There was a bit of hue and cry earlier regarding Mayor Bloomberg’s report on the matter of prescription drug abuse and restrictions on new prescriptions for painkillers through the emergency department.

Initially, I was concerned. I completely agree with this comment: “Here is my problem with legislative medicine,” said Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians. … “It prevents me from being a professional and using my judgment.”

The verbiage used regarding the new rules was worrisome: restricted sharply … city policy … will not be dispensed … regulatory authority to impose, and the like.

I’m like most doctors in that even when I agree with the purpose of proposed rules, I quite object to interference in how I practice, to “the government coming between you and your doctor.” as it was so memorably put in the past.

And given that Bloomberg is getting something of a reputation for being a little dictator I was all ready to get my pitchfork and torches and head down to join the mob.

While I was getting my outrage machine up to operating temperature, I took a moment to read the official press release and the actual source document (PDF), though, and one word in the very first paragraph, notably absent from the press coverage of the proposal, jumped out at me:

Voluntary: Well, that’s a horse of a different color, isn’t it? Doctors and hospitals are encouraged but not obligated to follow the new guidelines. I’m good with that. So what about the meat of the policy?

Key points jumped out at me:

• A new/improved database for tracking narcotic prescriptions and making it available to prescribing doctors.
• Not prescribing more than a 3-day supply of most narcotics, and not at all prescribing oxycontin, fentanyl, or methadone through the ER, and not refilling these meds.
• All narcotics to be electronically prescribed (to limit forged prescriptions).
• Changing the defaults on EMRs to have lower amounts of tablets dispensed.

Frankly, these all seem reasonable, as long as physician discretion is preserved. If someone has a long-bone fracture and won’t be into see ortho for a week, well then a week’s worth of pain meds is reasonable, for example.

In our state, we put forth some very similar guidelines in our “Seven best Practices” for reducing ER overuse and abuse.

The “guidelines” are particularly useful for a practicing doc in that it gives you permission to say “no.” Currently, if I see a patient I suspect is “working me” for narcotics, but don’t have clear evidence to support that suspicion, I am in a bind.