opioid use in the emergency department

1. Opioids Free
ED
Hassan Zahoor

2. Concept Of Opiate Free Ed
Dr Sergey Motov MD, with particular interest in Pain
management in ED, ran ED shift without prescribing
single opiate as part of research work, also and website
painfree.com with lectures and resources.
Swedish Ed physicians in most medical centres have
taken initiative of oxy fee ED based on risks associated
with opiates prescription
2

3. Areas To Cover
Concept and rationale of opiate free ED:
Why do we need alternatives to opioids in
ED
Different analgesic options depending upon
patient population
Choosing right opioids if you have to

4. Need Of Alternative to Opiates
( Problems with opiate prescribing)
1. Severe Side effects esp. elderly patients
http://www.ncbi.nlm.nih.gov/pubmed/24033733

5. 2. Addiction and Misuse ( non medical use)
Clear Evidence of overdose, injection related harms, and
dependance
Data from the United States FDAAdverse Event Reporting
System shows that oxycodone contributed to the largest
number (5548) of all drug-related deaths in North America
during the period 1998 to 2005 (morphine ranked fourth,
contributing to 1616 deaths).11
In another study investigating North American accidental
pharmaceutical overdose deaths, non-medical use of
pharmaceuticals was involved in 63%.
http://www.ncbi.nlm.nih.gov/pubmed/24629443

7. 3. No consensus on optimum opioid doses
(weight-based, fixed, nurse initiated?)
http://www.ncbi.nlm.nih.gov/pubmed/20825
766
4. Poor Titration Practices
http://www.ncbi.nlm.nih.gov/pubmed/21908
134

8. 5. Regulatory Concerns of prescribing opiates
? Concerns from AHPRA
? only consultants will be authorised to
prescribe oxycodone.

9. Pain Team at SCGH
Acute pain service will support any measures to reduce
oxycodone prescription in this hospital, as it is too
addictive, and there are equally efficacious analgesics
which do not cause social carnage and hyperalgesic
consequences.
Focus is on avoiding oxycodone prescribing except in
elderly people.

10. Practical Consideration
Dual/tripple analgesia combination
Different classes of analgesia together provide synergistic effect
small doses of each agent result in decreased potential of adverse
effects
less sedation, early mobilisation and decreased LOS with opioid
free analgesia

11. Multimodal Receptor
Targeted analgesia
NSAIDS COX1-2 eg celecoxib, naproxen,
meloxicam
NMDA receptors eg ketamine, NO
Central Ca receptors eg pregabalin, gabapentin
Less Addictive opioids
Alpha 2 central agonists eg clonidine

12. Choosing opioids

14. What options we have
Tramadol :
Centrally acting , atypical opioid analgesic
Serotinine and NA reuptake inhibitor
Active metabolites similar to opioids
Oral or IV 50-100 mg 4/24 PRN

15. Buprenorphine
Partial Mu opioid agonist ( Ceiling Effect)
High receptor affinity
SL route, transdermal patch onset 12-24 hours
Minimal gut effect
Primary site of action is spine not brain, less
abuse potential

16. Gabapentinoids
Inhibit presynaptic ca channels
Also inhibit NMDA receptors
Modulate pain and inhibit central sensitisation
Antihyperalgesic
Reduce opioid requirements

17. Gabapentinoids
Reduce opioids side effects
Reduce post operative ch pain by 50-90 percent
No pharmacokinetic drug interactions
Not lethal in overdose
Easily dialiasable

18. 22 years old male, BIBA , involved in motor bike
accident, sustaining right open tib-fib fracture,
splinted by SJA. haemodynamically stable, nil
active bleeding, crying with pain. What will you
give??or what have you used in past??

19. http://www.ncbi.nlm.nih.gov/pubmed/25197
290
http://www.ncbi.nlm.nih.gov/pubmed/23602
757
http://www.ncbi.nlm.nih.gov/pubmed/23041
484

20. 45 years old male, presented to Ed
with left sided renal colicky pain,
previous h/o same side kidney stone,
pain feels the same. What will you
use??/what have you used in past???
What will you give on discharge??
http://www.ncbi.nlm.nih.gov/pubmed
/25197573
http://www.ncbi.nlm.nih.gov/pubmed
/24381620

21. 50 year old female, known ch back pain ,
recent acute exacerbation with radiculopathy
signs left side , nil motor weakness or red
flags, nil infection or tumor signs. What are
the options??or what have you used in past??
What will you give on discharge??
http://www.ncbi.nlm.nih.gov/pubmed/25682
273