Opioid Prescribing In An Emergency Department

Introduction: Concerns regarding excessive opioid prescribing, particularly in the USA, have led to guidance being written to limit opioid prescribing in the Emergency Department.

Aims: To assess the appropriateness of opioid prescribing for patients presenting with pain both in the emergency department and on discharge. To present the findings to the department and thus educate prescribers regarding the deficiencies in opioid analgesia prescribing.

Method: Attendances with the presentation of pain (back pain, limb problems, abdominal pain) to the ED during the period of one week were selected for chart review. After exclusions, 161 patient records were included in the audit. The re-audit (n=145) was performed on attendances over the course of a week after the results of the first iteration had been presented.

Results: A pain score was documented in 15% of the patient records. 6% of patients had a documented history of chronic pain and 5% were already on opioids. 33% received analgesia in the department, with 40% prescribed paracetamol as the first line analgesic. Opioids were prescribed in 64% of cases receiving analgesia, with 53% receiving an opioid as first line treatment. The majority were prescribed Solpadeine (56%), with 12%, 9% and 6% prescribed Tramadol, Solpadol and Morphine respectively. 3% of patients were prescribed an opioid by an advanced paramedic prior to attendance.27% of those discharged got an opioid prescription. 60% were prescribed Solpadeine and 28% were prescribed Solpadol or Tylex. No MDA scripts were written on discharge. Apart from one script for a sustained release product, no scripts were for longer than two weeks.

The re-audit showed a pain score was documented in the doctor’s notes in only 6% of charts. 18% had a history of chronic pain and 10% were on opioids prior to attendance. Similar prescribing patterns to that in the first cycle were seen. 48% of those of the audit group received analgesia in the department with paracetamol the first line in 43% of cases. 49% of those prescribed analgesia in the department were prescribed an opioid, with 40% prescribed one as first line analgesia. The predominant opioid of choice was Solpadeine (44%). There were fewer discharge prescriptions of opioids (13% of discharges) and 50% of these were prescribed Solpadeine.

Discussion: The prescribing in the department was judicious in terms of opioid prescribing during the patient’s stay and on discharge with only one sustained release prescription supplied in the first cycle and none in the second cycle. No MDA prescriptions were given on discharge in either cycle. However, the poor documentation of a pain score made the comparison of the correct level of analgesia for the patient’s presentation unfeasible. Prescribing of analgesia on discharge should be limited to the lowest level on the analgesic ladder while still efficacious in terms of pain relief. The prescription should be of limited duration with guidelines suggesting three days as an appropriate period.