A Bridge to Nowhere? Challenging Outpatient Transitions of Care for Acute Pain Patients in the Opioid Epidemic Era

Abstract

Opioid misuse is reducing Americans’ life expectancy, thereby catalyzing professional societies and legislators to action. Efforts to combat the opioid epidemic must work hand-in-hand with appropriate efforts to reduce the severity and duration of suffering. Pharmacologic analgesia is temporizing. Current opioid prescribing guidelines focus on reducing the frequency and quantity of narcotics prescribed, but lack attention to alleviation of the source of pain. Conditions eliciting acute pain sometimes require additional specialist management following discharge from the emergency department. Patients frequently lack timely access to these specialists, particularly if underinsured. This essay explores acute dental pain, extremity fractures, and back pain as three common examples whereby complex healthcare systems must efficiently adapt in order to serve the dual objectives of reducing the risk of opioid-related adverse consequences and minimizing the duration of patient suffering.

Background

The United States (US) is in the midst of an epidemic confronting a 400% increase in opioid overdose deaths between 1999 and 2010.¹ For the first time since the 1960s, life expectancy in the US has decreased for two consecutive years, partially as a consequence of increasing opioid misuse.² The scope of this public health crisis motivated the Division of Emergency Medicine at Washington University in St. Louis to host an interdisciplinary health policy symposium in August 2017 in order to engage frontline healthcare providers, hospital administrators, addiction specialists, legislators, and afflicted families in proactive problem solving.³ Missouri Medicine is supporting a series of essays stemming from that symposium. This inaugural essay explores the challenges of and opportunities for interdisciplinary improvement of patient-centric outpatient transitions of care for common subsets of acute pain patients from the emergency department (ED).

On average, the ED accounts for 47% of hospital-associated medical care delivered in the US with acute and acute-on-chronic pain as common precipitants for an ED encounter.⁴ Pain is a subjective ailment and physical exam measures like vital signs do not correlate well with reported pain.⁵ Two decades ago a constellation of events laid the foundation for the current opioid epidemic, including pain society lobbyists’ support of Patient’s Bill of Rights, poor quality data implying acceptably low risk of addiction,^6,7 aggressive and misleading pharmaceutical industry marketing,^8,9 and Centers for Medicare and Medicaid Services financial incentives based upon patient satisfaction with pain control.¹⁰ A predictable consequence of this perfect storm was increased opioid prescribing in office-based and ED practices (277% and 275%, respectively) between 1996 and 2012.¹¹ Observational research suggests that 17% of discharged ED patients are prescribed opioids, most commonly for extremity fractures, back and abdominal pain, and dental issues.¹² Notably, significant variability exists between providers regarding opioid prescribing criteria. The risk for any patient to develop opioid use disorder is associated with the type and dose, frequency, and duration of the opioids prescribed.¹³ ED providers generally prescribe only immediate-release formulations in small pill counts.¹²

An early response by specialty organizations, hospitals, and governments has been promotion of guidelines to encourage or legally restrict the quantity of opioid analgesics that providers prescribe. Two Philadelphia hospitals established ED guidelines dissuading discharge opioid prescriptions exceeding a seven-day supply and completely avoiding long acting narcotics, and a policy against refilling of opioid prescriptions. Their rate of opioid prescribing declined 23% between 2012 and 2014.¹⁴ The Ohio Governor’s Cabinet Opiate Action Team released prescribing guidelines in 2012 encouraging ED physicians to check the state’s prescription drug monitoring program, prescribe less than four days’ supply, and provide referral to primary care or pain specialists. While opioid prescribing diminished prior to introduction of the governor’s report, this trend accelerated to a 12% statewide reduction after the guideline’s release.¹⁵ Three Rhode Island hospitals of varying size implemented prescribing guidelines in 2013, noting a reduction in all three sites most pronounced among the higher baseline prescribers.¹⁶ Nationally, the American College of Emergency Physicians provides analgesia prescribing clinical policy recommendations,¹⁷ while federal legislation in the Comprehensive Addiction and Recovery Act proposes limiting opioid prescriptions to three days for acute pain without exception.¹⁸ Some emergency providers view prescribing guidelines as a shield to justify limiting prescriptions at discharge with the added benefit of diverting problematic drug-seekers away from their ED.¹⁹ On the other hand, patients report that ED providers rarely discuss opioid alternatives or the anticipated duration of pain.²⁰

Astonishingly, the recommendations and effectiveness of these guidelines focus exclusively on prescribing. This disease-centric perspective neglects and fails to contemplate the patient viewpoint or priorities, including establishing a timely plan for definitive management of the underlying cause of pain in a fragmented healthcare system.²⁰ The public realizes that the ED is the only reliable 24/7/365 resource available to address immediate needs like pain. The vast majority of ED patients with acute pain desire definitive, permanent alleviation from suffering – the ED provides only temporary management. Many patients understand that analgesics provide temporizing, variable relief of pain and that opioids carry the risk of addiction.

Efforts to reduce opioid prescribing in acute pain scenarios will largely succeed or fail depending upon how well they incorporate implementation science principles, including alignment with patient priorities. The Knowledge Translation Pipeline (Figure 1) illustrates the “leaks” occurring at the physician-patient level before research evidence (prescribing guidelines) becomes routine practice. The first five leaks occur at the physician provider level including awareness of the new practice approach, acceptance of the superiority or non-inferiority of the recommended change, applicability to their setting and patients, and ability to do so with available resources. The last two leaks constitute patients and their families agreeing with the diagnosis and management plan and then adhering to the elements of that plan. If patients perceive an inadequate or unreliable pain management plan at the time of ED discharge, other pain remedies will be sought. For example, some patients will opt for supra-therapeutic dosing of over-the-counter medications like acetaminophen. Acetaminophen is already the leading cause of acute liver failure in the US with almost half of these overdoses unintentional.^21,22 Additionally, patients may purchase prescription narcotics illicitly with street drugs often adulterated with potent synthetic opioids increasing the risk of unintentional overdose.²³ Some frustrated and uncomfortable patients will predictably return to the same or another ED with persistent undertreated pain and no alternatives available in the days to weeks ahead. Ensuring timely post-ED access to care to the appropriate specialists for pain management must be included in prescribing guidelines to serve the dual aim of reducing opioid-prescribing related addiction risk and ensuring patient-centric alleviation of suffering. In the disjointed US healthcare system with priorities and motivating influences between hospital administrators, physicians, payers, and patients often misaligned, complex system thinking is paramount.²⁴ Definitive care for dental pain, extremity fractures, and acute-on-chronic back pain may require subspecialty management not only unavailable in the ED, but also unavailable to vulnerable patients for months after discharge from the ED, which is a significant and underreported obstacle to combating the opioid epidemic.

Figure 1.

The Knowledge Translation Pipeline (from Reference ³)

Toothache and Acute Dental Issues

Toothache is the fifth most common reason for an ED visit.²⁵ Many Americans lack dental insurance and do not receive adequate preventative dental care. This results in dental emergencies comprising 1% to 4.3% of all ED visits each year at an estimated cost of about $1 billion per year.^26,27 In choosing their initial site of care (dental clinic versus ED), patients may mistakenly assume that ED staffing includes a dentist. Providing toothache management recommendations with a list of nearby dental clinics reduces both ED return visits and opioid prescriptions.²⁸ Most dental care-related ED encounters (92%) do not include any other acute health issues, 94% are discharged from the ED, and 40% involve patients with no Medicare, Medicaid, or dental insurance.²⁷ ED visits for dental issues also likely reflects a degree of patient convenience as indicated by the finding that greater travel distances to the ED are associated with lower rates of ED use for dental care.²⁹ Ironically, an ED visit for a dental complaint is inversely associated with dental follow-up within six months, offering an opportunity for low-risk ED diversion programs for Medicaid patients if reasonably rapid follow-up can be collaboratively developed with dentists in the community.³⁰

Lacking dental training beyond the basics of acute tooth trauma or recognition of infectious maxillofacial conditions like Ludwig’s angina³¹ – yet compelled to display more empathy than “sorry, I can offer ibuprofen, acetaminophen, or nothing”³² – ED providers sometimes prescribe antibiotics despite evidence of ineffectiveness as a substitute for opioid analgesics.³³ Alternatively, ED providers sometimes advocate for nerve blocks as a substitute for opioids. Unfortunately, nerve blocks only provide analgesia for a few hours, which may be inadequate if follow-up is delayed. Although emergency physicians may prescribe opioid analgesics for dental pain, non-opioid alternative are often effective. Extrapolating surgical extraction data to non-traumatic toothache patients, non-steroidal anti-inflammatory drugs (NSAIDs) achieve similar analgesia at a median of 30 minutes compared with acetaminophen/codeine and sustain relief for 17 hours longer than the opioid agent.³⁴ The effectiveness of codeine as an analgesic depends upon an individual’s metabolism of codeine into the active molecule, so alternative opioids are considered more predictably effective. The combination of oxycodone and ibuprofen (5 mg and 400 mg, respectively) more effectively relieves dental pain at six hours than hydrocodone 7.5/acetaminophen 500 mg combinations.³⁵ However, dentists are also increasingly encouraged to select non-opioid management of acute odontalgia,³⁶ which may encourage some patients to seek opioid prescriptions from the ED despite access to a dentist. Mutual understanding between EDs and dental clinics regarding non-opioid analgesia recommendations and reasonable follow-up intervals will be required to prevent asynchronous messages to patients or further ED crowding by those seeking a second prescriber.

Dental insurance has historically been separate from medical insurance, despite the reality that oral health is associated with pain, social status, and overall well-being. ³⁷ Opportunities to improve transitions of care between EDs and primary care clinics with definitive dental care confront daunting logistical and financial challenges. Community emergency dental clinics that rely on philanthropy and foundation support struggle to sustain care for indigent populations.³⁸ As primary care is redesigned for more conscientious opioid prescribing,³⁹ dental analgesia protocols need to adapt, including provision of timely access to dental care. Adaptive transition of care responses to simultaneously reduce opioid prescribing and alleviate the duration of patient suffering might include EDs or hospitals contracting with a dental clinic via mobile applications,⁴⁰ linking dentists’ electronic medical records with EDs for free exchange of appointment availability and patient care plans, or substantial financial incentives for dentists providing timely access and definitive management for acute dental pain crises in economically vulnerable populations.³⁷

Extremity Fractures

Alleviating acute fracture pain often requires appropriately compassionate opioid prescribing.³⁹ Post-ED fracture management usually involves orthopedic referrals, which are often challenging to obtain within weeks or even months of an ED encounter for underinsured patients. In addition, underinsured patients are sometimes referred from one hospital’s ED to another neighboring ED despite the availability of orthopedic services at the initial ED. These “insurance transfers” increase the financial challenges to the receiving, often non-profit, hospitals. In addition, receiving hospitals also tend to be further away from the patient’s home, which renders follow-up more challenging. In one Texas hospital estimated six month uncompensated orthopedic care for the receiving hospital was $1.7 million.⁴¹ While the link between underinsured orthopedic transfers and opioid prescribing remains undefined, these transfers are likely associated with delays to timely analgesia in the ED, prolonged waiting times for all patients in the receiving ED, and delays to timely outpatient follow-up as the receiving hospital’s orthopedic clinics seek to preferentially schedule insured patients and/or await Medicaid registration for referrals.^42,43 Transferring fracture patients from one orthopedic-capable hospital to another safety net hospital could be dissuaded by modifying the Disproportionate Share Hospital non-profit rule to disallow hospitals from including costs of transferred patients from public reimbursement claims or non-profit status.⁴¹ While the Emergency Medical Treatment and Labor Act (EMTALA) was intended to reduce preventable transfers related to ability to pay, some modifications to EMTALA could improve this objective, including alignment of Medicaid reimbursements with Medicare and random audits for appropriateness of Medicaid transfers for uncomplicated fractures linked to penalties if acceptable thresholds are consistently breached.⁴⁴ Additional ED transition of care adaptations targeting the dual objective of reduced opioid prescribing with timely outpatient orthopedic evaluation could include empowering ED case managers to schedule appropriate next day follow-up appointments in conjunction with shared decision making to align risks/benefits of different analgesic options with patient priorities while differentiating subjective pain from the philosophy of suffering.⁴⁵ Telecare also provides an opportunity for more timely orthopedic evaluation, though technology and payer barriers await resolution.⁴⁶

Acute-on-Chronic Back Pain

Acute low back pain accounts for 3% of ED visits and represents the leading cause of disability under age 45 years.⁴⁷ Clinicians traditionally learned that low back pain is a self-limited problem with resolution within six weeks in 90% of patients regardless of analgesic prescribed or referral to physiotherapy, imaging, or specialist. Back pain as a generally self-limited problem now appears to be an oversimplification that may misinform patients and fuel disparities in timely analgesia.⁴⁸ Multiple recent systematic reviews highlight that two-thirds of acute non-specific low back pain patients report persistent and often disabling pain at one-year.^49,50

Therefore, to affect and sustain reductions in opioid prescribing, both ED providers and primary care providers must learn to manage expectations rather than meet them. A tiered analgesic approach is worthwhile since both acetaminophen and NSAIDs compare favorably to morphine.^17,51 ED back pain patients should certainly be referred back to their primary care providers for re-evaluation to guide additional medical or sub-specialty referrals. However, many acute back pain patients have no identifiable primary care provider. Others present to the ED frustrated with their primary care provider, expressing misalignment between their understanding of back pain and the degree of relief obtained with their current opioid or non-opioid analgesic. Referrals to physiotherapy or Pain Medicine services from the ED might alleviate patient angst and accelerate recovery,⁵² but insurers often refuse reimbursement for direct ED referrals whereas insurers pay for opioids which are easily obtained at the pharmacy. In addition, when back pain patients are already under the care of a pain medicine physician, ED providers frequently lack access for referral or discussion with that physician to help provide timely follow-up or non-opioid management recommendations. Telemedicine between the ED and Pain Medicine may provide one viable alternative to these barriers,⁵³ although simple accessibility by telephone might be equally effective. Another concept worthy of exploration is the “ambulatory pain physician” using anesthesiology as an in-person ED consultant to provide short- or long-term opioid and non-opioid options for back pain patients.⁵⁴

Conclusion

Valiant efforts to promote responsible opioid prescribing are necessary to reverse the ill effects of the current epidemic. Decreased subscribing alone is inhumane and unethical with an imminent threat of swinging the pendulum from an emphasis on pain as a fifth vital sign with little concern for adverse effects of opioid analgesia to an illogical one-size fits all legislated rationing of effective analgesia without connecting patients to providers in a reasonably timely fashion. Successful patient-centric ED transitions of care for acutely painful conditions require a paradigm shift that engages emergency medicine, follow-up specialists and primary care providers, insurers, and patients.

Biography

Christopher R. Carpenter, MD, MSc, MSMA member since 2016, Associate Professor; Lawrence Lewis, MD, Professor; Randall S. Jotte, MD, MSMA member since 2016, Associate Professor; and Evan S. Schwarz, MD, MSMA member since 2014, Associate Professor, are in the Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Mo.

Contact: carpenterc@wustl.edu