium/Precipitated Withdrawal
Methadone
DEPENDENCE ≠ ADDICTION
In 1996, France responded to its heroin overdose epidemic by training GP’s to prescribe bup
Over 8 years….
3x increase methadone treated patients (~15K pts)
+ 4.5x increase in bupe tx pts
(~90K pts)
90% reduction in heroin overdoses!!
Auriacombe, et al, Am J Addict. 2004;13 Suppl 1:S17-28.
Heroin overdose deaths and opioid agonist treatment: Baltimore, MD, 1995–2009
• Rate of heroin overdose deaths drops in half.
• Despite a substantial increase in local heroin purity
Schwartzet al, Am J Public Health. 2013 May;103(5):917-22
MEDICATION FIRST MODEL
ED Initiated Suboxone Treatment for Opioid Dependence
JAMA 2015;313(16):1636-1644
Non medical prescription use or heroin use in last 30 days
+UDS
MINI score ≥ 3
Patients: 53% IVDA; 25% prescriptiondrugs only> 50% with psychiatric d/oETOH and cocaine abuse
At 30 Days
Information on 327/329 patients
Referral BI Suboxone
38/102 (37% CI 28-47) 50/111 (45% CI 36-54) 89/114 (78% CI 70-85)
Inpatient: 37% Inpatient: 35% Inpatient: 11%
Buprenorphine group also had larger reduction in mean days of illicit use
What It Is Already Like Working in the ED
We Can’t Handle Anything Else!
NEJM 2018;379:1-4
NEJM 2018;379:1-4
Unfortunately Nearly 80% Don’t Receive Treatment!!
Did Any Of This Really Make A Difference?
D’Onofrio. J Gen Intern Med 2017;32(6):660-6
Patients in treatment/compliant with Meds
Journal of the American Medical Association
What It Is Already Like Working in the ED
We Can’t Handle Anything Else!
This is Outside of What We Do
We Don’t Have the Resources
It’s Too Hard
Someone Else Will Do It
The Benefits
OndansetronHaldol
PromethazineProchlorperazine
45 minutes to place an IV
And Nothing Really Works
OR…
Maybe an IM or SL dose of Ondansetron
Start Buprenorphine
Titrate if Needed
Discharged within an hourBusch SH. Addiction 2017;112(11):2002-2010.
Addictionpolicy.org
April 18, 2019
D’Onofrio. N Engl J Med 2018;379:2487-2490
So How Do You Give Buprenorphine?• SL Formulation with poor bioavailability
• Either film or tabs take approximately 5 minutes to absorb
• The combo product is only there for misuse
• Should get effects within 15-20 minutes
• Dose 12-24 mg/day
MD Calc
ED Bridge
Some More Considerations
• An X-waiver is not required (72 hour rule)
• Don’t feel like you need to start with everyone
• Can be difficult to combine with sedatives (benzo or alcohol dependent)
• Start with the easy patients!
• No issue with renal impairment
• What about hepatic issues?
• Aside from HCG, no labs are required
• They can be obtained at follow up
What About Poor Follow up: High Dose Bup Loading?
Some Thought That A Single Dose is BeneficialSmartphrase for documentation
What Is Precipitated Withdrawal?Treatment = More Buprenorphine
Using COWS Can HelpMany Patients Actually Are Familiar with This
ED: Calls Central Agency
5 Treatment Centers in St. Louis Receiving State Funds
Recovery Coach
Recovery Coach In the ED
• Meets with patient. Gets additional ‘buy-in’
• Sets up follow up and arranges them getting there
• Normally in 0-3 days
• Gives them naloxone
• Each patient receives a phone number to call
• Fills buprenorphine prescription
• Between 20-30 waivered ED physicians
PATIENTS HAVE BEEN VERY RECEPTIVE TO THIS!
If you have good insurance or financial resources?
ED Calls Treatment CenterFollow up Obtained
Bup in the ED/Naloxone prescription
Treatment Programs Contacted Us Once they Saw We Had This InterestThey Actually Want Our Referrals and Are Willing to Work With Us
• Pts with an ID consult requiring at least 2 weeks of IV antibiotics
• Pt had an OUD
• Addiction consults at primary team’s discretion
• Included 38 pts with a consult and 87 without
ICU Total Re-Admit Days: 9 days vs 88 days
https://ed-bridge.org/
https://www.projectshout.org/
ActionPre-
contemplation
https://www.acepnow.com/article/your-overdose-patient-doesnt-want-to-quit-now-what/
Missouri Institute of Mental Health
HARM REDUCTION
Broad Support for Community Naloxone Distribution
April 5, 2018
Greene J. Ann Emerg Med 2018;72(2):a113-16.
Doleac JL. The Moral Hazard of lifesaving innovations: naloxone access, opioid abuse, and crime.https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3135264
➢12,000 dosages administered from 2013-2015
➢93.5% survived overdose
➢84.3% alive at 1 year
Abstract Presented at ACEP October 2017
Addiction & Overdose: Deadlier than STEMI @ 1 Year
Of all patients (including patients not surviving to d/c):
•CAD – a disease primarily of age 60+
Of discharged patients who survived after 3 days:
• OUD – a disease primarily of age 20 - 50
Other Harm Reduction Efforts
So What Do We Know?
1. We still don’t have a great way to predict who will go on to develop a substance use disorder and who will not
2. Opioids are not always the best treatment for pain
So When PossibleKeep Opioid Naïve patients Naïve
N Engl J Med 2017;376:663-73.
And Our Prescribing Does Have Long Term Consequences
http://epmonthly.com/article/unpacking-opioid-blame-game/
NNH 49
Results
•Returns to ED similar in both groups•Results similar when review by prescription number or median dose or other stratifications
•Opioid related hospitalizations in the next 12 months•9.96 vs 9.73%; OR 1.03 (1-1.05)
•Doesn’t answer appropriateness or why
Butler et al. Ann Emerg Med 2016;68(2):202-208
ED Prescription Opioids as an Initial Exposure Preceding Addiction
Time to Type of Non-Medical use, by Substance Use Disorder
J Hand Surg AM 2016;41(10):947-957
13% of opioid naïve patients continue to fill prescriptions 90-180 days later
10% continued to fill opioid prescriptions beyond 3 months after surgery
Plast Reconstr Surg 2017;140(6):1081-90.
Courtesy of Dr. Jeanmarie Perrone
But Sometimes You Do Need An Opioid
“Oral oxycodone has a substantially elevated abuse liability compared to oral morphine or hydrocodone”
So What If You Need an Opioid?
“noninferiority of injectable hydromorphone relative to diacetylmorphine for long-term opioid dependence”
Anesth Analg 2017;125(6):2105-2112
Median of 6 (3-9.5) digital pills over 7 days
JAMA Surg 2018:e184234 PMID: 30422239
For More About These Articles and Their Full References
https://www.acepnow.com/article/reduce-opioid-duration-and-quantity-to-limit-use-avoid-addiction/
So What About Keeping them
Opioid Naive When Possible???
Ketamine
• Discovered when looking for PCP derivatives
• Introduced into general practice in the 1970s
• 5-10% of the potency of PCP
• Already commonly used in the ED
Ketamine for Acute Pain in the ED
Karlow et al. Acad Emerg Med 2018 Jul 17. published online
Ketamine
Dose 0.1-0.3 mg/kg…..but generally 10-30 mg IV
Issues with Ketamine
Significantly less psych issues when placed in 100 ml and administered over 15 minutes
Another oldie but a goodie: Lidocaine
4% Much Cheaper Than 5%
Lidocaine
Lidocaine for Renal Colic• A few prior trials from the Middle East evaluating this (3 trials)
• Retrospective chart review of adults with nephrolithiasis
• Included 44 patients
• 45% lidocaine only, 45% with ketorolac, 10% with morphine
• Weight base dose of 1% lidocaine @ 1.5 mg/kg IV
Motov et al. Am J of EM 2018;36:1862-64
Ann Emerg Med 2018;72:135-144
• Systematic review that included 8 trials and 536 patients• 6 RCTs and 2 case series• Dosing different between studies• What was reported was very different between studies
• Positive results in renal colic and limb ischemia• Not found to be effective for migraine headaches• 20 adverse events in 225 pts
• Only 1 severe (error in dosing)
Nerve BlocksFigures
Fig 1 . Sphenopalatine Ganglion ( Wikipedia )
Trigger Points
• Trigger point: focal areas of hyperirritable muscle spasm• Reproducible and painful on palpation
• Goal is direct mechanical inactivation of the trigger point
Topical Medications• For patients with contraindications to oral medications
• Neuropathic pain, musculoskeletal pain
• Be careful over areas of non intact skin
NNT of 5.7-8.1 (for 50% pain reduction)
Gabapentin and Pregabalin
• In addition to being antiepileptics also work for neuropathic pain
•Used by many to decrease opioid use
Journalfeed.org
US Pharmacist.com
Nonpharmacologics for Pain in the ED
• Osteopathic manipulation (physical)
• Chiropractic treatment (physical)
• Physical therapy (physical)
• Acupuncture (direct)
• TENS (direct)
• Music therapy (indirect)
• CBT (education)
• Aroma therapy (indirect)
Sakamoto JT, et al. Acad Emerg Med 2018. epub.
“Based on our analysis, we feel that theseinterventions have potential to improve acute pain management & pt satisfaction& improve pt outcomes, while reducingoverall ED utilization and LOS”
Of course it can’t be that easy…
September 10, 2017
Other References
• Title slide: https://www.sciencenews.org/article/opioid-epidemic-spurs-search-new-safer-painkillers
• heroin: https://heroin.palmbeachpost.com/history-of-heroin/
• puking person: https://www.101x.com/blogs/jason-and-deb-0/%E2%80%99s-crap-ton-puke-deb
• NAS: https://www.bhpalmbeach.com/blog/tragedy-opioid-addicted-babies/
• boulder: https://www.realityblurred.com/realitytv/2018/08/million-dollar-mile-cbs/
• Harvard students: https://www.thecrimson.com/article/2018/12/7/students-push-for-narcan/
• methadone: https://www.thefix.com/content/take-home-methadone-doses-sold-streets91255
• naltrexone: http://fmntx.com/services/vivitrol/
• line: https://strother.wordpress.com/2012/10/26/communist-russia-milk-bread-and-meijer-are-no-match-for-family-bonds/
• vomtiing: https://www.vectorstock.com/royalty-free-vector/ill-man-vomiting-cartoon-vector-14825609
• sublingual: http://blog.hannasherbshop.com/2013/07/22/sublingual-supplements/
• harm reduction: http://www.unaids.org/en/resources/presscentre/featurestories/2017/june/20179623_harm-reduction
• time for a break: http://afterschoolcentre.org/why-you-should-take-a-break-after-working-for-a-while/
