Monday, February 29, 2016

Getting Chronic Pain Out of the Emergency Department

This is yet another entry into the parade of narcotic-overuse articles – but, at least, this one shines some light on potential solutions.

Their introduction is full of the standard lovely doom-and-gloom statistics:
  • From 1999 to 2008 there was a concomitant increase in prescription drug abuse with reported opioid overdose deaths tripling.
  • Health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills.
  • Approximately 16,000 deaths in the United States (U.S) are attributed to prescription opioid overdose annually.
Their report is simply a single-center pre- and post-intervention study.  They look backwards at, specifically, 46 patients identified as “high utilizers” with chronic pain and prior documentation of Emergency Department misuse.  Each of these patients was evaluated in concert with their primary care physician or chronic pain specialist, and a specific follow-up plan-of-care was established.  Patients were all informed of their care plan, the most salient portion being narcotics and benzodiazepines would be essentially omitted from any Emergency Department visit.

Patient visits to the ED declined from an average of 6.2 in the six-month pre-intervention period to 2.2 in the post-intervention period.  These data would also indicate a more profound effect excepting for one patient whose change in treatment plan paradoxically increased his ED visits four-fold, resulting in nearly 40 ED visits in the post-intervention period.  Unfortunately, these data only reflect ED use of one hospital, and does not indicate whether visits to other EDs were affected.

The reduction in ED visits is certainly apparently favorable – but, better yet, the median number of narcotic pills, as recorded in the state database, prescribed to each patient dropped from 664 to 471.  Changes in pill use, however, were much more heterogenous – and could be confounded by pill prescribing in closely neighboring states.  And, regardless of the improvement, pain management clearly continued to consist of fairly robust quantities of narcotics.

It’s at least a start, and, definitely some improvement.  If your system has the resources to develop care plans for individual patients, the benefits likely outweigh the drawbacks.

“Impact of a Chronic Pain Protocol on Emergency Department Utilization”
http://www.ncbi.nlm.nih.gov/pubmed/26910248

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