Morbilliform drug eruptions in palliative care are often misattributed to active drugs, leading to inappropriate "opioid allergy" labels. Generic medications contain varying inactive excipients that can trigger delayed hypersensitivity. A man in his 70s with a prior history of ibuprofen-associated angioedema and metoclopramide-associated rash developed a pruritic morbilliform eruption after switching from a Mallinckrodt hydrocodone-acetaminophen product to a Camber oxycodone-acetaminophen formulation (National Drug Code [NDC] 31722-0951-05). During a washout period, the patient successfully tolerated SpecGx-manufactured morphine (NDC 00406-5118-01) and Aurobindo potassium chloride (NDC 65862-0987-99) while the rash resolved. Comparison of NDC data identified croscarmellose sodium as the likely culprit, as it was unique to the offending formulation. Clinicians should document the NDC rather than broad drug classes when reactions occur after a generic substitution to preserve future therapeutic options and ensure continued access to essential analgesia.

Introduction Opioid prescription reduction is a high-priority quality improvement area in the emergency department (ED) with significant opportunities for harm reduction. While electronic health records (EHR) default dispense quantities have been used to help practitioners become more efficient, automated prescription quantities may influence prescribers to provide more than what they would otherwise deem necessary. We sought to evaluate the prescribing behavior of residents, advanced practice providers (APPs), and attending physicians after the removal of the default dispense quantity of the most prescribed opioid in the ED. Methods This is a single-center retrospective pre-post observational study in the ED of the four months before and the four months after removing the default dispense quantity of 20 tablets of oxycodone/acetaminophen per prescription. We compared the changes in prescribing patterns of emergency medicine (EM) attendings, EM APPs, EM residents, surgical attendings, surgical residents, and surgical APPs. Results During the study period, there were a total of 2,468 prescriptions for oxycodone/acetaminophen, resulting in 41,612 tablets prescribed. There were 1,314 prescriptions for oxycodone/acetaminophen before and 1,154 prescriptions written after the removal of the default dispense quantity. The average number of tablets per prescription was reduced from 18.16 to 15.35 after the removal of the default dispense quantity. There was no significant difference in the number of prescriptions written before and after the intervention in terms of patient age, gender, race, Emergency Severity Index (ESI) level, or department of the prescriber. An overall 15% reduction in the number of tablets of oxycodone/acetaminophen prescribed was observed. This reduction was significant among EM attendings, EM residents, EM APPs, and surgical attendings. There was no significant change among surgical residents and surgical APPs. Conclusion Removing the default dispense quantity was associated with a reduction in the amount of oxycodone/acetaminophen prescribed in most but not all categories of prescribers. While lower default quantities have reduced opioid prescription quantities, a default dispense quantity of 20 tablets may lead to overprescribing. As practice patterns and recommended guidelines change, default dispense quantities should periodically be evaluated for unintended influence on residents, APPs, and attendings' behavior.

A 27-year-old woman at 33 weeks' gestation presented with severe pain and swelling in her lower leg following a fall from a standing height at home.

An 86-year-old woman presented to the emergency department following a ground-level fall with fractures of the left posterior ribs 9-11 and right posterior ribs 5-8. She was admitted, and multimodal pain management, including acetaminophen, methocarbamol, oxycodone, and hydromorphone, was initiated. On the second day of hospitalization, she developed somnolence and confusion attributed to opioid administration. She was unable to receive a thoracic epidural due to recent clopidogrel administration, and bilateral erector spinae plane catheters were shown to be a reasonable alternative. This intervention provided effective pain relief, leading to improved mental status, pain control, and incentive spirometry.