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ACEP Now: Vol 34 – No 07 – July 2015

Image Credit: © SHUTTERSTOCK.COM

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.

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).

This 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.

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.

In 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.

Dr. Weiner is in the division of health policy translation in the department of emergency medicine at Brigham and Women’s Hospital in Boston.

References

1. Phillips DM. JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. JAMA. 2000;284:428-429.
2. Tamayo-Sarver JH, Hinze SW, Cydulka RK, et al. Racial and ethnic disparities in emergency department analgesic prescription. Am J Public Health. 2003;93:2067-2073.
3. Todd KH, Ducharme J, Choiniere M, et al. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain. 2007;8:460-466.
4. Governale L. Outpatient prescription opioid utilization in the U.S., years 2000–2009. US Food and Drug Administration Web site. Accessed March 25, 2015.
5. Volkow ND, McLellan TA, Cotto JH, et al. Characteristics of opioid prescriptions in 2009. JAMA. 2011;305:1299-1301.
6. Menchine MD, Axeen S, Plantmason L, et al. Strength and dose of opioids prescribed from US emergency departments compared to office practices: implications for emergency department safe-prescribing guidelines. Ann Emerg Med. 2014;64:S1.
7. Weiner SG, Perrone J, Nelson LS. Centering the pendulum: the evolution of emergency medicine opioid prescribing guidelines. Ann Emerg Med. 2013;62:241-243.
8. MHA guidelines for emergency department opioid management. Massachusetts Hospital Association Web site. Accessed March 25, 2015.
9. Yokell MA, Delgado MK, Zaller ND, et al. Presentation of prescription and nonprescription opioid overdoses to US emergency departments. JAMA Intern Med. 2014;174:2034-2037.
10. Owens PL, Barrett ML, Weiss JA, et al. Hospital inpatient utilization related to opioid overuse among adults, 1993–2012. Agency for Healthcare Research and Quality Web site. Accessed March 25, 2015.
11. Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use United States, 2008–2011. JAMA Intern Med. 2014;174:802-803.
12. Murphy M. With data, Baker launches group to tackle opioid addiction. State House News Service. Accessed March 25, 2015.
13. Logan J, Liu Y, Paulozzi L, et al. Opioid prescribing in emergency departments: the prevalence of potentially inappropriate prescribing and misuse. Med Care. 2013;51:646-653.