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  • 1. Safe Opioid Prescribing in the Emergency Department     Safe Opioid Prescribing in the Emergency Department 7121 1212 Pain in the Emergency Department • Pain is a common complaint in the emergency department, accounting for 42% of ED visits, and 37% of patients receive opioids.1 • In 2009, EM physicians wrote an estimated 11 million prescriptions for immediate- release opioids.2 • From 1998-2008, opioid prescribing has increased 4-fold, as has the overdose death rate. Substance abuse treatment admissions have increased 6-fold.3 As reported by DAWN, there was a 111% increase from 2004- 08 in ED visits for non-medical use of opioids. • Given these alarming statistics, all providers should practice safe opioid prescribing.            ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐           Chronic Opioids in Primary Care • Patients sign patient-provider agreements which include a stipulation that patients will not seek controlled medications from outside providers, including the emergency department and urgent care, without communicating with their provider unless s/he has had an acute change in their condition. • This agreement also states that prescriptions may not be refilled early, nor be replaced in the event of lost or stolen medications. • If you have questions, please call the clinic to speak with the provider or a member of the staff.   o Access a contact list of community clinics HERE. As patient-centered medical homes, clinics can provide prompt appointments: http://www.sfdph.org/dph/comupg/oservices/medSvs/hlth Ctrs/ Back line numbers (subject to change): • Gen Med Clinic (SFGH): 206-6913 • Potrero Hill HC: 920-1221 • Southeast HC: 671-7054 • Housing & Urban Health: 353-5095 (x 2) • Tom Wadd HC: 327-0175, 355-7450 • Glide: 674-6142 • Family Health Center: 206-8609 Additional Resources in San Francisco: o Substance Use Referral: Treatment Access Program, 1380 Howard St (at 10 th ). Walk-in (M-F 8:00am-5:00pm), Or call (800) 750-2727; Provider line (415) 538-5500 o Opioid Dependence Treatment with Buprenorphine: (415) 552-6242, (415) 503-4791 (fax) o Mental Health: 24-hr Central Access number (415) 255-3737, or toll free (888) 246-3333 o 24/7 Nurse Advice Line (877) 977-3397 o Psychiatry Emergency Services: (415) 206-8125                                                              1  Pletcher et al. JAMA. 2008;299(1):70‐78.  2  Governale L. US Food and Drug Administation. 2010. Available at:  www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/DrugSafetyandRiskManage  3  MMWR Nov 4, 2011: Vital Signs: Overdoses of Precription Opoid Pain Relievers in the Unites States, 199‐2008  3  Rockett IRH et al. Ann Emerg Med. 2003;41:802‐13. 
  • 2.   Safe Opioid Prescribing in the Emergency Department 7121 1212 Opioid Prescribing: Universal Precautions o Strong Indications for Acute Opiods: acute fracture dental abscess burn significant acute trauma o Weak Indications for Acute Opioids: ANY chronic pain condition acute-on-chronic low back pain mild musculoskeletal injuries dental pain in absence of abscess o Examples of non-opioid therapy for sciatica or low back pain: Baclofen 5-10mg PO tid, Disp #15 Cyclobenzaprine 5-10mg po TID, Disp #15 Naproxen 250-500mg PO tid, Disp #15 Gabapentin 100mg po tid, Disp #15 o If you prescribe opioids for acute pain, only 3-5 days of medication are recommended. New York City public hospitals now prescribe a 3-day supply because of the epidemic of prescription opioid misuse Screen for Substance Use Disorders   o The 4Cs of addiction: Loss of Control over use Use despite harmful Consequences Compulsion to use Craving o Screen for substance use disorders (single-question screens): "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" “How many times in the past year have you had more than 5 drinks in a day? If you prescribe opioids, do so cautiously:   o Studies show that provider “hunches” about who misuses opioids are inaccurate. Exhibit universal precautions with the following: o Check a urine drug screen Tennessee ED study: 90% of the patients who tested positive for opioids denied taking them in the previous month.4 If a patient is POSITIVE for opioids and stimulants or benzodiazepines, s/he is at increased risk for overdose. Only prescribe opioids if strongly indicated, and refer to substance use treatment o Check a patient activity report or “CURES report” (very quick): https://pmp.doj.ca.gov Use of multiple prescribers is a risk factor for overdose death A one-time notarized registration is required; SFHP can arrange a notary to attend an ED meeting and do a group registration. Talking to Patients: o Sample language: o “I understand you want pain medication, but I’m responsible for your safety, and I think the risks outweigh the benefits for those medications.” o “I hear that you are in pain. You need to talk to your primary care provider about your pain medications.” o “Our Emergency Department has a policy that we cannot give pain medications in this situation. I know that you are in pain; you will need to talk to your primary care provider.” o “I know that sometimes it is hard to reach your primary care provider in urgent situations; please talk to your provider about future planning, and how to manage predictable bad pain days so that you don’t get stuck without medications.”