CORRESPONDENCE
Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor should not exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial ManagerTM (http://www.editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. Financial association or other possible conflicts of interest should always be disclosed, and their presence or absence will be published with the correspondence. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters may be edited and shortened. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors.
0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians.
A Performance Improvement Prescribing Guideline Reduces Opioid Prescriptions for Emergency Department Dental Pain Patients To the Editor: I commend the efforts of Fox et al1 to examine emergency department (ED) opioid prescription guidelines for dental pain patients. To my knowledge, they are the first to publish outcome measures after institution of prescription guidelines for opioids in the ED. A few questions arise from reading this article. First, was tramadol considered an opioid for the purposes of this study?2 Second, were patients in the nonopioid group treated with alternatives such as nerve blocks, nonsteroidal anti-inflammatory drugs, etc, or expediently referred to the dentist? Third and most important, the authors’ analysis is limited to the number of prescriptions and strays from the broader objective of safe prescribing. Fewer prescriptions for fentanyl dermal patches are not necessarily safer (or better) than more prescriptions of hydrocodone/acetaminophen. Did the authors examine pre- versus postmetrics, such as type, strength, dose, and dispensation amount of opioids per prescription? Examining 367 individual prescriptions to extract this information is feasible. A broader scope of outcome measures that include the safety issues surrounding opioid prescribing would be helpful. Suzanne Doyon, MD, ACEP Maryland Poison Center University of Maryland School of Pharmacy Baltimore, MD http://dx.doi.org/10.1016/j.annemergmed.2013.09.033
Volume 63, no. 3 : March 2014
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. 1. Fox TR, Li J, Stevens S, et al. A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Ann Emerg Med. 2013;62:237-240. 2. Katz K. Tramadol is an opioid. J Med Toxicol. 2008;4:145.
In reply: In our original methods, we did not classify tramadol with other prescription opioids. In Maine, tramadol is not a scheduled drug and accounts for little abuse. (As in the rest of the nation, most prescription opioid abuse and diversion in our region arises from oxycodone and hydrocodone.) Nevertheless, we understand and appreciate your points. Tramadol has definite opioid receptor activity and, though small, also has real potential for abuse.1 Given your suggestion, we reviewed our data and provide the following analysis, updated to include tramadol prescriptions. Before the implementation of our prescription guideline, our specific tramadol prescription rate for emergency department patients discharged with painful dental conditions was 7% (35/515). After implementation, the rate was 7% (11/153; 95% confidence interval [CI] for difference in rates –4% to 6%). If we combine tramadol with the rest of the opioid prescriptions we originally counted, our overall preimplementation opioid prescription rate was 66% (339/515). After implementation, the rate was 50% (76/153). Thus, the absolute reduction in opioid prescription rates was 16% (95% CI 7% to 25%, unchanged from the original analysis). Annals of Emergency Medicine 371
Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor should not exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial ManagerTM (http://www.editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. Financial association or other possible conflicts of interest should always be disclosed, and their presence or absence will be published with the correspondence. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters may be edited and shortened. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors.
0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians.
A Performance Improvement Prescribing Guideline Reduces Opioid Prescriptions for Emergency Department Dental Pain Patients To the Editor: I commend the efforts of Fox et al1 to examine emergency department (ED) opioid prescription guidelines for dental pain patients. To my knowledge, they are the first to publish outcome measures after institution of prescription guidelines for opioids in the ED. A few questions arise from reading this article. First, was tramadol considered an opioid for the purposes of this study?2 Second, were patients in the nonopioid group treated with alternatives such as nerve blocks, nonsteroidal anti-inflammatory drugs, etc, or expediently referred to the dentist? Third and most important, the authors’ analysis is limited to the number of prescriptions and strays from the broader objective of safe prescribing. Fewer prescriptions for fentanyl dermal patches are not necessarily safer (or better) than more prescriptions of hydrocodone/acetaminophen. Did the authors examine pre- versus postmetrics, such as type, strength, dose, and dispensation amount of opioids per prescription? Examining 367 individual prescriptions to extract this information is feasible. A broader scope of outcome measures that include the safety issues surrounding opioid prescribing would be helpful. Suzanne Doyon, MD, ACEP Maryland Poison Center University of Maryland School of Pharmacy Baltimore, MD http://dx.doi.org/10.1016/j.annemergmed.2013.09.033
Volume 63, no. 3 : March 2014
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. 1. Fox TR, Li J, Stevens S, et al. A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Ann Emerg Med. 2013;62:237-240. 2. Katz K. Tramadol is an opioid. J Med Toxicol. 2008;4:145.
In reply: In our original methods, we did not classify tramadol with other prescription opioids. In Maine, tramadol is not a scheduled drug and accounts for little abuse. (As in the rest of the nation, most prescription opioid abuse and diversion in our region arises from oxycodone and hydrocodone.) Nevertheless, we understand and appreciate your points. Tramadol has definite opioid receptor activity and, though small, also has real potential for abuse.1 Given your suggestion, we reviewed our data and provide the following analysis, updated to include tramadol prescriptions. Before the implementation of our prescription guideline, our specific tramadol prescription rate for emergency department patients discharged with painful dental conditions was 7% (35/515). After implementation, the rate was 7% (11/153; 95% confidence interval [CI] for difference in rates –4% to 6%). If we combine tramadol with the rest of the opioid prescriptions we originally counted, our overall preimplementation opioid prescription rate was 66% (339/515). After implementation, the rate was 50% (76/153). Thus, the absolute reduction in opioid prescription rates was 16% (95% CI 7% to 25%, unchanged from the original analysis). Annals of Emergency Medicine 371
