Open Access Open Access  Restricted Access Subscription or Fee Access

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


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.


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

Full Text:



Blanch B, Pearson S-A, Haber PS: An overview of the patterns of prescription opioid use, costs and related harms in Australia. Br J Clin Pharmacol. 2014; 78(5): 1159-1166.

Deyo RA, Von Korff M, Duhrkoop D: Opioids for low back pain. BMJ (Clinical research ed). 2015; 350: g6380.

Cameron PA: Managing pain following injury: Time to change. Injury. 2019; 50(2): 221-222.

Humphreys K: Avoiding globalisation of the prescription opioid epidemic. Lancet. 2017; 390(10093): 437-439.

Barnett ML, Olenski AR, Jena AB: Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med. 2017; 376(7): 663-673.

Hoy D, March L, Brooks P, et al.: The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014; 73(6): 968-974.

Foster NE, Anema JR, Cherkin D, et al.: Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018; 391(10137): 2368-2383.

Australian Institute of Health and Welfare. Musculoskeletal fact sheet: back problems. Arthritis series no. 21. Cat. no. PHE 185. Canberra, Australia: AIHW; 2015.

Schreijenberg M, Koes BW, Lin C-WC: Guideline recommendations on the pharmacological management of non-specific low back pain in primary care—is there a need to change? Expert review. Clin Pharmacol. 2019; 12(2): 145-157.

Mathieson S, Valenti L, Maher CG, et al.: Worsening trends in analgesics recommended for spinal pain in primary care. Eur Spine J. 2018; 27(5): 1136-1145.

Almeida M, Saragiotto B, Richards B, et al.: Primary care management of non-specific low back pain: Key messages from recent clinical guidelines. Med J Aust. 2018; 208(6): 272-275.

Sayer JM, Kinsella RM, Cary BA, et al.: Advanced musculoskeletal physiotherapists are effective and safe in managing patients with acute low back pain presenting to emergency departments. Aust Health Rev. 2018; 42(3): 321-326.

Murphy DL, Lebin JA, Severtson SG, et al.: Comparative rates of mortality and serious adverse effects among commonly prescribed opioid analgesics. Drug Saf. 2018; 41(8): 787-795.

Cicero TJ, Adams EH, Geller A, et al.: A postmarketing surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States. Drug Alcohol Dependence. 1999; 57(1): 7-22.

Cicero TJ, Inciardi JA, Adams EH, et al.: Rates of abuse of tramadol remain unchanged with the introduction of new branded and generic products: Results of an abuse monitoring system, 1994-2004. Pharmacoepidemiol Drug Safety. 2005; 14(12): 851-859.

Schug S: Conventional and atypical opioids. Med Today. 2018; 19(9): 5-11.

Osborn SR, Yu J, Williams B, et al.: Changes in provider prescribing patterns after implementation of an emergency department prescription opioid policy. J Emerg Med. 2017; 52(4): 538-546.

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): 21-27.

Schwartz GD, Harding AM, Donaldson SR, et al.: Modifying emergency department electronic prescribing for outpatient opioid analgesia. Emerg Med Aust. 2019; 31(3): 417-422.

Kline TV, Savage RL, Greenslade JH, et al.: Affecting emergency department oxycodone discharge prescribing: An educational intervention. Emerg Med Aust. 2019; 31(4): 580-586.

Kaye KI, Welch SA, Davis SR, et al.: Pethidine in emergency departments: Promoting evidence-based prescribing. Med J Aust. 2005; 183(3): 129-133.

Taylor SE, Braitberg G, Lugt J: Multifaceted education initiative minimizes pethidine prescribing in the emergency department. Emerg Med Aust. 2007; 19(1): 25-30.

Mitra B, Cameron PA: Pethidine in emergency departments: Promoting evidence-based prescribing. Med J Aust. 2006; 184(1): 1.

O’Connor AB, Lang VJ, Quill TE: Eliminating analgesic meperidine use with a supported formulary restriction. Am J Med. 2005; 118(8): 885-889.



  • There are currently no refbacks.