Physicians often don’t feel comfortable giving steroids or other anti-inflammatories to diabetic patients due to issues with blood sugar control, concurrent renal failure or the possibility that an infection in the foot is mimicking gout. However, steroids are frequently used to treat gout in outpatient settings and it is possible to manage diabetes in this population using conventional agents without significant problems, says Dr. Dalal.
The study also reports that receiving appropriate anti-inflammatory treatment had no impact on the prescribing patterns of opioid medications.
The most common opioid analgesic at discharge was oxycodone or compound drugs that combined oxycodone with another analgesic (81%). Hydrocodone was used in 8% of patients and tramadol in 9% of visits.
Rationale
Although outside the scope of the study itself, Dr. Dalal and colleagues had some informal discussions with the director of quality improvement for their healthcare system. They came out with some insight into the emergency department physicians’ reasoning for prescribing opioids in this population.
“One of the leading reasons for opioid prescribing was that the emergency department doctors were not sure when the patient would be able to see their rheumatologist to assess improvement in the disease. That is where there may be some scope for improving quality of care in these patients,” says Dr. Dalal.
He suggests that finding a way to make sure these patients are followed up quickly in outpatient settings may help reduce opioid prescriptions in the emergency department.
When patients do return to the outpatient setting, it falls to the primary care physician or the rheumatologist to manage expectations going forward. Dr. Dalal points to a patient whose first two incidents of gout were treated in the emergency department. In both instances, he was prescribed an opioid for pain.
“Now, every time he comes to me with a gout attack, he expects to be given Vicodin, even though we have had discussions about how an opioid is not needed,” Dr. Dalal says. “I have had numerous talks with him, indicating that treatment with steroids and NSAIDs give an equal amount of analgesia. Still, he has an inherent belief that it won’t be enough and that it was the Vicodin that gave him immediate relief. It makes proper management harder.”
Takeaways
“The main takeaway for rheumatologists is to know that this is happening in emergency departments,” Dr. Dalal says. “There is a need to start managing expectations in pain management from the start.”
