Improving Outcomes, Improving Throughput, Neurology

Opiates beget Opiates – Headache edition.

This is a study comparing 3 EDs in my homeland of CT and their (mis)use of opiates for headaches over a 14 month period. This compared an academic tertiary care center with an approximate 110,000 annual patient volume; an urban hospital with an approximate 85,000 patient annual volume, and a community ED that sees approximately 19,000 patients annually. A total of 1,222 visits were included for final analysis.

Results? Opiates, are not good, mmmmkay?

Patients given opioids as first line treatment had a 37.7% increase in visits over the study period compared to those who were not given opioids. If you were given opioids as first line, 36.0% required rescue treatment compared to 25.1% in those who were not given opioids. Strangely, female patients were significantly more likely to have opioids ordered than male patients (38.2% vs 24.2%).

Need more reason not to give opiates? Patients not given opioids had a 30.3% reduction in length of stay.

I’m surprised these numbers are so high.  As a community EM AP, I’m embarrassed at these numbers – A shocking 58% of headaches in a community setting were given opiates as first line compared to 6.9% of those at the academic center). Then again, opiates beget opiates.  Opiates lead to repeat visits, more rescue meds, and an increased length of stay, without an improvement in patient satisfaction with opiates.  I question how often those in the community ED just gave opiates to avoid conflict.

Just.  Stop.  Giving.  Opiates.  For.  Headaches.  NOW.

Improving Outcomes, Improving Throughput

How soon to safely discharge the opiate OD?

For those of us wondering how long we need to keep the thrashing, agitated, cursing “narcan’ed” patient in our ED, look no further. This is essentially a review of the literature on whether or not adopting a treat & release policy for opiate overdose in the prehospital realm is safe & feasible.

They review 4 papers, 3 of which contain data points from 1994-2003, of which two were non-US studies. In general, they look at some short time period for bouncebacks, (6-12 hours), and if the patient does not come back to receive chest compressions or repeat narcan dosing, they considered it a win. Ultimately, out of 3875 patients that received narcan in the field and were able to AMA after a 15-20 minute observation period, only 3 had a recurrence that resulted in death.

Digging a bit deeper, part of the problem here is that two of the papers had exclusion criteria that does not necessarily fit what happens in practice. One paper excluded patients brought to the hospital, while another excluded those with polysubstance abuse. I’m not sure about your patient population, but the heroin abusers I’ve like to chase with China White with a stick of xanax. Fortunately, the two US studies were more likely applicable, with almost no exclusion criteria – and of which zero patients out of 1550 prehospital treat & release patients died within 12 hours.

So how does this apply to the ED? It is important to note that there are clinical decision rules to help guide who can go home relatively quickly.  If patients can ambulate, has normal vitals and a GCS of 15, then your miss rate is likely well below 1% for them to return in the next few hours from this particular overdose. So, by the time a patient is reversed with narcan, you write the chart and get discharge papers ready, if they remain alert, oriented, competent and reasonable, they can likely go. However, it should be noted that there were a small number of patients who returned within a few weeks with various other issues – one patient hung themselves within 48 hours. Another overdosed 4 days later. All in all, still <1% dying within 30 days, but this is potentially a teachable moment. Patients do have the right to make bad decisions, but that shouldn’t necessarily allow us to stigmatize them and not at least offer them the help they likely need.


Chronic opiate use leads to worse surgical outcomes

No surprises here. This study looks at outcomes after major elective abdominal surgery ~500 patients on chronic opiates vs ~1900 opioid naive patients from a single center from 2008-2014.

9.2% higher costs, 12.4% longer LOS (5.9 vs 5.2 days), higher complication rate (20% vs 16%), more readmits (10% vs 6%), without a difference to discharge destination (home, SNF, etc).

On one hand, you play the hand youre given – you help the patient the best way you can. But, what if that means you detox them first? It will be interesting to see if some providers go to that extreme. Especially if they (or hospitals) are not reimbursed at a higher rate to take on the added risk / LOS / bounceback rates. I know of orthopaedics refusing surgery based on a patients weight – I can envision a scenario in which the (currently) heavily-stigmatized opiate addicted patient is deemed unfit for non-emergent surgery so that facilities and providers retain their “5 star” ratings for various non-emergent surgical procedures to gain the insurance dollars of the “educated consumer”.

Sigh. This is quite the ethical pickle.

Next question – does this spill into EM? Should we withhold 1-2 doses of opiates for fear of worse outcomes? A perforated viscous seems like a good indication for opiates if ever there was one.