Intended for healthcare professionals

CCBYNC Open access

Rapid response to:

Research

PAin SoluTions In the Emergency Setting (PASTIES)—patient controlled analgesia versus routine care in emergency department patients with non-traumatic abdominal pain: randomised trial

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3147 (Published 21 June 2015) Cite this as: BMJ 2015;350:h3147

Rapid Response:

Re: PAin SoluTions In the Emergency Setting (PASTIES)—patient controlled analgesia versus routine care in emergency department patients with non-traumatic abdominal pain: randomised trial

Letter to the Editor: PAin SoluTions In the Emergency Setting (PASTIES)—patient
controlled analgesia versus routine care in emergency department patients with non-traumatic abdominal pain: randomised trial

Xiulu Ruan, MD, Adjunct Clinical Associate Professor of Anesthesia (corresponding author)
Dept. of Anesthesiology, Louisiana State University Health Science Center
1542 Tulane Ave. New Orleans, LA 70112
Alan David Kaye, MD, Ph.D., Professor and Chairman of Anesthesia
Dept. of Anesthesiology, Louisiana State University Health Science Center
1542 Tulane Ave. New Orleans, LA 70112
Word Count Without References: 862
We read with interest the article by Smith and colleagues, “PAin SoluTions in the Emergency Setting (PASTIES)—patient controlled analgesia versus routine care in emergency
department patients with non-traumatic abdominal pain: randomised trial” published in the June, 2015 issue of British Medical Journal (1).

In order to determine whether patient controlled analgesia (PCA) is better than routine care in providing effective analgesia for patients presenting to emergency departments with moderate to severe non-traumatic abdominal pain, the authors conducted a multicenter, randomized controlled trial, which concluded that PCA provided more effective analgesia than routine care. They found a modest reduction in overall pain scores, although the PCA group used significantly more morphine. Smith and colleagues suggested, based on the finding that the PCA group were more than twice as likely to be “very” or “perfectly satisfied” with their pain management, patients may value a degree of autonomy in the ability to control their pain.

However, we wonder what the specific inclusion criteria are that were used to decide to offer patients parenteral morphine for pain relief in addition to patients’ subjective pain ratings. How did the authors know they had excluded potential drug seekers? The exclusion criteria included those with opioid addiction. How was this information obtained from patients or verified from other treatment database, or from point of care urine testing? It is well-established that point of care urine immune assays are notoriously inaccurate, e.g. flawed with both false positive and false negative results (2). It has been shown that emergency department (ED) triage medication lists are inaccurately obtained by patient recall when compared to medications detected in urine using mass spectrometry analysis (3).

The USA is considered to be the center of prescription drug abuse (4). Given that drug abuse is a worldwide phenomenon, Giraudon and colleagues have decided to investigate whether the trend of increasing prescription opioid misuse and abuse seen in the USA is developing in the UK.
To compare trends in deaths associated with prescription opioid drugs, mortality data were obtained online for England, Wales, and Scotland from the Office for National Statistics and the National Records of Scotland and for the USA from The National Vital Statistics System (NVSS). Although the number of deaths related to drug poisoning reviewed from England and Wales is not as high as the USA, the overall trends are remarkably similar (4).

In the US, patients who present to the ED to obtain medications for nontherapeutic reasons are estimated to be as high as 20% of all ED patients (5). Throughout the US, there has been a significant increase in opioid prescribing in the ED (6). Mazer-Amirshahi and colleagues reported that between 2001 and 2010, the greatest relative increases were noted in the ED utilization of hydromorphone, measured at a growth of 668.2%. The most notable relative increase in hydromorphone prescribing was related to chest pain, which increased 798.2% during this same time period(6). Poon and colleagues concluded that ED physicians were caught in the middle between timely pain control and patient satisfaction ratings, which contributed significantly to the increase in opioid prescribing from EDs during the last decade (7).

A marked rise in accident and emergency (A&E) attendances in the UK in recent years
has been accompanied by sharp increases in short-stay admissions and associated costs (8). Inappropriate attendances may account for up to 40% of presentations at A&E (8). Reducing inappropriate attendance has long been recognized as an important area for intervention by policymakers (9). Harris et al. investigated the relationship between access to primary care physician and avoidable ED visits, which found avoidable emergency department attendance appeared to be mostly driven by underlying deprivation rather than by the degree of access to primary care (10) Notably, there were 222,957 emergency department attendances during 2007–2009. Of these attendances, 173,980 could be attributed as potentially avoidable. In the 2007–2008 dataset, 68,409 of the 94,739 emergency department attendances (72.2%) were repeated visits by the same individuals. The figure for 2008–2009 was not statistically different (71.2%). The majority of these visits were carried out by individuals visiting the emergency department twice or three times in the year (66.5% in 2007–2008 and 65.3% in 2008–2009) (10).

Lastly, we wonder, after receiving the IV morphine PCA protocol for abdominal pain, regardless of etiology, what will follow as a future discharge pain regimen. Will the patient be discharged home with a tapering oral opioid or be placed on a non-opioid analgesic? Will opioid withdrawal be of any concern? In essence, although the study demonstrates a satisfactory analgesia rate in the ED with IV PCA morphine, there are many unanswered questions related to the source of pain, role of substance abuse in the ED population, and post ED visit issues related to additional potential opioid prescribing, whether appropriate or not. We believe if a patient presents to the ED with a clear cut acute pain etiology, such as fracture, trauma, burn, etc., then an IV morphine PCA protocol recommended by Smith et al. may be a reasonable approach; however, treating all patients who come in with a complaint of “moderate to severe abdominal pain”, may not be a strategic approach for the reasons described in this letter to the editor.

References:

1. Smith JE, Rockett M, Creanor S, Squire R, Hayward C, Ewings P, et al. PAin SoluTions In the Emergency Setting (PASTIES)—patient controlled analgesia versus routine care in emergency department patients with non-traumatic abdominal pain: randomised trial. 2015.
2. Passik S, Heit, H., Rzetelny, A., Pesce, A., Mikel, C., & Kirsh, K. Trends in drug and illicit use from urine drug testing from addiction treatment clients. Proceedings of the International Conference on Opioids Boston, MA. 2013.
3. Kreshak AA, Wardi G, Tomaszewski CA. The Accuracy of Emergency Department Medication History as Determined by Mass Spectrometry Analysis of Urine: A Pilot Study. The Journal of emergency medicine. 2015;48(3):382-6.
4. Giraudon I, Lowitz K, Dargan PI, Wood DM, Dart RC. Prescription opioid abuse in the UK. British journal of clinical pharmacology. 2013;76(5):823-4.
5. Grover CA, Garmel GM. How do emergency physicians interpret prescription narcotic history when assessing patients presenting to the emergency department with pain? The Permanente Journal. 2012;16(4):32.
6. Mazer‐Amirshahi M, Mullins PM, Rasooly I, den Anker J, Pines JM. Rising opioid prescribing in adult US emergency department visits: 2001–2010. Academic Emergency Medicine. 2014;21(3):236-43.
7. Poon SJ, Greenwood-Ericksen MB. The opioid prescription epidemic and the role of emergency medicine. Annals of emergency medicine. 2014;5(64):490-5.
8. Ismail SA, Gibbons DC, Gnani S. Reducing inappropriate accident and emergency department attendances. British Journal of General Practice. 2013;63(617):e813-e20.
9. Roland M, Abel G. Reducing emergency admissions: are we on the right track? BMJ. 2012;345.
10. Harris MJ, Patel B, Bowen S. Primary care access and its relationship with emergency department utilisation: an observational, cross-sectional, ecological study. British Journal of General Practice. 2011;61(593):e787-e93.

Competing interests: No competing interests

04 July 2015
Xiulu Ruan
Adjunct Clinical Associate Professor, Dept. of Anesthesiology
Alan D. Kaye, MD, PhD, Professor and Chairman, Dept. of Anesthesiology, LSU HSC
LSU HSC
1542 Tulane Ave. New Orleans, LA 70112, USA