Search

Objective: To ascertain and develop recommendations for analgesic management, discharge planning and further healthcare utilisation of adults presenting to an Australian tertiary ED with radicular or low back pain (LBP). Methods: This prospective cohort study included adults presenting with non‐specific LBP or radicular pain to an Australian tertiary ED. Participants with trauma/cancer‐related pain, and those requiring hospital admission or surgical interventions were excluded. The primary outcome was pharmacological and non‐pharmacological management delivered in ED, retrospectively collected via electronic medical records. The secondary outcomes include discharge management use, and changes made due to post‐discharge healthcare utilisation, as observed by weekly telephone questionnaires over 4‐weeks follow‐up. Results: Of the 100 participants recruited, 94 completed follow‐up. In ED, pharmacological management was received by 85%, including opioids (62%) and non‐steroidal anti‐inflammatory drugs (NSAIDS, 63%). Non‐pharmacological management was received by 73%, including patient education (71%) and exercise prescription (37%). In the first‐week post‐discharge, changes to initial discharge plan occurred in 50%, mostly carried out by GPs (76%). Over the follow‐up period, 51% received additional investigations/referrals. Pharmacological use decreased by 38% and non‐pharmacological use decreased by 10%. 16% of opioid‐naïve patients continued using opioids 4‐weeks post‐discharge. Conclusion: ED presentations for LBP were more often treated pharmacologically than non‐pharmacologically, with opioids commonly prescribed and NSAIDs potentially under‐utilised. Post‐discharge, additional investigations/referrals, discharge analgesia reductions and maintenance of non‐pharmacological management were common. Opioid initiation as a result of LBP presentations, signifies a potential 'gateway' towards unintentional long‐term use. Key study findings form our nine recommendations to inform ED LBP pain management. [ABSTRACT FROM AUTHOR]

Background: The prescription of opioids in emergency care has been associated with harm, including overdose and dependence. The aim of this trial was to assess restriction of access to oxycodone (ROXY), in combination with education and guideline modifications, versus education and guideline modifications alone (standard care) to reduce oxycodone administration in the Emergency Department (ED). Methods: An unblinded, active control, randomised controlled trial was conducted in an adult tertiary ED. Participants were patients aged 18–75 years who had analgesics administered in the ED. The primary intervention was ROXY, through removal of all oxycodone immediate release tablets from the ED imprest, with availability of a small supply after senior clinician approval. The intervention did not restrict prescription of discharge medications. The primary outcome measure was oxycodone administration rates. Secondary outcomes were administration rates of other analgesic medications, time to initial analgesics and oxycodone prescription on discharge. Results: There were 2258 patients eligible for analysis. Oxycodone was administered to 80 (6.1%) patients in the ROXY group and 221 (23.3%) patients in the standard care group (relative risk (RR) 0.26; 95% CI: 0.21 to 0.33; p <.001). Tapentadol was prescribed more frequently in the ROXY group (RR 2.17; 95% CI: 1.71–2.74), while there were no differences in prescription of other analgesic medications. On discharge, significantly fewer patients were prescribed oxycodone (RR 0.51; 95% CI: 0.39–0.66) and no differences were observed in prescription rates of other analgesic medications. There was no difference in time to first analgesic (HR 0.94; 95% CI: 0.86–1.02). Conclusions: Restricted access to oxycodone was superior to education and guideline modifications alone for reducing oxycodone use in the ED and reducing discharge prescriptions of oxycodone from the ED. The addition of simple restrictive interventions is recommended to enable rapid changes to clinician behaviour to reduce the potential harm associated with the prescribing of oxycodone in the ED. [ABSTRACT FROM AUTHOR]

Objective: The objective was to evaluate the effectiveness of methoxyflurane versus standard care for the initial management of severe pain among adult emergency department (ED) patients. Methods: This randomized parallel‐group open‐label phase IV trial of methoxyflurane was conducted in a tertiary hospital ED setting in Australia. Inclusion criteria required adult patients to have an initial pain score ≥ 8 on the 11‐point Numerical Rating Scale (NRS). Patients were randomized 1:1 to receive either inhaled methoxyflurane (3 mL) or standard analgesic treatment at ED triage. The primary outcome was the proportion of patients achieving clinically substantial pain reduction, defined as a ≥50% drop in the pain score at 30 minutes. Secondary outcomes included the pain score at multiple time points (15, 30, 60, 90 minutes) and the difference in the proportion of patients achieving a >2‐point reduction on the NRS. Results: There were 120 patients randomized and analyzed between September 4, 2019, and January 16, 2020. The primary outcome was achieved in six (10%) patients in the methoxyflurane arm and three (5%) in the standard care arm (p = 0.49). A higher proportion of patients in the methoxyflurane arm reported a >2‐point drop on the NRS at all time points (17% vs. 5% at 15 minutes, 25% vs. 9% at 30 minutes, 30% vs. 10% at 60 minutes, and 33% vs. 13% at 90 minutes). Methoxyflurane use was also associated with lower median pain scores at all time points. Conclusion: Initial management with inhaled methoxyflurane in the ED did not achieve the prespecified substantial reduction in pain, but was associated with clinically significant lower pain scores compared to standard therapy. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to assess the introduction of an analgesic ladder and targeted education on oxycodone use for patients presenting to the emergency department (ED)., Design: A retrospective pre-post implementation study was conducted. Data were extracted for patients presenting from June to July 2016 (preintervention) and June to July 2017 (post-intervention)., Setting: The EDs of a major metropolitan health service and an affiliated community-based hospital., Participants: Patients with back pain where nonpharmacological interventions such as mobilization and physiotherapy are recommended as the mainstay of treatment., Interventions: A modified analgesic ladder introduced in May 2017. The ladder promoted the use of simple analgesics such as paracetamol and nonsteroidal anti-inflammatory drug (NSAIDs) prior to opioids and tramadol in preference to oxycodone in selected patients., Main Outcome Measure(s): The proportion of patients prescribed oxycodone and total doses administered., Results: There were 107 patients pre and 107 post-intervention included in this study. After implementation of the analgesic ladder, 78 (72.9 percent) preintervention patients and 55 (51.4 percent) post-intervention patients received oxycodone in ED (p = 0.001). The median oxycodone doses administered in the ED was 14 mg (interquartile range: 5-20 mg) and 5 mg (interquartile range: 5-10 mg; p < 0.001), respectively. On discharge from hospital, a prescription for oxycodone was issued for 36 (33.6 percent) patients preintervention and 26 (24.3 percent) patients post-intervention (p = 0.13)., Conclusions: Among patients with back pain, implementation of a modified analgesic ladder was associated with a statistically significant but modest reduction in oxycodone prescription. Consideration of multifaceted interventions to produce major and sustained changes in opioid prescribing is required.