As a member of the board of the Massachusetts College of Emergency Physicians, I get the opportunity to review legislation that is put forth at the state level that would affect care of patients in the ED. Our legislative consultant brings the bills, and our group decides what position to take on the proposed legislation. This season, I was taken aback by a single-line bill, introduced by a state representative, that read: “A physician practicing in an emergency room shall not be permitted to provide to a patient seeking emergency care more than 72 hours’ worth of a controlled substance as defined by this chapter.”
My first thought upon seeing the text was, I’ll just ask my physician assistant colleagues to write opioid prescriptions for me, as they would not be excluded under the law—just another reiteration that lawmakers need education about the realities of how medicine is practiced. My second thought was, How did it come to this? How did the pendulum swing so far that legislators want to severely limit how emergency physicians write prescriptions for pain medications?
“A physician practicing in an emergency room shall not be permitted to provide to a patient seeking emergency care more than 72 hours’ worth of a controlled substance as defined by this chapter.”
Shifts in Thinking on Pain Management
It didn’t used to be like this. I completed my residency in the early 2000s. During that time, physicians were accused of undertreating pain. The Joint Commission proclaimed that pain should be documented as the fifth vital sign.1 The term “oligoanalgesia” was coined and introduced into the medical literature. We were told that emergency physicians were undertreating pain in racial minorities.2 The seminal Pain and Emergency Medicine Initiative (PEMI) study by Knox Todd, MD, MPH, FACEP, and colleagues concluded that “ED pain intensity is high, analgesics are underutilized, and delays to treatment are common.”3 In summary, we were not doing a good job at keeping our patients comfortable.
So how did we get to the point, a mere decade later, where it is proposed that I would be breaking the law by writing more than 72 hours of pain medication for my patient? To discover the answer, it’s helpful to look at the role of emergency medicine in overall opioid prescribing. Surprisingly, our specialty’s contribution is not quite clear. The Food and Drug Administration (FDA) released information based on SDI’s Vector One: National (VONA) data, which is a national-level projected prescription database.4 After analyzing this data, it was determined that emergency physicians provided 4.7 percent of immediate-release opioid prescriptions (about 11 million dispensed prescriptions) in 2009. This value is far below that of family practitioners (26.7 percent) and internists (15.4 percent), and it trails both dentists (7.7 percent) and orthopedic surgeons (7.7 percent). Of note, emergency medicine didn’t even make the list for the prescribing of extended-release/long-acting opioids.