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Abstract
An audit at a Scottish DGH found that large numbers of Emergency Department (ED) patients were being sent home with ‘To Take Out’ (TTO) boxes of Co-Codamol (30/500 mg) – a concerning finding given rising rates of prescription opioid addiction in the UK. Informal conversations suggested that many clinicians were prescribing high-dose codeine because ‘patients expect to be given something they can’t buy over the counter’. A survey-based study was therefore designed to explore this assumption.
A short survey (figure 1) was developed to explore ED patients’ expectations of analgesia and knowledge of common painkillers. In the first stage of the study, the survey was circulated among 25 ED prescribers who were asked how they thought ‘most patients’ with mild to moderate pain would answer these questions. In the second stage, 50 ED patients with mild to moderate pain were asked to complete the survey. Prescribers’ and patients’ answers were then compared.
There was a significant difference between how prescribers thought ‘most patients’ would answer and how most patients actually answered the questions. Fewer patients expected to be sent home with painkillers than the prescribers predicted (figure 2), and patients were prepared to tolerate significantly more pain than prescribers expected (figure 3). A relatively high number of patients were aware of the addictive potential of codeine, yet some were unaware of the addictive potential of morphine, while others thought that paracetamol and ibuprofen were also addictive. Almost all patients indicated that if a painkiller could lead to addiction, they would expect their ED doctor to inform them of this risk.
These results suggest that strong painkillers are sometimes given out on the mistaken assumption that this is what patients expect. Involving patients in shared decision making about TTO analgesia may be a useful strategy to reduce ED opioid dispensing.