A recent press article from the Massachusetts State House News Service discussed our new governor’s plan to curb opioid overdoses.11 The paper talks about “how freely and available these opiates are” and highlights the 4,570 ED visits in 2013 for non-fatal overdose in our state. I can see how it would be easy for a policymaker to connect the two: opioid overdoses and emergency departments always go hand in hand because we are the ones who treat the overdoses and people come to us with the acute, painful conditions.
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ACEP Now: Vol 34 – No 07 – July 2015In 2010, there were more than 135,000 ED visits for overdose (80,000 of which were related to prescription drugs).
What We Can Do
To be clear, I’m not proposing that emergency providers not take any responsibility. Although less than 20 percent of opioid pain relievers used for non-medical use are prescribed, the vast majority are either given or purchased from a friend or relative.12 Some of those diverted prescriptions do come from us. Prior studies have demonstrated that inappropriate prescribing does occur in the ED.13 Also, I do not believe the concept that one pill won’t make an addict; someone has to be the first prescriber of the medication that gets a person hooked, and that can happen at the time of an acute injury when the prescription comes from the ED. We owe it to our patients to appropriately screen them prior to prescribing and counsel them on the risks and benefits of these medications that strongly mask pain but also carry the risk of devastating side effects and addiction. Although we do not often write prescriptions for long-acting/extended-release opioids, and the pill counts of our prescriptions are probably smaller than those of other specialties, we are high-frequency prescribers; lots of small prescriptions can add up to a large number of circulating opioids. Finally, by implementing and adopting guidelines, our specialty becomes a leader and a willing part of the solution, and hopefully other specialties will follow our example.
That said, as lawmakers attempt to infringe on our duty and ability to adequately treat pain when indicated, it is time for us to advocate and educate. Each of us, when dealing with our government representatives and hospital administrators, has a duty to inform that we are just a small part of the opioid puzzle. Think of it like ED crowding: for years, the ED was blamed as the reason for crowding. It took a decade of study and education to convince administrators and policymakers that the ED experiences the burden of crowding but that system issues at the hospital level are mainly to blame. The opioid problem is the same. Although EDs feel the effect of the opioid epidemic on a daily basis, we now must educate policymakers that although we bear the majority of the burden, we are but one small part of the cause.
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5 Responses to “Emergency Medicine’s Role in Prescription Opioid Abuse”
July 26, 2015
Frank Fower,MD,FACEPThe Fact is there is Narcotic Diversion from ER.
The New Laws are Intenede to Curb this Diversion.
No body will blame a provider for prescribing Narcotics for a Cancer patient or after splinting a fracture.
Every body will point @ Providers who : Refill Narcotics for Chronic pains, and prescribing Narctocis for frequent. ER. clients that only visit ER under different scenarios with bottom line :Narcotic s prescribed. And for transients who forget / lost their Narcotics,
And for ER shoppers that cross the town bypassing many Hospital s or maybe stopping by every Hospital on their path in big inner cities to visit a nice /soft prescriber.
-my thought is we will Alleviate Pain, and treat what is causing this pain, we need to Refrain from being a source to easy obtain something for pain, after 30 years of ER practice , I did not find the Disease that some providers call Pain by itself and they just prescribe Narcotics to treat it.
July 26, 2015
Derek McCalmont MDThe author might have given some consideration to the fact that not all pain medications are opiates. Another unaddressed issue is what percentage of these prescriptions are being written for chronic or recurring complaints vs. new diagnoses. What percentage are being written for medically inappropriate conditions?
When ED physicians address these questions at the same time they will be in a much better position to argue that limits on prescribing are harmful and intrusive.
July 26, 2015
Alex Genty CNPThank you for the extremely well written article above. As a NP staffing a remote/rural ER in a solo provider situation, I am familiar with the challenges of pain medication prescribing, particularly due to long waiting times to see specialists such as orthopedic surgery etc.
Oklahoma (where I work) has some draconian laws regarding NP prescribing that definitely impact quality of care for patients with acute pain, and I would like to see ACEP development an Emergency Medicine specific pain management education program that is open to NPs and PAs as well as EM physicians. Education is clearly the key in safe and competent prescribing. The move in Massachusetts is just as poorly thought out as current NP/PA prescribing laws in states such as Texas and Oklahoma.
I appreciate your thoughts and research in this area, and will use some of your resources to work to affect change, and enhance safety and quality of care in our NP staffed ER. It is my sincere hope that ACEP will open more education opportunities to NPs and PAs, because while a board certified EM physician in every ER is ideal, reality is that an EM certified nurse practitioner or PA with an EM CAQ is definitely better than a moonlighting ENT resident. The ability for NPs and PAs to access specific ACEP information and education, and perhaps become affiliated with ACEP in some way would be a huge step forward in improving quality and safety in emergency medicine practice and prescribing as well.
Thanks again,
Alex
July 27, 2015
Rob Oelhaf, MDThank you so much for this timely article. The pendulum has, indeed, swung too far in the minds of influential people on this topic. Treat acute pain with meds that work, using good judgement and appropriate, modest prescriptions while attempting to avoid the social profiling that got the oligoanalgesia ball rolling in the first place. I deeply appreciate your very sensible take on this problem and hope that this content is widely distributed.
August 9, 2015
Mark Ibsen MDThe Institute of Medicine report of 2011: Pain in America declared: the are 100 million Americans in pain. Opiophobia has replaced oligoanalgesia as the current Monday morning quarterback topic.
Unintendended consequences abound.
Addiction by other substances is not managed by ERs.
Car dealers are not expected to screen customers for speeding tendencies.
Heroin has become a massive problem because it is cheap and accessible- why?
We were blamed for under treating pain, ER overcrowding, now this: we must stand FOR patients, and give up our role as scapegoats for societies’ ills.