Pain is a leading presenting complaint to the ED. Failure to adequately relieve pain may be viewed as a failure of treatment. Pain can neither be verified nor disproved. Err on the side of the patient. Acute pain that is unrelieved by non-pharmaceutical measures and unrelieved by paracetamol or NSAIDs may require use of opiates after discharge from ED.
The patients most likely to have a serious adverse event from oral opiates are older patients on high-dose, long-acting opiates and benzodiazepines. The most serious adverse event is excessive sedation and respiratory depression.
Prescribing long courses of oral opiates for non-cancer pain risks the patient becoming physically dependent on opiates without any long term relief of their pain. Prolonged courses of opiates may lead to habituation, requiring ever higher doses, with diminishing effectiveness and physical dependence.
Although there are some patients that game the system to obtain opiates for non-medical use, identifying them in the Emergency Department can be difficult. Some will be obvious from frequent presentations, grossly abnormal illness behaviour, history of drug misuse, or those seeking prescription for lost or stolen S8 drugs. Other more skilled individuals may easily go undetected. Be familiar with drug seeking behaviours (listed below). Check registries for opiate users or suspected doctor shoppers;
- Drug Dependency Register WA DoH phone 9388 4945 during office hours – only available for Medical Practitioners with a prescriber number.
- Prescription Shopping Information Service phone 1800 631 181
- For Next Step clients dosing at the Next Step Clinic, telephone 9219 1919 and ask for the dispensary.
- Only use short-acting opiates for the treatment of acute pain when opiates are indicated.
- Use non-opiate alternatives including; paracetamol, NSAID, carbamazepine, amitriptyline, gabapentin, pregabalin, diazepam, clonidine, dexamethasone, etc.
- Start with the lowest possible effective dose of opiate.
- Discuss with ED Consultant or most senior ED doctor before prescribing discharge opiates.
- Prescribe no more than three days or 20 tablets of short acting opiate if indicated.
- Make clear to anyone given a prescription for opiates that no repeat prescriptions will be provided by ED.
- Do not prescribe opiates to patients on opiate dependence program (e.g. methadone) before contacting dispensing source, confirming dose and advising that dose has been given ED (i.e. patients requiring admission or prolonged stay in ED).
- Counsel patients on the risk of adverse reactions, especially sedation and respiratory depression, and not to drive or operate heavy machinery.
- Patients already taking benzodiazepines and/or other opiates have a higher risk of adverse event.
- Do not initiate treatment with long-acting or extended-release opiates in the Emergency Department.
- Opiates are not generally useful for the management of chronic pain. Address exacerbations of chronic or recurrent pain conditions with non-opioid analgesics and non-pharmacological therapies. Liaise with Chronic Pain clinician when possible.
- Do not use parentral opiates for exacerbation of chronic pain.
- Do not prescribe opiates if a patient claims a lost, stolen, or destroyed prescription unless exceptional circumstances and then only provide a one to two-day supply.
- Contact the usual practitioner if prescribing opiates (e.g. phone or Communik8 letter)
- Consider prescribing opiate agonist/antagonist if risk of drug seeking behaviour.
Drug Seeking Behaviour
From The Journal of Emergency Medicine, Vol. 42, No. 1, page 18, 2012. Note, these behaviours are suggestive but not diagnostic.
Behaviours associated with patients who had a pre-existing management plan including referral to a drug dependency program or to reduce use of opiates or muscle relaxants (compared to a control group with no management plan).
Table 3. Odds Ratios for Studied Behaviours
|Odds Ratio||95% CI|
|Requesting parenteral analgesia||N/A||N/A|
|Three visits in 7 days||30.8||10.84–87.30|
|Over 3 pain complaints||29.3||12.18–70.33|
|States out of medication||26.9||12.28–58.72|
|Drug requested by name||26.3||11.54–59.86|
|Presents for prescription refill||19.2||7.42–49.52|
|Lost or stolen medication||14.1||1.82–109.37|
|10 out of 10 pain||13.9||7.98–24.19|
Also examine for evidence of current or previous IVDU. Search electronic records for history of IVDU or drug dependence, frequent presentations to different hospitals with pain related problems, and use of aliases.
Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e Chapter 38. Acute Pain Management in Adults
|Drug||Use||Initial Dosage||Titrate||Typical Effective Dosage (maximum daily dose)|
|Amitriptyline||Chronic pain||0.1 milligram/kg PO once in the evening||Increase over 2–3 weeks||0.5–2.0 milligrams/kg/day
(150 milligrams per day)
|Carbamazepine||Trigeminal neuralgia||100 milligrams PO twice a day||Increase 100–200 milligrams per day||200–400 milligrams PO twice a day (1200 milligrams per day)|
|Gabapentin||Neuropathic pain, post-herpetic neuralgia||300 milligrams PO per day||Increase up to 300 milligrams per day||300–1200 milligrams PO three times a day
(3600 milligrams per day)
|Pregabalin||Neuropathic pain, post-herpetic neuralgia||50 milligrams PO three times a day||Increase over 1 week||300 milligrams per day divided twice a day or three times a day (600 milligrams per day)|