Iroquois Healthcare Association (IHA) Opioid Alternative Project. Clinician Training Materials

Transcription

1 Iroquois Healthcare Association (IHA) Opioid Alternative Project Clinician Training Materials

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3 Introduction IHA Opioid Alternative Project Clinician Toolkit Course Overview Thank you for participating in the Iroquois Healthcare Association (IHA) Opioid Alternative Project. The IHA Opioid Alternative Project Clinician Toolkit provides information and resources to assist in the education of clinicians, in the following areas: The opioid crisis Use of alternatives to opioids (ALTOs), procedures and pain pathways IHA treatment guidelines Harm reduction strategies Treatment of addicted patients and referrals IHA Opioid Alternative Project Training Curriculum The IHA Opioid Alternative Project clinician training curriculum has two main components: training sessions and podcast links. CLINICIAN ALTO TRAINING SESSIONS The IHA Opioid Alternative Project clinican training is presented in multiple sessions, either by PowerPoint presentation by your organization s identified trainer or recorded webinars. PODCAST LINKS The IHA Opioid Alternative Project training kit offers a variety of podcasts from Emergency Medical Minute, a Colorado-based non-profit, that can be accessed at the convenience of the clinician. For additional opioid-related podcasts, visit Emergency Medical Minute. IHA Opioid AlternativeProject Clinician Toolkit 1

4 Multi-Media Podcast Series INTRODUCTION Thank you for joining us for the IHA Opioid Alternative Project. The following podcasts go through a history of our nation s opioid epidemic, then focus on three major topics of the Colorado Chapter of the American College of Emergency Physicians (CO-ACEP) 2017 Opioid Prescribing & Treatment Guidelines. Part III Alternative to Opioids from Emergency Medical Minute in Podcasts discusses the use of alternatives to opioids (ALTOs) in the emergency department, a focus of both Colorado ALTO Project and IHA Opiod Alternative Project. These podcasts will help you begin to understand the why and how of the ALTO Projects. Listen to PART I: Medicine s Greatest Folly from Emergency Medical Minute in Podcasts. Dr. Don Stader describes how opioids became medicine s drug of choice for pain, documenting the dubious science andmarket forces that helped create the opioid epidemic ?mt=2&i= Listen to PART II: Limiting Opioids in the Emergency Department from Emergency Medical Minute in Podcasts. Dr. Don Stader and Dr. Erik Verzemniks discuss COACEP 2017 Opioid Prescribing & Treatment Guidelines recommendations to limiting opioids in the ED, including in-depth discussion of keys to limiting opioids and speaking with patients about opioids ?mt=2&i= Listen to PART III: Alternative to Opioids from Emergency Medical Minute in Podcasts. Pharmacist Rachael Duncan reviews ALTO medications, how they are used and tips to using ALTOs safely and effectively ?mt=2&i= Listen to Part IV: Harm Reduction from Emergency Medical Minute in Podcasts. Dr. Don Stader and Harm Reduction Action Center Executive Director Lisa Raville discuss harm reduction and keys to speaking with patients with opioid use disorder and IV drug use emphasizing points on how to keep these patients safe ?mt=2&i= IHA Opioid AlternativeProject Clinician Toolkit

5 Multi-Media Videos INTRODUCTION The following YouTube videos provide an overview on trigger point injections and occipital nerve blocks, two important procedures used by emergency department clinicians in the alternative treatments. I. Trigger Point Injections A YouTube video on performing trigger point injections, done by Dr. Mellick, who championed trigger points in the ED. id epidemic. HOW TO DO THEM Trigger point injections are a highly effective, easy-toperform procedure that are extremely effective for headache, low back pain, torticollis and trapezius pain. There are multiple studies about their efficacy when performed in the ED. Learning to do trigger point injections and becoming facile in their usage is a key ALTO technique. 2. Occipital Nerve Blocks An informational YouTube video on performing occipital nerve blocks followed by how to do an occipital nerve block. IHA Opioid AlternativeProject Clinician Toolkit 3

6 Selected References Opioid overview 1. Cantrill, et al. ACEP Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department. Ann Emerg Med. 2012; 60: Barnett ML, Olenski AR, Jena AB. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. N Engl J Med Feb 16;376(7): Fallon E, Fung S, Rubal-Peace G, Patanwala AE. Predictors of patient satisfaction with pain management in the emergency department. Adv Emerg Nurs J ;38(2): Headache treatment 4. Voight CL, Murphy MO. Occipital nerve blocks in the treatment of headaches: safety and efficacy. Journal of Emergency Medicine. 48(1) , Tang Y, Kang J, Zhang Y, Zhang X. Influence of greater occipital nerve block on pain severity in migraine patients: A systematic review and meta-analysis. American Journal of Emergency Medicine. 35(911) , Nov Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006;46(9): Mellick LB, Mellick GA. Treatment of acute orofacial pain with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 114 patients. J Orofac Pain. 2008;22(1): Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache Jan;55(1):3-20. Low back pain treatment 9. Roelofs PDDM, Deyo RA, Koes BW, et al. Non-steroidal anti inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2008;(1):CD Trigger point injection 10. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002;65(4): Renal colic treatment 11. Soleimanpour H, Hassanzadeh K, Vaezi H, et al. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol. 2012;12(13):1-5. Soft tissue injury treatment 12. Jones P, Dalziel SR, Lamdin R, et al. Oral non-steroidal antiinflammatory drugs versus other oral analgesic agents for acute soft tissue injury. Cochrane Database Syst Rev Jul 1. Dental pain treatment 13. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after thirdmolar extractions. JADA. 2013; Ketamine: 14. Ahern TL, Herring AA, Miller S, Frazee BW. Low-dose ketamine infusion for emergency department patients with severe pain. Pain Medicine. 2015;16: Sin B, Ternas T, Motov SM. The use of subdissociative ketamine for acute pain in the emergency department. Acad Emerg Med. 2015;22: Ketorolac 16. Pizzo PA, Clark NM. Alleviating suffering 101 pain relief in the United States. N Engl J Med. 2012;366: IHA Opioid AlternativeProject Clinician Toolkit

7 IHA Opioid Alternative Project Treatment Guidelines Musculoskeletal Pain FIRST APPROACH: Ibuprofen PO 600 mg OR Ketorolac 15 mg IV / 30mg IM Lidoderm Patch (if appropriate) Cyclobenzaprine 5 mg PO OR Diazepam 5 mg PO (if muscle spasm component) SECOND APPROACH: Ketamine Gabapentin Trigger Point Injections Ketorolac (If not previously given) Dexamethasone ADDITIONAL OPTIONS AT PROVIDER DISCRETION Additional IV therapy as needed Diazepam/Other Benzodiazepine Repeat and/or use additional first approach treatment Abdominal Pain/Gastroparesis FIRST APPROACH: Haloperidol 5mg IV Acetaminophen 1000mg PO OR Ketorolac 15 mg IV or 30mg IM Capsaicin Cream (for Cannabinoid Hyperemesis) Metoclopramide 10 mg IV Prochlorperazine 10 mg IV Diphenhydramine 25 mg IV Dicyclomine 20 mg PO/IM SECOND APPROACH: Haloperidol Ketamine Lidocaine ADDITIONAL OPTIONS AT PROVIDER DISCRETION Repeat First Approach drugs Diphenhydramine as secondary medication with any other primary drug treatment Renal Colic FIRST APPROACH: APAP 1000 mg PO or IV Ketorolac 15 mg IV or 30 mg IM SECOND APPROACH: Lidocaine IV AND/OR Ketamine ADDITIONAL OPTIONS AT PROVIDER DISCRETION 1 L NS Bolus Antiemetic as needed Headache FIRST APPROACH: Prochlorperazine 10 mg PO / IV OR Metoclopramide 10 mg IV Ketorolac 15 mg IV OR 30 mg IM Sphenopalatine block, occipital block, or Trigger Point Injection Acetaminophen 1000 mg PO + Ibuprofen 600 mg PO 1 L 0.9% NS + high-flow oxygen Sumatriptan 6 mg SC SECOND APPROACH: Lidocaine IV Caffeine Ketamine Promethazine Dexamethasone Haloperidol Magnesium Valproic acid Propofol ADDITIONAL OPTIONS AT PROVIDER DISCRETION May give 2nd dose of Reglan before Second Approach treatments Diphenhydramine Dental Pain Acetaminophen 1000 mg PO Ketorolac 30 mg IM Dental Block IHA Opioid AlternativeProject Clinician Toolkit 5

8 Ibuprofen PO 600 mg OR Ketorolac 15 mg IV/30 mg IM Lidoderm Patch Spasm Cyclobenzaprine 5 mg PO OR Diazepam 5 mg PO Musculoskeletal Ketamine Gabapentin Trigger Point Injections Ketorolac Dexamethasone Prochlorperazine 10 mg PO / IV OR Metoclopramide 10 mg IV Ketorolac 15 mg IV OR 30 mg IM Sphenopalatine block, occipital block, or Trigger Point Injection Acetaminophen 1000 mg PO + Ibuprofen 600 mg PO 1 L 0.9% NS + high-flow oxygen Sumatriptan 6 mg SC Headache Lidocaine IV Caffeine Ketamine Promethazine Dexamethasone Haloperidol Magnesium Valproic acid Propofol Diphenhydramine and 2nd dose of Metoclopramide at provider s discretion 6 IHA Opioid AlternativeProject Clinician Toolkit

9 Abdominal Pain Haloperidol 5mg IV Acetaminophen 1000mg PO OR Ketorolac 15 mg IV OR 30mg IM Metoclopramide 10 mg IV Prochlorperazine 10 mg IV Diphenhydramine 25 mg IV Dicyclomine 20 mg PO/IM (Cannabinoid Hyperemesis) Capsaicin Cream Haloperidol Ketamine Lidocaine Repeat First Approach drugs and diphenhydramine as secondary medication at provider s discretion Acetaminophen 1000 mg PO or IV Ketorolac 15 mg IV OR 30 mg IM 1 L NS Bolus and Antiemetic as needed Renal Colic Lidocaine IV AND/OR Ketamine Acetaminophen 1000 mg PO Ketorolac 30 mg IM Dental Block Dental Pain IHA Opioid AlternativeProject Clinician Toolkit 7

10 Drug Dosage Reference Table GENERIC TRADE NAME USUAL DOSES AVAILABLE ROUTES ACETAMINOPHEN Tylenol 1,000 mg PO, IV CAFFEINE caffeine 500 mg IV CAPSAICIN CREAM Capsaicin Cream cream, patch trans dermal CYCLOBENZAPRINE Flexeril 5-10 mg PO DEXAMETHASONE Decadron 8 mg IV DICYCLOMINE Bentyl 20 mg PO, IM DIAZEPAM Valium 5 mg PO, IV DIPHENHYDRAMINE Benadryl 25 mg PO, IV PROPOFOL* Diprivan MG IV GABAPENTIN Neurontin mg PO HALOPERIDOL Haldol mg IV IBUPROFEN Motrin mg PO, IV KETAMINE** Ketamine 0.5 mg/kg IN KETOROLAC Toradol mg IV, IM LIDOCAINE# Lidocaine 1.5 mg/kg IV LIDODERM PATCH Lidocaine 5% patch trans dermal MAGNESIUM^ Magnesium 1 gm IV METOCLOPRAMIDE Reglan 10 mg IV PROCHLORPERAZINE Compazine 10 mg PO, IV PROMETHAZINE Phenergan mg PO, IV SUMATRIPTAN Imitrex 6 mg SQ VALPROIC ACIDŦ Depakote 500 mg IV Doses and routes of administration are common suggestions. Actual drug choice, dose, and route of administration remain the responsibility of the individual provider. * Can repeat q10 minutes ** Maximum dose of 50 mg # Place in 100 ml NS and given over 10 min with a max dose of 200 mg ^ Administer over 60 min ŧ Place in 50 ml NS and administer over 30 min 8 IHA Opioid AlternativeProject Clinician Toolkit

11 Opioid Free Pain Options by Indication at Discharge Headache ACUTE ATTACKS: Sumatriptan 100 mg Acetaminophen/Aspirin/Caffeine DHE 2 mg nasal spray Naproxen mg twice daily Metoclopramide 10 mg every 6 hours Ibuprofen 600 mg PO every 6 hours PREVENTION: Propranolol 40 mg twice daily Divalproex DR 250 mg twice daily OR ER 500 mg daily Topiramate 25 mg at bedtime Magnesium supplementation 600 mg daily Sore Throat Ibuprofen 600 mg every 6 hours Dexamethasone 10 mg once Viscous Lidocaine Fibromyalgia Cardiovascular Exercise Strength Training Massage Therapy Amitriptyline 10 mg at Bedtime Cyclobenzaprine 10 mg every 8 hours Pregabalin 75 mg twice daily Simple Sprains Immobilization Ice Ibuprofen 600 mg every 6 hours Diclofenac 1.3% patch TD twice daily Diclofenac 1% gel 4 g four times daily PRN Uncomplicated Neck Pain Ibuprofen 600 mg every 6 hours Cyclobenzaprine 5 mg every 8 hours Physical therapy Lidocaine 5% patch Q12 hours Uncomplicated Back Pain Ibuprofen 600 mg every 6 hours Lidocaine 5% patch Q12 hours Diclofenac 1.3% patch TD twice daily Diclofenac 1% gel 4 g four times daily PRN Cyclobenzaprine 5 mg PO three times daily Heat Physical therapy Exercise program Contusions Compression Ice Ibuprofen 600 mg every 6 hours Lidoderm 5% patch Non-Traumatic Tooth Pain Ibuprofen 600 mg every 6 hours AND (clove oil, other topical anesthetics) Viscous Lidocaine topically Osteoarthritis Diclofenac 50 mg every 8 hours Naproxen 500 mg twice daily Celecoxib 200 mg daily Diclofenac 1.3% patch TD twice daily Diclofenac 1% gel 4 g four times daily PRN (topical NSAIDs, capsaicin) Undifferentiated Abdominal Pain Dicyclomine 20 mg every 6 hours Metoclopramide 10 mg every 6 hours Prochlorperazine 10 mg every 6 hours Neuropathic Pain Gabapentin 300mg every 8 hours Amitriptyline 25 mg at bedtime Pregabalin 75 mg twice daily IHA Opioid AlternativeProject Clinician Toolkit 9

12 15 Executive Park Drive, Clifton Park, NY (518) Copyright 2018 Colorado Hospital Association. Adapted with permission.