Another analysis by Nora Volkow, MD, director of the National Institute on Drug Abuse, analyzed the same dataset and concluded that emergency physicians are among the top five opioid prescribers for patients ages 0–39 years.5 I have two concerns about this data. The first is that in many states it’s hard to link prescriptions to specialty type, so I’m not quite clear how they discovered that the prescribers were emergency physicians. This is compounded by the fact that many emergency department prescriptions are written by advanced practice providers and residents who may not have a specialty listed. Furthermore, in underserved and rural areas, EDs may be staffed by non–emergency physicians, and I don’t know how prescribing databases can capture this nuance. My second concern is that the aforementioned studies from the FDA and Dr. Volkow reported numbers of prescriptions but not the number of pills or morphine milligram equivalents (MMEs) prescribed. There is, of course, a big difference between writing 10–20 pills (as an emergency physician may do) versus 100–120 pills (as a primary care physician may do).
Explore This Issue
ACEP Now: Vol 34 – No 07 – July 2015This difference between emergency physician and primary care prescribing was highlighted by Michael Menchine, MD, MPH, and colleagues, who presented abstract #1 at the ACEP Research Forum October 2014.6 In their study, the researchers evaluated the medical expenditure panel study and discovered that, when comparing ED prescriptions to prescriptions given in the office setting, ED prescriptions had 17 percent lower daily MMEs and were much less likely to be the high-risk prescriptions for >100 MMEs per day (0.26 percent versus 2.62 percent). The abstract concludes, “Given the very low rate of high-dose prescribing from the ED, policy efforts to reduce risky opioid prescribing should not focus on the ED settings.”
Why Us?
So given this information, why do policy efforts focus on the ED? We’re bombarded with efforts to curb opioid prescribing from the ED. These efforts include everything from proposed laws to prescribing guidelines that have been created all around the country, including Washington State, New York City, Ohio, and, most recently affecting my practice, Massachusetts.7,8 Thus far, I haven’t seen similar efforts and accompanying publicity for prescribing from family practitioners, orthopedic surgeons, or dentists.
I think the reason for this is that policymakers are confusing causality with burden. Emergency physicians are exposed to the devastating effects of opioids on a daily basis. We take care of the patients who present with overdose. We drain the abscesses caused by injectable drugs. We identify and assist patients with substance abuse and try our best to refer them to treatment, an effort unfortunately limited by lack of adequate funding. Michael Yokell, ScB, and colleagues recently characterized opioid overdose presentations to the ED using the Nationwide Emergency Department Sample.9 In 2010, there were more than 135,000 ED visits for overdose (80,000 of which were related to prescription drugs). Including admissions, these overdoses cost the system more than $2 billion. Similarly, the Agency for Healthcare Research and Quality determined that there were more than 700,000 opioid-related hospital stays in 2012.10 I guarantee that the vast majority of these stays were not direct admissions; you and I know that they came through the ED first. However, treating the complications of opioid abuse doesn’t mean you caused them.
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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.