This study investigates the factors that have contributed to a decrease in opioid prescriptions among drug-seeking patients in the Emergency Department (ED). The purpose is to discover why the ED is perceived as unsuitable for administering opioids to patients. Opioid addiction and overdose increased from the 1990s to the mid-2000s as their use in pain management increased, causing substantial concern. Opioid use in the treatment of chronic pain necessitates continual monitoring and close interaction with the patient to monitor discomfort as well as any signs of addiction or side effects. The paper will then highlight guidelines put in place that guide the ED practitioners on how to handle drug seeking patients who present with pain in the ED. These guidelines have contributed the most to the reduction of opioids use in the ED. The EDIE system focuses on saving patient's medical records on computer databases. Health centers use the information with the pharmacy department and the Prescriber to improve patients ultimate pain care.
Keywords: Opioids, Addiction, Abuse, Overdose, Drug seeking, Chronic pain,
Decreased Opioid Prescription in the Emergency Department
Opioids are substances used to relieve patients pain and have morphine-like effects. Morphine is the prototype in the group of opioids. Drug seeking patients are individuals who are drug addicts and intentionally show behavior signs that suggest medical attention obtain drugs of abuse such as opiates and others like tranquilizers. Pain is the most common presenting symptom in the emergency department. It is a discomforting feature brought about by a stimulus such as cut or press on body parts. Opioids have long been used to treat some forms of pain in the Emergency Department (ED) so as to relieve either chronic pain or unbearable acute pain. However, the trend of Opioid administration in the EU has decreased due to many factors.
The purpose of this research paper is to look at those factors that have contributed to the decline of opioid prescription in the Emergency unit. Pain being a primary symptom in the ED, 42% of all cases presenting there has been an increased focus on pain management (Cantrill, 2012, p. 500). The pain was named the fifth vital sign in a bid to improve its management in 1999 by the veterans' health administration. Pain can either be acute or chronic. Causes of acute pain include injury by cuts or bacterial, viral or parasitic infections. It is treated and disappears after a short while like days to weeks. Chronic pain in the other hand is pain that stays for more than three months, and any form of treatment does not resolve it. Acute pain can also become a chronic pain if it's hard to resolve. Stress factors, environmental and physical factors can cause chronic pain. Therefore, it reduces the quality of a patient's life. It has therefore led to sudden increase in administration of drugs which later cause substance abuse especially the opioids. According to Cantrill, opioid abuse is rapidly growing in the United States.
There has been a rise in opioid abuse and related deaths since the early 1990s (Manchikanti, 2012, p. 15). Data has shown that drug overdose contributes largely to deaths relating to accidents. In the present day, opioid causes more deaths than cocaine and heroin abuse combined. It has raised the alarm in the medical field especially in the emergency unit where opioids are used increasingly to relieve pain. The dilemma of reducing pain while avoiding the death of patients has also lead to reduced opioid prescription in the ED. The increase in opioids uses caused deaths in the pediatrics. In the EDs it has resulted in the promotion of the Opioid prescription guidelines which focusses of the safety of the patient and disposal of the medications. Research has shown that this step has led to reduced opioid prescription. Data has shown that public policies such as these have affected the patient's decision making and discourage them from using opioids in the recent past.
Opioid abuse and addiction among the general population have also impacted on the reduced rate of their prescription in the E.Ds. It's is already clear that pain is a primary presenting symptom and with increased opioid abuse and overdoses some patients in the E.Ds. are abusers of the drugs. There are two categories; one of those who is positive patients who present with pain but are addicts and secondly those who are referred to as the drug seeking patients. Both, in recent past, have led to a measure being put in place to prevent adverse effects of the opioids. The strategies put in place limit some opioid prescriptions in the E.Ds. and state that they should be administered by one qualified personnel. Opioid drug monitoring is compulsory to monitor the effects of the drugs and prevents adverse effects. It has resulted in decreasing in opioid use in the E.Ds.
Emergency Department Opioid prescribing guidelines have had the significant impact on the reduction of opioid prescription in the E.Ds.
The most commonly used guidelines are made by the Washington State Department of Health. The guidelines were formulated by many people in the medical field and are comprehensive, detailed and clearly spelled out. These guidelines include:
Firstly, it states that only one Medic takes the responsibility of giving all opioids doses to patients with chronic pain.
Chronic pain requires constant and frequent monitoring by the Medic and the E. Ds do not provide such a convenient environment for that to happen. It is also not appropriate because patients and doctor's relationships in the E.D are small and chronic pain management requires a medic to be in constant contact and have a long friendly relationship with the patient.
The use of opioids via the intramuscular and intravenous routes in the E.Ds. to relieve chronic pain was abolished (Cantrill, 2012, p. 60).
It is because it causes euphoria and addiction. Euphoria is a desirable effect that occurs due to a massive release of dopamine in the brain after an opioid dose. Euphoria lead does substance abuse and overdose. IV injections of morphine and hydromorphone have been used in acute pain however to relieve intense pain.
Thirdly, Emergency medical officers have been exempted from giving replacement to prescriptions on controlled drugs that were misplaced or lost.
It is to avoid scenarios where patients seek to change medication to the commonly abused substances such as the opioids. E.D Medical officers should not replace methadone to patients who skipped doses. It is because it is taken in a strictly monitored environment to prevent withdrawal and the Emergency departments do not provide an ideal location to control the symptoms.
Opioids which are long acting like methadone and fentanyl patches are monitored by various signs and also their effectiveness.
Emergency departments do not have facilities to follow their values hence not advisable to give long-acting opioids in there. Prescription of opioids and other controlled drugs in the E.D must accompany an identification card from the patient to prevent the issue of drug seeking from patients. Photographs for identification should be taken to those who don't identify themselves with appropriate government documents.
Administration of some opioid in the Emergency Department is discouraged because of their fatal adverse effects.
Meperidine is a good example. It is thought to lower seizure thresholds when used as an intravenous injection. It may also aggravate the serotonin syndrome. With better alternatives available, IV morphine use in the pain-relieving in E.Ds has reduced significantly.
Medical officers in the E.D are expected to contact the primary opioid prescriber of the patient in case of any complications.
It emphasizes the importance of ED collaboration between medics in chronic pain control.
EDIE System
Emergency departments are advised to collect patient's information on ED visits and store it in the Emergency Department Information Exchange (EDIE). The Washington state ED Opioid Abuse Workgroup created a platform for all ED workers and ensured that patients received quality and appropriate pain control without risking their health (Mazer‐Amirshahi, 2014, p. 242). The system involves a database which is stored in a computer and is secured safely with a password and accessible only to the intended personnel like the pharmacy and prescribers. The EDIE system helps in providing quality prescriptions without risking patient's safety.
ED patients who present with acute pain requiring opioid management undergo tests for any prior use of opioids either for medical purpose of abuse. It is in place so as to reduce addiction. The patient is referred to appropriate treatment centers after screening in the Emergency departments.
Finally, use of opioids in the treatment of many diseases associated with pain contributes significantly to psychopathologic aspects of the illness.
Many specialists who treat pain have therefore felt that opioids should not be used to treat pain except in Cancer patients. A common contraindication to opioid prescription is a past addiction to narcotics. An opioid is now utilized in the ED through the guidelines stipulated. Two critical points highlighted are; Opioids should be employed if they improve a patient’s quality of life and only one prescriber should be responsible for administration and control patient drug intake.
Conclusion
Prescription of opioids in the emergency units has in no doubt reduced significantly in the recent past. Administration of opioids in the ED poses a major challenge especially for chronic pain management which requires constant monitoring by the Medics. Other problems include the risk of developing fatal adverse effects, the possibilities of patients diverting their medication, precipitation of withdrawal symptoms and many others. It has led to the formulation of guidelines that govern the ED personnel of opioid use. These guidelines help the prescribers provide safe pain management to patients.
REFERENCES
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Mazer‐Amirshahi, M., Mullins, P. M., Rasooly, I., den Anker, J., & Pines, J. M. (2014). Rising opioid prescribing in adult US emergency department visits: 2001–2010. Academic Emergency Medicine, 21(3), 236-243.
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