Introduction of a modified analgesic ladder in the emergency department: Effect on oxycodone use for back pain

Jenny Ly, BPharm, GradCertPharmPrac; Cristina P. Roman, BPharm (Hons), MPP; Carl Luckhoff, MB, ChB, FACEM; Peter A. Cameron, MBBS, MD, FACEM, FCEM (Hon); Michael J. BPharm, GradDipHospPharm, PhD, AdvPracPharm, FSHP, FISOPP; Biswadev Mitra, MBBS, MHSM, PhD, FACEM

doi:10.5055/jom.2021.0613

Authors

Jenny Ly, BPharm, GradCertPharmPrac
Cristina P. Roman, BPharm (Hons), MPP
Carl Luckhoff, MB, ChB, FACEM
Peter A. Cameron, MBBS, MD, FACEM, FCEM (Hon)
Michael J. BPharm, GradDipHospPharm, PhD, AdvPracPharm, FSHP, FISOPP
Biswadev Mitra, MBBS, MHSM, PhD, FACEM

DOI:

https://doi.org/10.5055/jom.2021.0613

Keywords:

acute pain, oxycodone, analgesia, back pain, anti-inflammatory agents, nonsteroidal

Abstract

Objective: The aim of this study was to assess the introduction of an analgesic ladder and targeted education on oxycodone use for patients presenting to the emergency department (ED).

Design: A retrospective pre-post implementation study was conducted. Data were extracted for patients presenting from June to July 2016 (preintervention) and June to July 2017 (post-intervention).

Setting: The EDs of a major metropolitan health service and an affiliated community-based hospital.

Participants: Patients with back pain where nonpharmacological interventions such as mobilization and physiotherapy are recommended as the mainstay of treatment.

Interventions: A modified analgesic ladder introduced in May 2017. The ladder promoted the use of simple analgesics such as paracetamol and nonsteroidal anti-inflammatory drug (NSAIDs) prior to opioids and tramadol in preference to oxycodone in selected patients.

Main outcome measure(s): The proportion of patients prescribed oxycodone and total doses administered.

Results: There were 107 patients pre and 107 post-intervention included in this study. After implementation of the analgesic ladder, 78 (72.9 percent) preintervention patients and 55 (51.4 percent) post-intervention patients received oxycodone in ED (p = 0.001). The median oxycodone doses administered in the ED was 14 mg (interquartile range: 5-20 mg) and 5 mg (interquartile range: 5-10 mg; p < 0.001), respectively. On discharge from hospital, a prescription for oxycodone was issued for 36 (33.6 percent) patients preintervention and 26 (24.3 percent) patients post-intervention (p = 0.13).

Conclusions: Among patients with back pain, implementation of a modified analgesic ladder was associated with a statistically significant but modest reduction in oxycodone prescription. Consideration of multifaceted interventions to produce major and sustained changes in opioid prescribing is required.

Author Biographies

Jenny Ly, BPharm, GradCertPharmPrac

Pharmacist, Pharmacy Department, Alfred Health, Melbourne, Australia

Cristina P. Roman, BPharm (Hons), MPP

Lead Pharmacist, Pharmacy Department, Alfred Health, Melbourne, Australia; Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; Emergency and Trauma Centre, Alfred Health, Melbourne, Australia

Carl Luckhoff, MB, ChB, FACEM

Emergency Physician, Emergency and Trauma Centre, Alfred Health, Melbourne, Australia

Peter A. Cameron, MBBS, MD, FACEM, FCEM (Hon)

Academic Director of The Alfred Emergency and Trauma Centre, Emergency and Trauma Centre, Alfred Health, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia

Michael J. BPharm, GradDipHospPharm, PhD, AdvPracPharm, FSHP, FISOPP

Director of Pharmacy, Pharmacy Department, Alfred Health, Melbourne, Australia; Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia

Biswadev Mitra, MBBS, MHSM, PhD, FACEM

Director of Emergency Medicine Research, Emergency and Trauma Centre, Alfred Health, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia

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