1. Gillon, Jennifer BSN, RN
  2. Muller, Lynn S. JD, BA-HCM, RN, CCM

Article Content

Emergency departments (EDs) across the country are faced daily with an ever-growing epidemic of opioid-seeking patients. These patients may present in an acute or chronic episode of pain. Opioids are highly addictive, are often prescribed as a first-line medicine in the emergency setting, as well as are used in the ongoing treatment of postoperative and chronic pain. According to a 2013 study, nearly 1,150 people per day across the country visited EDs for treatment related to prescription opioids (Hoffman, 2016). Patients with chronic pain exhaust other outlets such as primary care or pain management providers, thereby returning to the ED for pain relief. With a little "out-of-the-box" thinking, there are tools and protocols EDs and other case managers, along with their multidisciplinary colleagues, can universally implement to interrupt the cycle of drug misuse, overuse, and abuse. Simply outlawing possession of opioids is not the answer because many street drugs begin as valid prescriptions. This is a complex issue that extends far beyond the emergency level; however, EDs across the nation can become a foundation for stopping addiction rather than starting it.


Opioids are defined as "any of a group of naturally occurring peptides, e.g., enkephalins, that bind at or otherwise influence opiate receptors, either with opiate-like or opiate antagonist effects" (Dorland, 2007), including naturally occurring substances such as morphine; synthetic and semisynthetic drugs such as methadone and oxycodone; and certain peptides produced by the body such as endorphins, also called opiates. Approximately 70% of all visits to an ED are related to pain (Allen, 2014). It is important that assessment include what type of pain is affecting the patient, acute or chronic. Acute pain can last for only minutes and upward of 6 months and is seen in injuries such as broken bones, burns, and complicated lacerations. Chronic pain, however, is a type of pain that persists despite the initial healing. Emotions such as anger, depression, and anxiety can have a major effect on chronic pain.


Opioids are very useful in emergency medicine and are appropriate in such cases as acute traumatic pain, providing powerful and immediate relief. Opiates should be reserved for cases of severe pain, not for mild to moderate pain. Emergency providers are trained in the triage and treatment of acute pain, with the assistance of standards of care and hospital protocols; however, patients with chronic pain are a group that presents different challenges. Chronic pain management, a highly specialized service, in which emergency providers are not trained, opens the doors to misuse of opioids and their derivatives. The treatment of a patient with chronic pain requires a multidisciplinary approach led by a primary care provider and case managers with an eye to such interventions as pain management and mental health services. Typically, the ED is not equipped with these types of services. Specialists have the ability to manage the number of prescription opioids, offer alternatives to opioids, offer conjunctive therapies, as well as monitor for potential dangerous side effects and interactions between medications. In addition to the need for a specialist, there are several other factors that make treatment of patients with chronic pain more of a challenge in the ED.


Legal Consequences of Unlawful Opioid Possession

Once filled, ED prescriptions for opioids, intended to relieve pain for one individual, all too often are converted to cash. Unfortunately, these medications are popular for street sale. It is illegal to knowingly possess opioids and the consequences can include arrest, fines, and even jail. In New York State, illegal possession of an opioid in a fourth-degree felony (New York State Penal Code, 2003). At all levels of government, well-intentioned elected officials are trying to attack the problem of opioids with new legislation. One such example comes from a congresswoman from Orange County, California, who sponsored the Comprehensive Opioid Abuse Reduction Act, which would create a grant program that would help state and local governments combat opioid addiction. The proposal seeks to bring funding to various levels of community action such as "prescription drug monitoring programs, overdose treatment training for first responders, or rehabilitation programs" (Walters, 2016, p. 1). Although government seeks to regulate, and in some cases criminalize opioid use, there are more practical approaches that can change the need, use, and distribution of opioids on the front line.


Why Is This an ED Problem?

First, EDs are open 24 hours a day, 7 days a week, thereby making it easily accessible to any patient. Research has shown that EDs are frequently used as an option for patients who engage in drug-seeking behavior. Easy accessibility makes the ED a primary target for such patients. In contradiction with the availability of EDs is the lack of specialists and primary care providers' availability; they are not on-site in the ED. The lack of accessibility to specialists makes the emergency provider a de facto primary decision maker by default. Emergency providers will treat pain with what they are comfortable prescribing, which unfortunately lends itself to an increase in the use of opioids. Second, "Medicare participating hospitals must meet the Emergency Medical Treatment and Labor Act (EMTALA) statute codified at [S]1867 of the Social Security Act, (the Act) the accompanying regulations and the related requirements at 42 CFR 489.20(l), (m), (q), and (r)" (Centers for Medicare & Medicaid Services [CMS], 2010, p. 2). The Act requires a hospital to medically screen and stabilize every patient who comes through its doors, no matter his or her ability to pay.


Pain Is a Subjective Finding

Pain is a subjective finding, making it very difficult or near impossible to measure precisely. Pain scales in current use measure the patient's perception of his or her pain by using a numeric scale, ranging from 0 to 10, where 0 represents an absence of pain and 10 represents the most severe pain. One patient may report a pain level of 3, whereas a different patient, with the same diagnosis and complaints, reports the pain at a level of 10. In addition to the subjectivity of pain, patients with chronic pain always report some level of pain and therefore do not start at a score of 0. For patients with acute pain, a score of 0 is an attainable goal; however, for patients with chronic pain, a score of 0 is an unreasonable expectation. Providers seek a goal of a score of 0 for their patients; in turn, a larger number of opioids are given, which immediately could lead to a decreased level of consciousness, or in the long term, produce a tolerance to opioids. This degree of medication use invites the patient to return to the ED for additional opioids.


On the flip side, when a provider does not order the opioid medication a patient is seeking, the patient then perceives his or her pain has not been addressed appropriately, causing dissatisfaction. The problem of dissatisfaction can have immediate, as well as long-term, effects on the ED. In the immediate setting, patients who do not receive an opioid can go to extreme measures such as becoming verbally, even physically, abusive to the staff. Such behavior is emotionally draining for the staff but poses an actual risk of physical violence as well. Emergency staff should not have to put themselves at risk for a patient who is engaging in drug-seeking behavior. Steps must be taken prior to that level of severity, so health care workers are safe.


Is Patient Satisfaction the Best Measure?

Patient satisfaction is a driving force that both hospitals and providers alike must contend with on a continuing basis. The CMS has based hospital reimbursements with a direct correlation to patient satisfaction. Patient satisfaction is measured by way of a written survey, sent to the home of a discharged patient, after his or her hospital experience. Included in this survey are questions referring to pain and how well the patient perceived the pain was addressed. A patient who has not received the opioids he or she was seeking will not relay a high level of satisfaction regarding his or her experience with that hospital. If a hospital has a consistently low score, the hospital will not be reimbursed for the care rendered. This places providers in an even more precarious situation, as without money coming in to the hospital, the hospital will not survive.


Assessment and Plan

Emergency departments have the ability to empower themselves by developing tools and guidelines for pain management within their facility. Implementation of such tools will provide standardization of care while providing pathways for consistency. A five-step assessment tool has been developed to identify levels of pain and options for treatment (see Box 1). This assessment tool can be used during the initial triage of a patient, takes only a few minutes, and can be administered by a physician, physician assistant, case manager, nurse practitioner, or registered nurse. This tool will provide pertinent information that is helpful to the health care provider.

Box 1 - Click to enlarge in new windowBOX 1. Assessment Tool

This assessment tool, requires the patient to communicate his or her pain in a different way than he or she is traditionally accustomed to; this alteration alone can improve the accuracy of reporting. The patient is now asked to measure his or her level of "suffering" rather than the level of actual pain. Patients with acute pain will not be affected by the change, as their level of pain was at a zero prior to the injury or illness, thereby making suffering and pain synonymous. A patient with chronic pain will never be at a baseline pain level of zero and with this tool will be made to view pain in a new way.


Chronic pain means just that; the patient is living daily with some degree of pain. If the patient is now asked to rate his or her suffering on a scale of 0-10, the patient's response will be more accurate and more reflective of the impact of pain. For example, one patient with chronic back pain will report a pain level of 4 at all times but may have a suffering level of 0. A change in the patient's baseline pain prompts a visit to the ED. Upon arrival, the patient is now asked to rate suffering, thereby rendering a more accurate indicator of the actual pain. This assessment tool takes into consideration pain tolerance and coping variables.


Step 2 is assessed by simply asking questions related to the patient's pain and the duration of pain. It is important for the health care provider to distinguish whether the pain the patient is presenting with is acute or chronic in nature. The institution of electronic medical records (EMRs) permits providers' access to the medical records in real time, making it easier to identify a pattern of patient visits and use of painkillers, for either the same or similar complaints, thus enabling the provider with insight into patients' drug-seeking behavior. This tool is extremely useful to emergency providers, who work on shifts and therefore have less continuity of care than their peers in a primary care provider setting. In primary care, patients are followed by the same provider, or a group of providers, unlike in the ED, where patients from any provider, group, or specialty present for treatment.


Step 3 identifies opioid use at home, if any, and can be assessed by utilizing medication reconciliation and prescription drug monitoring programs (PDMPs). Members of the ED health care team must perform a baseline medication reconciliation, thus furnishing the provider much needed information regarding a patient's medical history. In addition, PDMPs identify those patients with multiple medications, thus helping alert providers of possible abuse or misuse. Some patients are on medications for long-term issues, such as hypertension or hypercholesterolemia, which is consistent with protocols, but some are on multiple medications for pain. Commonly prescribed, combination therapies used with opioids are muscle relaxants, such as chlorzoxazone, carisoprodol, or cyclobenzaprine, and/or benzodiazepines, such as diazepam.


In a recent study conducted by Express Scripts, one of the largest mail order pharmacies, servicing a large segment of the population, including the military and their dependents through TRICARE (Express Scripts, 2016), 6.8 million prescriptions were analyzed over a 4-year period between 2009 and 2013. The study revealed that among the group identified, "sixty percent were taking opioids for pain as well as additional drugs" (Bresnick, 2014, p. 1). Among the drugs that were found, many were being prescribed by several different providers, none of whom knew what the others were prescribing. Within the group taking a high-risk combination of drugs, one third were taking an opioid and a benzodiazepine combination (Bresnick, 2014). The use of polypharmacies can have a harmful effect on patients, such as overdoses and even death.


In the age of EMRs, identification of abusers and misusers of opioids is becoming an easier and less daunting task. Quick review of EMRs identifies recent visits, complaints, and treatments, permitting recognition of a drug-seeking patient within minutes of arrival to the ED. However, the issue of reliability of the patient reporting is a factor that cannot be ignored. To shift the reliability from patients, PDMPs have been created. Currently, 49 of the 50 states have PDMPs. These programs, both government and insurer run, provide a helpful service that allows practitioner access to data relating to controlled dangerous substances (CDSs), as well as human growth hormone.


The concept of PMDPs is extremely useful; however, it has several limitations ranging from underutilization to nonutilization, as well as a gap in communication. Although 16 of the 49 states mandate a prescriber report to the database, if a prescriber fails to report to the database, there is no legal penalty or consequence. In addition, at present, each state has its own separate database, limiting its usefulness. New Jersey, for example, does report data on CDSs filled within and out of the state; however New York reports only on Schedule II, III, and IV controlled substances filled within New York. The gap in communication is perhaps the greatest and potentially a grave flaw with the PMDPs. There is, however, an easy, yet long-term, solution to facilitate communication between medication reconciliation and PMDPs. The development of interfacing software or cloud-based software will be necessary to make the program successful. The federal government must set specific standards and guidelines for all states to adhere to, making communication among the programs not only possible but also probable. This solution, although sounding simplistic in nature, is one for the long term and requires financing and resources for implementation. In the meantime, health care providers must use their currently available resources and maintain hypervigilance to protect all their patients.


Repurposing Well-Known Medications

Step 4 is the development of pain algorithms with specific nonopioid medication alternatives that target common conditions. Providers will be less compelled to prescribe an opioid when evidence-based protocols are in place within their institution offering real alternatives. Some institutions are light years ahead of their peers in the opioid war by currently implementing opioid-free algorithms that are condition specific. Dr. Sergey Motov of Maimonides Medical Center in Brooklyn, NY, has developed nonopioid medication alternatives for pain management.


At Maimonides, a patient who presents in the ED with a complaint of back pain is administered medications, such as intravenous acetaminophen (Tylenol), in conjunction with an oral anti-inflammatory (ibuprofen), muscle relaxant (diazepam [Valium]), and/or methocarbamol (Robaxin), along with a topical lidocaine patch, and/or trigger-point myofascial injections (Lowry, 2015). Another common complaint seen in the ED, musculoskeletal pain, is treated with acetaminophen, ibuprofen, lidocaine patch, naproxen (Naprosyn), nitrous oxide (laughing gas), and or regional nerve blocks (Lowry, 2015). Many of these opioid-free medications can be used for different conditions, as they possess analgesic, anti-inflammatory, and muscle relaxant properties. Not only do these algorithms prevent a possible path to addiction to opioids but they also prevent adverse side effects such as nausea, vomiting, and constipation, preventing the further need for additional pharmacological interventions.


Alternatives to Pharmacological Intervention

Step 5, the final step, allows providers to find alternatives to pharmaceutical interventions in the emergency setting. Once a patient is identified as a possible candidate for nonpharmaceutical treatments, measures such as relaxation and deep breathing, electrical stimulation, massage, Reiki therapy, or music therapy can be implemented. At St. Joseph's Regional Medical Center in Paterson, NJ, an ED that sees approximately 170,000 patients each year, has been able to reduce its opioid use by 38% over a 5-month period using such techniques (Hoffman, 2016). St Joe's, as it is known to locals, reported that 500 patients with acute pain were treated with nonopioid protocols, of which a 75% success rate was reported (Hoffman, 2016).



The importance of nonopioid treatments is imperative to address not only in the emergency setting but also throughout all of medicine. Opioid use and abuse are believed to be a gateway to the use of heroin. Heroin, a much cheaper alternative to prescription opioids, provides a similar and more intense high and is highly addictive. Although ED physicians write less than 5% of all opioid prescriptions, EDs have been identified as a starting point on a patient's path to opioid and even heroin addiction (Hoffman, 2016). The Centers for Disease Control and Prevention (CDC, 2016) calculated that "in 2014, more than 14,000 people died from overdoses involving prescription opioids" (p. 1). For the same period, there were 10,574 heroin overdose deaths (CDC, 2016). Acknowledging complete commitment to culture change, Dr. Lewis S. Nelson, a professor of emergency medicine at New York University School of Medicine, said, "St. Joe's is on the leading edge" (Hoffman, 2016, p. 1).


Case managers, as part of the acute care team in EDs across the country, have the skills and insights needed to stand united with their multidisciplinary colleagues on the front lines in the crusade to eradicate excessive opioid use and misuse. If adoption of this culture and practice change can save one life, it has value. This culture change has the potential of reducing not only opioid use and abuse but also the market for street sale and use, whereby communities can be spared from epidemic levels of addiction or deaths. Creativity on the front line is a new and unique approach to the fight, which continues, and is a battle worth fighting.




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