Alleviating pain – an important aspect of emergency care – has made opioids a mainstay in treatment. So what steps can ED providers take to turn the tide of the national opioid crisis?

Patrick Zelley, M.D., ABEM, a practicing physician and Regional Medical Officer with Schumacher Clinical Partners, offers this advice:

Change Treatment Habits in the ED

Dr. Zelley recommends that providers make a concerted effort to change their habits regarding what medications to use when treating pain in the ED.

“For many doctors, it’s a common reaction to order dilaudid or morphine without even considering alternatives,” he says. “It has become a habit for many physicians, and that’s what we need to overcome now.”

He recommends that ED physicians not rely on the established status quo when treating pain, but look for other options.

If the severity of pain is such that a narcotic is appropriate during ED care, then reasonable dosing is justifiable. It is important, however, to think about alternatives to narcotics when ordering medications.

Prescribe Alternative Medications When Possible

Dr. Zelley says there is a key distinction between the drugs used in treating patients while they are in the ED and the drugs that providers prescribe when sending them home.

Dr. Zelley’s recommendation aligns with the 2016 CDC guidelines for prescribing opioids for chronic pain, which state a preference for non-opioid therapy along with the need to assess whether the benefits of chronic opioid therapy regarding managing pain and function outweigh the risk.

“The way we prescribe depends on the source of pain,” he says, citing the difference between acute and chronic pain. He advises that with chronic problems such as headaches, back, or joint pain, it’s wise to look for alternatives, such as steroids, NSAIDS, and muscle relaxers. These medications, in many cases, serve to eliminate the cause of pain instead of just masking it like narcotics often do.

Dr. Zelley says it is not unreasonable for physicians to prescribe a narcotic when warranted but suggests that physicians consider the following when doing so:

• Be thoughtful regarding the medications prescribed. Stronger painkillers like morphine pills and hydrocodone could be more addictive than alternatives like Tylenol 3. The least potent medication required should be prescribed in order to make a narcotic prescription appropriate.
• Use a lower dosage when possible. For example, consider a 5mg pill instead of a 10mg pill. Dr. Zelley says that using a lower strength medicine may decrease the risk of addiction to pain medications and will also lower the severity of dangerous side effects.
• Reduce the amount of medication. He recommends that doctors heed the CDC guidelines for acute pain by prescribing the smallest number of pills necessary for appropriate care. These scripts would preferably provide no more than three days’ worth of therapy.
• If you do prescribe an opioid, explain to the patient the risks of opioid use and the reason the drug is necessary.
• Providers should also be aware of and follow their state laws and medical board recommendations with regards to opioid prescriptions.

Communicate Reasons for Prescribing Alternatives

Concerns about patient satisfaction have potentially played a part in a doctor’s willingness to write narcotic prescriptions over the years. Doctors should feel confident about limiting the delivery of narcotics to patients. One of the most important components of providing the appropriate care is establishing good communication with the patient.

“Take time to communicate with the patient regarding why you’re doing this,” he says. “Explain your reasoning by discussing the dangers associated with opioid use and that you are trying to do what is safe. This is essential to addressing patients’ expectations and increasing their understanding of the treatment provided.”

It is not uncommon for patients to express an understanding of this decision-making process. Even if they do not agree with the doctor, the patient often becomes less demanding as a result of respectful communication.

Conclusion

As Emergency Medicine physicians, our primary focus is the accurate diagnosis and appropriate treatment of acute medical conditions. At the same time, however, we can also play a part in stemming the tide of opioid addiction and death.

Changing treatment habits in the ED, prescribing alternative medications, and communicating the decision-making process to patients are all steps ED physicians can take to combat the growing narcotic epidemic while adequately addressing the legitimate pain relief needs of our patients.