Pethidine prescribing in the ED… Let’s be rational!Kaye KI, Maxwell DJ, Graudins L, on behalf of the the NSW Therapeutic Assessment Group (NSW TAG)

Drug Use Evaluation (DUE) Support Group, PO Box 766 Darlinghurst NSW 2010

INTRODUCTION

15 hospitals in the TAG network are participating. DUE methodology will be used to facilitate data collection, evaluation of data against agreed standards, feedback of evaluated data and targeted intervention. Over a 12-month period, multiple DUE cycles will be implemented in each participating hospital, the first scheduled for January 2003.  A steering committee has been convened to provide advice for development of feedback reports, educational materials and mechanisms for on-going sustainability of the program.  Each hospital has nominated a project coordinator who is responsible for liaison with ED staff and hospital committees. They are also coordinating data collection and feedback programs in their hospital. NSW TAG will provide information and support to hospital coordinators to facilitate these processes.  Hospital coordinators will record the number of patients receiving pethidine in the ED (from existing Schedule 8 drug registers) and indications for that use. Stock issues from pharmacy for a range of analgesics will also be recorded. 

A feedback summary will be prepared by each hospital coordinator using a format prepared by NSW TAG. Prescribing patterns will be compared with evidence-based guidelines and areas of non-concordance highlighted. Feedback will be distributed to the ED Director, individual prescribers and the hospital Drug Committee. Targeted educational interventions will be introduced to promote rational prescribing.  

OBJECTIVE

FURTHER INFORMATION

Pain management is an ongoing area of interest for NSW TAG. In 1998 NSW TAG produced guidelines for rational use of opioids for GPs Prescribing for Pain in Migraine and Low Back Pain. These are currently being revised and updated. NSW TAG has also produced guidance documents on the use of newer analgesics in hospitals, including COX-2 inhibitors and tramadol. These documents can be downloaded from the NSW TAG web site.  Pain management in hospital emergency departments (EDs) is a topical issue. The ongoing use of pethidine in EDs is of concern. Despite its limitations (Figure 1), pethidine is still widely used in hospitals. A recent survey of 18 NSW hospitals showed that a significant proportion of pethidine prescribing occurred in Emergency Department (Table 1)

To increase awareness of the appropriate place for pethidine in pain management and to optimise pethidine prescribing by implementing a simple, ongoing DUE process in hospital EDs.

NSW TAG is an initiative of NSW clinical pharmacologists and pharmacists, funded by the NSW Health Department.For more information about the NSW TAG network, visit our web site at www.nswtag.org.au.

THE PROBLEM WITH PETHIDINE[i] Pethidine has a shorter duration of action than morphine

with no additional analgesic benefit Pethidine has just as many side-effects as morphine

(including bronchospasm and increased biliary pressure) Pethidine is metabolised to norpethidine, which has

potential toxic effects (eg convulsions), especially in patients with renal dysfunction,

Pethidine is associated with potentially serious interactions in combination with other drugs. Because of its euphoric effects:

Pethidine is the drug most commonly requested by patients seeking opioids, and

Pethidine is the drug most commonly abused by health professionals.

[i] National Health and Medical Research Council. Acute pain management: scientific evidence, Commonwealth of Australia, 1999

METHODS

Table 1 Pethidine usage TAG/TAGNet hospitals July-Sept 2001

Hospital Pethidine units issued to ED

Pethidine units issued overall

Percentage ED/total

A 950 5,813 16.3%B 0 320 0.0%C 121 2,149 5.6%D 140 445 31.5%E 3,304 8,660 38.2%F 290 2,933 10.0%G 340 2,693 12.6%H 460 3,260 14.0%I 400 2,641 15.1%J 640 2,690 24.0%K 255 2,865 8.9%L 502 4,330 11.6%M 370 1,080 34.0%N 137 2,764 5.0%O 105 1,345 7.8%P 115 905 12.7%Q 200 2,190 9.0%R 389 2,224 17.5%

Average 15.2%

This study is funded by a grant from the National Institute for Clinical Studies

www.nicsl.com.au

For further information about the Pethidine in ED Project contact the NSW Therapeutic Assessment Group

Email: nswtag@stvincents.com.au Phone: 02 8382 2852

Figure 1