American Academy of Emergency Medicine Model ED Pain Treatment Guidelines

Introduction

Prescription drug abuse has become an issue of national importance. The number of deaths from prescription opioids now exceeds those caused by heroin and cocaine combined. In order to help stem this epidemic there has been a call for more judicious prescribing on the part of physicians.1 The AAEM offers this model guideline to its members. It may be adopted in whole or in part and should be modified to address local circumstances and state and local laws and regulations.

Guidelines for treating non-cancer pain

This document is a guideline and is not meant to replace the individual judgment of the treating physician who is in the best position to determine the needs of the individual patient.

  1. Narcotic analgesics are appropriate to treat acute illness or injury. Discharge prescriptions should be limited to the amount needed until follow-up and should not exceed 7 days worth.
  2. The patient should not receive narcotic prescriptions from multiple doctors. Emergency physicians should not prescribe additional narcotics for a condition previously treated in their ED or by another physician unless there are extenuating circumstances.
  3. Patients with chronic non-cancer pain should not receive injections of narcotic analgesics in the ED.  
  4. Emergency physicians should not prescribe long acting narcotic agents such as oxycontin, extended release morphine or methadone. Oxycodone (ex. Percocet), hyrdocodone (ex. Vicodin) and hydromorphone (Dilaudid) have high abuse potential and the physician should consider using alternative agents.
  5. Emergency physicians should not replace lost or stolen prescriptions for controlled substances.
  6. Emergency physicians should not fill prescriptions for patients who have run out of pain medications. Refills are to be arranged with the primary or specialty prescribing physician.
  7. Narcotic pain medication is discouraged for certain conditions including:  
    1. Back pain whether acute or chronic
    2. Routine dental pain
    3. Migraines  
    4. Chronic abdominal or pelvic pain and gastroparesis
  8. Patients with suspected substance abuse behavior should be referred to appropriate resources.
  9. If circumstances warrant, EM physicians should consider accessing their state’s prescription data base (for states with physician access to this).
  10. Patients identified with multiple ED visits for pain, problematic or dishonest behavior (abusive, altering prescriptions, false reports) or use of multiple hospitals for pain should be reviewed by the ED physician leadership team which should consider the following actions:
    1. Sending a certified letter stating the patient will no longer be provided narcotics in the ED.
    2. Adding an internal code (ex. 555) identifying probable drug seeking behavior into their medical record

Reference:

1. Alexander GC, Kruszewski, SP, Webster DW.  Rethinking opioid prescribing to protect patient safety and public health. JAMA 2012;308:1865-66.

Disclaimer: This document is solely a model guideline and it should not be used to establish any standard of care or conduct.  Any deviation from these guidelines should not be considered as a basis for, or as evidence of, a breach of professional conduct or any professional standard.   These guidelines should be modified as necessary reflect applicable state and local laws and regulations.

These guidelines are not intended as a substitute for medical or legal advice and the content should not be relied as a primary basis for providing ED pain treatment in any particular instance. Readers should make their own independent determinations as to: (1) what constitutes appropriate medical and/or
administrative practices or procedures in any particular instance, and (2) how best to comply with laws, regulations and relevant administrative and medical standards relevant to the reader's own institution. It is recommended that the reader consult, as to any medical matters referenced in these materials, a qualified physician, and, as to any business or legal matters, an attorney familiar with pertinent legal concepts and state and federal laws. By using these guidelines, the user agrees and acknowledges that he or she assumes all risk arising out of such use and releases the American Academy of Emergency Medicine, Inc. and its directors, officers, and agents from and against any loss, damage, claim or liability arising out of such use.

 

Published: 2/10/13

 

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