First EDition: News for and about the practice of emergency medicine

CDC Issues New Opioid Prescribing Guideline

BY SHARON WORCESTER

Frontline Medical News

Nonopioid therapy is the preferred approach for managing chronic pain outside of active cancer, palliative, and end-of-life care, according to a new guideline released by the Centers for Disease Control and Prevention (CDC).

The 12 recommendations included in the guideline, which is available at http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm, center around this principle and two others: using the lowest possible effective dosage when opioids are used, and exercising caution and monitoring patients closely when prescribing opioids.

Specifically, the guideline states that “clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient” and that “treatment should be combined with nonpharmacologic and nonopioid therapy, as appropriate.”

The guideline also addresses steps to take before starting or continuing opioid therapy, and drug selection, dosage, duration, follow-up, and discontinuation. Recommendations for assessing risk and addressing harms of opioid use are also included.

The CDC developed the guideline as part of the US government’s urgent response to the epidemic of overdose deaths, which has been fueled by a quadrupling of the prescribing and sales of opioids since 1999, according to a CDC press statement. The guideline’s purpose is to help prevent opioid misuse and overdose.

“The CDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016 will help primary care providers ensure the safest and most effective treatment for their patients,” according to the statement. The CDC’s director, Dr Tom Frieden, noted that “overprescribing opioids—largely for chronic pain—is a key driver of America’s drug-overdose epidemic.”

In a CDC teleconference marking the release of the guideline, Dr Frieden said it has become increasingly clear that opioids “carry substantial risks but only uncertain benefits, especially compared with other treatments for chronic pain.

“Beginning treatment with an opioid is a momentous decision, and it should only be done with full understanding by both the clinician and the patient of the substantial risks and uncertain benefits involved,” Dr Frieden said. He added that he knows of no other medication “that’s routinely used for a nonfatal condition [and] that kills patients so frequently.

“With more than 250 million prescriptions written each year, it’s so important that doctors understand that any one of those prescriptions could potentially end a patient’s life,” he cautioned.

A 2015 study showed that 1 of every 550 patients treated with opioids for noncancer pain—and 1 of 32 who received the highest doses (more than 200 morphine milligram equivalents per day)—died within 2.5 years of the first prescription.

Dr Frieden noted that opioids do have a place when the potential benefits outweigh the potential harms. “But for most patients—the vast majority of patients—the risks will outweigh the benefits,” he said.

The opioid epidemic is one of the most pressing public health issues in the United States today, said Sylvia M. Burwell, secretary of the Department of Health & Human Services (HHS). A year ago, she announced an HHS initiative to reduce prescription opioid and heroin-related drug overdose, death, and dependence.

“Last year, more Americans died from drug overdoses than car crashes,” Ms Burwell said during the teleconference, noting that families across the nation and from all walks of life have been affected.

Combating the opioid epidemic is a national priority, she said, and the CDC guideline will help in that effort.

“We believe this guideline will help health care professionals provide safer and more effective care for patients dealing with chronic pain, and we also believe it will help these providers drive down the rates of opioid use disorder, overdose, and...death,” she said.

Of note, the guideline stresses the right of patients with chronic pain to receive safe and effective pain management, and focuses on giving primary care providers (PCPs)—who account for about half of all opioid prescriptions—a road map for providing such pain management by increasing the use of effective nonopioid and nonpharmacological therapies.

It was developed through a “rigorous scientific process using the best available scientific evidence, consulting with experts, and listening to comments from the public and partner organizations,” according to the CDC statement. The organization “is dedicated to working with partners to improve the evidence base and will refine the recommendations as new research becomes available.

“In conjunction with the release of the guideline, the CDC has provided a checklist for prescribing opioids for chronic pain (available at http://stacks.cdc.gov/view/cdc/38025), and a Web site (http://www.cdc.gov/drugoverdose/prescribing/resources.html) with additional tools for implementing the recommendations within the guideline.

Patients of PCPs who follow these new guidelines and alter their opioid prescribing practices might subsequently present more frequently to the ED seeking opioid pain medications.

Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. ePub: 15 March 2016. doi:http://dx.doi.org/10.15585/mmwr.rr6501e1er.

Legalization of Marijuana in Colorado Is Followed by an Increase in Marijuana-related ED Visits by Nonresidents

BY JEFF BAUER

FROM N ENGL J MED

"Marijuana tourism”—when individuals travel to a state where marijuana is legal for purpose of consuming the drug—may be responsible for a steep increase in marijuana-related visits by out-of-state residents observed at a Colorado ED from 2013 to 2014. Colorado legalized marijuana in 2012, and retail sales began in 2014.

Researchers looked at the rates of marijuana-related visits (determined by International Classification of Diseases, Ninth Revision codes) to the ED of a single urban academic hospital hospital in Aurora, CO from 2012 to 2014. Researchers compared the rate of such visits by Colorado residents versus out-of-state residents based on the ZIP code patients provided when they registered in the ED.

The rate of marijuana-related ED visits among out-of-state residents roughly doubled from 85 per 10,000 visits in 2013 to 168 per 10,000 visits in 2014. The rate of such visits among Colorado residents did not change significantly during that time: it was 106 per 10,000 visits in 2013 and 112 per 10,000 visits in 2014. From 2012 to 2013—before marijuana was legalized—the rate of marijuana-related ED visits did not change significantly among Colorado residents or out-of-state residents.

Statewide, according to data from the Colorado Hospital Association, the rate of marijuana-related ED visits by out-of-state residents increased from 112 per 10,000 visits in 2013 to 163 per 10,000 visits in 2014. Among Colorado residents, this rate increased from 86 per 10,000 visits in 2013 to 101 per 10,000 visits in 2014.

Kim HS, Hall KE, Genco EK, Van Dyke M, Barker E, Monte AA. Marijuana tourism and emergency department visits in Colorado. N Engl J Med. 2016;374(8):797-798. doi:10.1056/NEJMc1515009.

CDC Issues New Opioid Prescribing Guideline

BY SHARON WORCESTER

Frontline Medical News

Nonopioid therapy is the preferred approach for managing chronic pain outside of active cancer, palliative, and end-of-life care, according to a new guideline released by the Centers for Disease Control and Prevention (CDC).

The 12 recommendations included in the guideline, which is available at http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm, center around this principle and two others: using the lowest possible effective dosage when opioids are used, and exercising caution and monitoring patients closely when prescribing opioids.

Specifically, the guideline states that “clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient” and that “treatment should be combined with nonpharmacologic and nonopioid therapy, as appropriate.”

The guideline also addresses steps to take before starting or continuing opioid therapy, and drug selection, dosage, duration, follow-up, and discontinuation. Recommendations for assessing risk and addressing harms of opioid use are also included.

The CDC developed the guideline as part of the US government’s urgent response to the epidemic of overdose deaths, which has been fueled by a quadrupling of the prescribing and sales of opioids since 1999, according to a CDC press statement. The guideline’s purpose is to help prevent opioid misuse and overdose.

“The CDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016 will help primary care providers ensure the safest and most effective treatment for their patients,” according to the statement. The CDC’s director, Dr Tom Frieden, noted that “overprescribing opioids—largely for chronic pain—is a key driver of America’s drug-overdose epidemic.”

In a CDC teleconference marking the release of the guideline, Dr Frieden said it has become increasingly clear that opioids “carry substantial risks but only uncertain benefits, especially compared with other treatments for chronic pain.

“Beginning treatment with an opioid is a momentous decision, and it should only be done with full understanding by both the clinician and the patient of the substantial risks and uncertain benefits involved,” Dr Frieden said. He added that he knows of no other medication “that’s routinely used for a nonfatal condition [and] that kills patients so frequently.

“With more than 250 million prescriptions written each year, it’s so important that doctors understand that any one of those prescriptions could potentially end a patient’s life,” he cautioned.

A 2015 study showed that 1 of every 550 patients treated with opioids for noncancer pain—and 1 of 32 who received the highest doses (more than 200 morphine milligram equivalents per day)—died within 2.5 years of the first prescription.

Dr Frieden noted that opioids do have a place when the potential benefits outweigh the potential harms. “But for most patients—the vast majority of patients—the risks will outweigh the benefits,” he said.

The opioid epidemic is one of the most pressing public health issues in the United States today, said Sylvia M. Burwell, secretary of the Department of Health & Human Services (HHS). A year ago, she announced an HHS initiative to reduce prescription opioid and heroin-related drug overdose, death, and dependence.

“Last year, more Americans died from drug overdoses than car crashes,” Ms Burwell said during the teleconference, noting that families across the nation and from all walks of life have been affected.

Combating the opioid epidemic is a national priority, she said, and the CDC guideline will help in that effort.

“We believe this guideline will help health care professionals provide safer and more effective care for patients dealing with chronic pain, and we also believe it will help these providers drive down the rates of opioid use disorder, overdose, and...death,” she said.

Of note, the guideline stresses the right of patients with chronic pain to receive safe and effective pain management, and focuses on giving primary care providers (PCPs)—who account for about half of all opioid prescriptions—a road map for providing such pain management by increasing the use of effective nonopioid and nonpharmacological therapies.

It was developed through a “rigorous scientific process using the best available scientific evidence, consulting with experts, and listening to comments from the public and partner organizations,” according to the CDC statement. The organization “is dedicated to working with partners to improve the evidence base and will refine the recommendations as new research becomes available.

“In conjunction with the release of the guideline, the CDC has provided a checklist for prescribing opioids for chronic pain (available at http://stacks.cdc.gov/view/cdc/38025), and a Web site (http://www.cdc.gov/drugoverdose/prescribing/resources.html) with additional tools for implementing the recommendations within the guideline.

Patients of PCPs who follow these new guidelines and alter their opioid prescribing practices might subsequently present more frequently to the ED seeking opioid pain medications.

Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. ePub: 15 March 2016. doi:http://dx.doi.org/10.15585/mmwr.rr6501e1er.

Legalization of Marijuana in Colorado Is Followed by an Increase in Marijuana-related ED Visits by Nonresidents

BY JEFF BAUER

FROM N ENGL J MED

"Marijuana tourism”—when individuals travel to a state where marijuana is legal for purpose of consuming the drug—may be responsible for a steep increase in marijuana-related visits by out-of-state residents observed at a Colorado ED from 2013 to 2014. Colorado legalized marijuana in 2012, and retail sales began in 2014.

Researchers looked at the rates of marijuana-related visits (determined by International Classification of Diseases, Ninth Revision codes) to the ED of a single urban academic hospital hospital in Aurora, CO from 2012 to 2014. Researchers compared the rate of such visits by Colorado residents versus out-of-state residents based on the ZIP code patients provided when they registered in the ED.

The rate of marijuana-related ED visits among out-of-state residents roughly doubled from 85 per 10,000 visits in 2013 to 168 per 10,000 visits in 2014. The rate of such visits among Colorado residents did not change significantly during that time: it was 106 per 10,000 visits in 2013 and 112 per 10,000 visits in 2014. From 2012 to 2013—before marijuana was legalized—the rate of marijuana-related ED visits did not change significantly among Colorado residents or out-of-state residents.

Statewide, according to data from the Colorado Hospital Association, the rate of marijuana-related ED visits by out-of-state residents increased from 112 per 10,000 visits in 2013 to 163 per 10,000 visits in 2014. Among Colorado residents, this rate increased from 86 per 10,000 visits in 2013 to 101 per 10,000 visits in 2014.

Kim HS, Hall KE, Genco EK, Van Dyke M, Barker E, Monte AA. Marijuana tourism and emergency department visits in Colorado. N Engl J Med. 2016;374(8):797-798. doi:10.1056/NEJMc1515009.

CDC Issues New Opioid Prescribing Guideline

BY SHARON WORCESTER

Frontline Medical News

Nonopioid therapy is the preferred approach for managing chronic pain outside of active cancer, palliative, and end-of-life care, according to a new guideline released by the Centers for Disease Control and Prevention (CDC).

The 12 recommendations included in the guideline, which is available at http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm, center around this principle and two others: using the lowest possible effective dosage when opioids are used, and exercising caution and monitoring patients closely when prescribing opioids.

Specifically, the guideline states that “clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient” and that “treatment should be combined with nonpharmacologic and nonopioid therapy, as appropriate.”

The guideline also addresses steps to take before starting or continuing opioid therapy, and drug selection, dosage, duration, follow-up, and discontinuation. Recommendations for assessing risk and addressing harms of opioid use are also included.

The CDC developed the guideline as part of the US government’s urgent response to the epidemic of overdose deaths, which has been fueled by a quadrupling of the prescribing and sales of opioids since 1999, according to a CDC press statement. The guideline’s purpose is to help prevent opioid misuse and overdose.

“The CDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016 will help primary care providers ensure the safest and most effective treatment for their patients,” according to the statement. The CDC’s director, Dr Tom Frieden, noted that “overprescribing opioids—largely for chronic pain—is a key driver of America’s drug-overdose epidemic.”

In a CDC teleconference marking the release of the guideline, Dr Frieden said it has become increasingly clear that opioids “carry substantial risks but only uncertain benefits, especially compared with other treatments for chronic pain.

“Beginning treatment with an opioid is a momentous decision, and it should only be done with full understanding by both the clinician and the patient of the substantial risks and uncertain benefits involved,” Dr Frieden said. He added that he knows of no other medication “that’s routinely used for a nonfatal condition [and] that kills patients so frequently.

“With more than 250 million prescriptions written each year, it’s so important that doctors understand that any one of those prescriptions could potentially end a patient’s life,” he cautioned.

A 2015 study showed that 1 of every 550 patients treated with opioids for noncancer pain—and 1 of 32 who received the highest doses (more than 200 morphine milligram equivalents per day)—died within 2.5 years of the first prescription.

Dr Frieden noted that opioids do have a place when the potential benefits outweigh the potential harms. “But for most patients—the vast majority of patients—the risks will outweigh the benefits,” he said.

The opioid epidemic is one of the most pressing public health issues in the United States today, said Sylvia M. Burwell, secretary of the Department of Health & Human Services (HHS). A year ago, she announced an HHS initiative to reduce prescription opioid and heroin-related drug overdose, death, and dependence.

“Last year, more Americans died from drug overdoses than car crashes,” Ms Burwell said during the teleconference, noting that families across the nation and from all walks of life have been affected.

Combating the opioid epidemic is a national priority, she said, and the CDC guideline will help in that effort.

“We believe this guideline will help health care professionals provide safer and more effective care for patients dealing with chronic pain, and we also believe it will help these providers drive down the rates of opioid use disorder, overdose, and...death,” she said.

Of note, the guideline stresses the right of patients with chronic pain to receive safe and effective pain management, and focuses on giving primary care providers (PCPs)—who account for about half of all opioid prescriptions—a road map for providing such pain management by increasing the use of effective nonopioid and nonpharmacological therapies.

It was developed through a “rigorous scientific process using the best available scientific evidence, consulting with experts, and listening to comments from the public and partner organizations,” according to the CDC statement. The organization “is dedicated to working with partners to improve the evidence base and will refine the recommendations as new research becomes available.

“In conjunction with the release of the guideline, the CDC has provided a checklist for prescribing opioids for chronic pain (available at http://stacks.cdc.gov/view/cdc/38025), and a Web site (http://www.cdc.gov/drugoverdose/prescribing/resources.html) with additional tools for implementing the recommendations within the guideline.

Patients of PCPs who follow these new guidelines and alter their opioid prescribing practices might subsequently present more frequently to the ED seeking opioid pain medications.

Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. ePub: 15 March 2016. doi:http://dx.doi.org/10.15585/mmwr.rr6501e1er.

Legalization of Marijuana in Colorado Is Followed by an Increase in Marijuana-related ED Visits by Nonresidents

BY JEFF BAUER

FROM N ENGL J MED

"Marijuana tourism”—when individuals travel to a state where marijuana is legal for purpose of consuming the drug—may be responsible for a steep increase in marijuana-related visits by out-of-state residents observed at a Colorado ED from 2013 to 2014. Colorado legalized marijuana in 2012, and retail sales began in 2014.

Researchers looked at the rates of marijuana-related visits (determined by International Classification of Diseases, Ninth Revision codes) to the ED of a single urban academic hospital hospital in Aurora, CO from 2012 to 2014. Researchers compared the rate of such visits by Colorado residents versus out-of-state residents based on the ZIP code patients provided when they registered in the ED.

The rate of marijuana-related ED visits among out-of-state residents roughly doubled from 85 per 10,000 visits in 2013 to 168 per 10,000 visits in 2014. The rate of such visits among Colorado residents did not change significantly during that time: it was 106 per 10,000 visits in 2013 and 112 per 10,000 visits in 2014. From 2012 to 2013—before marijuana was legalized—the rate of marijuana-related ED visits did not change significantly among Colorado residents or out-of-state residents.

Statewide, according to data from the Colorado Hospital Association, the rate of marijuana-related ED visits by out-of-state residents increased from 112 per 10,000 visits in 2013 to 163 per 10,000 visits in 2014. Among Colorado residents, this rate increased from 86 per 10,000 visits in 2013 to 101 per 10,000 visits in 2014.

Kim HS, Hall KE, Genco EK, Van Dyke M, Barker E, Monte AA. Marijuana tourism and emergency department visits in Colorado. N Engl J Med. 2016;374(8):797-798. doi:10.1056/NEJMc1515009.