Article

Relevance of opioid guidelines in the emergency room (ROGER)

538 Correspondence / American Journal of Emergency Medicine 37 (2019) 530559

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    Relevance of opioid guidelines in the emergency room (ROGER)?

    Clearinghouse, etc.) were also completed. Guidelines were excluded if they addressed opioid prescribing at sub-national levels (e.g. state/ province, region, city, etc.), as it was felt that these were more locally fo- cused, and would not offer generalizable guidance for EM practice. In- cluded guidelines were evaluated for analytical methods used to evaluate supporting evidence and framing CPG recommendations, in- clusion of EM authors (with reporting of conflict of interest), and in- volvement of EM stakeholders in final draft evaluations (physicians, nurses, prehospital care).

    A total of 16 guidelines were included for analysis. The guidelines in- cluded in this review, and corresponding evidence evaluation/recommen- dation frameworks are listed in Table 1. A variety of different evidence evaluation systems and recommendation formulation frameworks were used by author groups. Four of 16 included CPGs did not report methods used, which raises questions about the validity of evidence analysis and recommendations suggested. The results of the CPG analyses are summa- rized in Table 2. Two CPGs made recommendations relevant to EM opioid prescribing, albeit with weak supporting evidence (based on rating frame- works used). Three CPGs included EM physician authors, including one with a potential conflict of interest. Finally, there is no reported involve- ment with any EM stakeholders (physicians, nurses, prehospital) in reviewing draft versions prior to final publication.

    Not all “guidelines” conformed to uniform construction and reporting standards, so they were not amenable to quality assessment using current rating tools (e.g. Institute of Medicine, AGREE-II instru- ment) [14].

    Guidelines can best inform clinical practice when the recommenda- tions and clinical settings are specified [14]. To that end, it is important to have appropriate inclusion & exclusion criteria that define the proper application of Guideline recommendations within the proper scope of

    Table 1

    International Opioid CPGs included in study.

    The increased use of Opioid pain medications in North America in the

    last 2 decades has given rise an epidemic of addictions, overdoses and deaths, to which both the US and Canadian governments have enacted strategies to help combat these crises [1-3]. While these strategies de- velop multiple interventions to curb opioid use, a common target is to reduce physician opioid prescribing. Many patients may receive their

    CPG (author group, Publication year) Frameworks for reviewing evidence

    and formulating recommendationsa Evidence review Recommendations

    Latin America (2017) N/R N/R

    US Centre for Disease Control (2016) GRADE GRADE

    first dose of opioid in the Emergency Department (ED), and recent stud- ies show that there has been a steady increase in opioid prescribing in US EDs to adults (relative increase of 49% from 2001 to 2010) [4, 5].

    Australian & New Zealand College of Anaesthetists (ANZCA 2015)

    Scottish Intercollegiate Guideline Network (SIGN)

    N/R N/R

    SIGN 50 SIGN 50

    Evolving evidence suggests that ED opioid prescribing can lead to long

    term opioid use/dependency, although preliminary results are conflict-

    Institute for Clinical Scientific Improvement (ICSI 2016)

    ICSI evidence grading system

    ICSI evidence grading system

    ing [6-10]. A recent review examining ED opioid prescribing outcomes indicates that approximately 10% are associated with indicators of inap- propriate prescribing, 10% may be diverted, 42% misused, and 1.8% may

    ICSI 2013 ICSI evidence ICSI evidence grading system grading system

    Pain Association of Singapore Task Force N/R N/R (2013)

    cause death [11].

    International clinical practice guidelines (CPGs) regarding opioid

    American Society of Interventional Pain

    Physicians (ASIPP 2017)

    Level I-IV

    (defined within CPG)

    Strong/mod/weak

    prescribing have been previously shown to be generally congruent re-

    garding patient assessment, risk stratification, urine drug screening

    ASIPP (2013) IOM, USPTF

    criteria

    N/R

    and opioid prescribing protocols [12, 13]. A key limitation of these inter-

    national CPGs remains the relative paucity of evidence-based recom-

    British Pain Society (2010) N/R N/R Canadian Opioid Update (2017) GRADE GRADE

    mendations to guide ED prescribing practices. The goal of this study was to review these international CPGs for emergency medicine (EM)- relevant recommendations, involvement in EM authors, and/or vetting

    Canadian National Opioid Users Group Guideline (NOUGG 2010)

    US Veterans Administration/Dept of Defence (US VA/DoD 2017)

    CTFPHC CTFPHC

    GRADE GRADE

    by EM practice organizations (physicians, nursing, pre-hospital care).

    US VA/DoD (2010) USPSTF USPSTF

    Prior search strategies for relevant guidelines were reproduced and updated to include the most recent guideline iteration [12, 13]. Manual searches of international pain society websites and guideline reposito-

    American Society of Anaesthesiologists Task Force/American Society of Regional Anaesthesia & pain medicine

    (AAS ASRA 2010)

    Expert consensus

    Expert consensus

    ries (e.g. Guideline International Network, National Guideline

    American Pain Society/American Academy of Pain Management (APS AAPM 2009)

    GRADE GRADE

    ? Presented at the Canadian Association of Emergency Physicians Annual Conference (May 2018).

    a N/R = not reported, GRADE = grading of recommendations, assessment, develop- ment and evaluation, USPSTF = US Preventive services task force, IOM = institute of medicine, CTFPHC = Canadian task force on preventive health care.

    Correspondence / American Journal of Emergency Medicine 37 (2019) 530559 539

    Table 2

    EM relevance of Included Guidelines (n = 16). Relevance domain Guideline specifics

    References

    Hsu DJ, EP McCarthy, Stevens JP, et al. Hospitalizations, costs and outcomes associ- ated with heroin and prescription opioid overdoses in the United States 2001-12.

    Practice recommendations

    (level of supporting evidence)

    Author involvement (conflict of interest)

    EM external review (physicians, nurses, prehospital)

    ICSI 2016 (Rec 13.8) – Use of drug monitoring

    programs prior to EM opioid prescribing (weak) Canadian NOUGG 2010 (Rec 24) – Limited prescribing of opioids in EM, consulting pharmacy/primary care resources, creating

    EM-specific policies (weak)

    ICSI 2016-1 EM physician (no conflicts) Canadian NOUGG 2010 – 1 EM physician (significant conflict)

    APS AAPM 2009 – 1 EM physician (unclear conflict)

    None

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    practice. Furthermore, such recommendations are inherently most valid and reliable when they have been constructed with appropriate stake- holder involvement as the assumption would be that they would have specific knowledge of the clinical setting and the nuances surrounding the practice [14]. In this review, the near absence of EM-relevant recom- mendations reflects the lack of meaningful input from EM stakeholders (physicians, nurses, Prehospital personnel). In the absence of contribu- tions from EM stakeholders during guideline construction, it is desirable to have the draft guidelines reviewed by EM expert organizations prior to final publication to ensure meaningful feedback. Such external re- view was not found during any phase of development in the guidelines included in this review.

    In the absence of useful EM-relevant recommendations from inter- national opioid prescribing guidelines, some specialty-specific organi- zations have tried to fill the void. The American College of Emergency Physicians (ACEP) published a specific clinical policy for prescribing short-acting opioids in limited acute and chronic pain conditions for adults in the EM [15]. Various regional jurisdictions and cities have tried to enact local ED opioid prescribing guidelines with variable supporting evidence and success [16-20]. These reports were not in- cluded in this review, as they did not meet inclusion criteria.

    In conclusion, international and pain specialty organization opioid prescribing guidelines have few relevant recommendations for EM practice, and any supporting evidence is weak. Emergency practitioners rarely participate in authorship groups, nor in external review of draft documents prior to final publication. This study reinforces the need for EM organizations to create guidance documents around opioid pre- scribing for EM practitioners, and involving appropriate EM authors and stakeholders.

    Funding

    This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

    Suneel Upadhye* Andrew Worster Rahim Valani

    McMaster University, Hamilton, Ontario, Canada

    *Corresponding author. E-mail addresses: [email protected] (S. Upadhye) [email protected] (A. Worster), [email protected] (R. Valani).

    25 June 2018

    https://doi.org/10.1016/j.ajem.2018.07.028

    cians and risk of long-term use. N Engl J Med 2017;376:663-73. https://doi.org/10. 1056/NEJM sa1610524.

    Jeffrey MM, Hooten WM, Hess EP, et al. Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use. Ann Emerg Med 2018;71:326-36.

  15. Henderson AW, Babu KM, Merchant RC, et al. Prescription Opioid use and misuse among older adult Rhode island hospital emergency department patients. R I Med J March 2015:28-31 Accessible at http://www.rimed.org.libaccess.lib.mcmaster.ca/ rimedicaljournal/2015/03/2015-28-cont-henderson.pdf.
  16. Lyapustina T, Castillo R, Omaki E, et al. The contribution of the emergency depart- ment to opioid pain reliever misuse and diversion: a critical review. Pain Pract 2017;17(8):1097-104.
  17. Cheung CW, Qui Q, Choi SW, et al. Chronic opioid therapy for chronic non-cancer pain: a review and comparison of treatment guidelines. Pain Physician 2014;17:401-14.
  18. Nuckols TK, Anderson L, Popescu I, et al. Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med 2014;160:38-47.
  19. IOM (Institute of Medicine). Clinical practice guidelines we can trust. Chapter 6: Pro- moting Adoption of Clinical Practice Guidelines. Washington, DC: The National Academies Press; 2011.
  20. Cantrill SV, Brown MD, Carlisle RJ, et al. Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency room. Ann Emerg Med 2012;60:499-525.
  21. Kunins HV, Farley TA, Dowell D. Guidelines for opioid prescription: why emergency physicians need support. Ann Intern Med 2013;158(11):841-3.
  22. Chacko J, Greenstein J, Ardolic B, et al. Effect of an emergency department opioid prescription policy on prescribing patterns. Am J Emerg Med 2017;35:1327-9.
  23. Weiner SG, Baker O, Poon SJ, et al. The effect of opioid prescribing guidelines on pre-

    scriptions by emergency physicians in Ohio. Ann Emerg Med 2017:1-10.

    Osborn SR, Yu J, Williams B, et al. Changes in provider prescribing patterns after an emergency department prescription opioid policy. J Emerg Med 2017;52(4): 538-46.

  24. Del Portal DA, Healy ME, Satz WA, et al. Impact of an opioid prescribing guideline in the acute care setting. J Emerg Med 2016;50(1):21-7.

    Effect of lumbar elevation on dilatation of the central veins in normal subjects

    The subclavian vein (SCV) and internal jugular vein are com- monly used to obtain central venous access [1]. In general, a small IJV (area <= 0.4 cm2) was reported in 5-14.6% of healthy subjects [2, 3] and 23% of patients [2]. Moreover, the maximum IJV area was 0.2 cm2 in dehydrated subjects [4]. A small IJV diameter measuring <=7 mm was shown to lead to catheterization failure (14.9%) and complications (8.5%) [5].

    On this account, techniques that facilitate successful central line

    placement, such as the Trendelenburg position (TP) and Valsalva ma- neuver, may be required [6]. Both techniques may improve the chance of successful cannulation.

    However, the issues reported were that a cheap or non-functioning bed could not change the patients’ position to the TP and that patients find it difficult to hold their breath for the Valsalva maneuver (disobedi- ent or uncooperative patients especially) throughout central line placement.

    This study aimed to determine the Body position that can result in the largest diameter of the central veins on an ordinary bed for cannulation.

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