When a patient comes into the emergency department at Roosevelt Hospital in New York City complaining of pain, director Gabriel Wilson, MD, has a mystery to solve. A commonplace, everyday mystery, but an important one nonetheless: Is this patient's pain legitimate, or is he angling for a prescription for opioid pain medication to feed a habit or sell to someone else?
Last October, the Centers for Disease Control and Prevention reported that the number of ED visits involving the nonmedical use of narcotic pain medications more than doubled in the United States between 2004 and 2008.
“Every day, in every ED, there are people coming in and trying to get opioids for non-legitimate reasons,” said Dr. Wilson, also an assistant clinical professor of medicine at the Columbia University College of Physicians & Surgeons. “The problem is that there are lots of people also in legitimate pain, and you don't want to withhold pain medications from people who really require them. It's always a challenge differentiating people who really need them and those who don't.”
In a recent article in the Journal of the American Medical Association, experts from the National Institute on Drug Abuse and the Center for Substance Abuse Solutions at the University of Pennsylvania suggest that all physicians, including emergency physicians, should adopt best practices put forward by the American Academy of Pain Medicine to keep opioid prescriptions out of the hands of drug-seekers while still effectively treating legitimate pain. (JAMA 2011;305:1346.) It's a four-step plan:
* Standardized screening procedures and special provisions for managing pain in those most at risk for abuse and dependence, including adolescents and young adults, those with a current or previous substance use disorder (including nicotine and alcohol), and individuals with a family history of substance use disorders.
* Guidelines for when and how long to prescribe opioid medications for pain control after exploring other options, such as nonopioid analgesics and nonpharmacological methods.
* Indications for when short- or long-acting opioids should be prescribed.
* Reasonable limits on the number of pills or amount of liquid prescribed, so that the prescribed amounts match the number of treatment days required.
Like pilots preparing for takeoff, doctors need a checklist of exactly what to do and when to do it when prescribing opioid medications so obvious steps aren't neglected, said Nora Volkow, MD, the director of the National Institute on Drug Abuse and a co-author of the article. In a fast-paced setting like the emergency department, she recommends a simple tool such as the NIDA Quick Screen (http://ww1.drugabuse.gov/nmassist). (See table.)
“These things appear to be obvious, but aren't always necessarily so,” said Dr. Volkow. “In many instances, physicians who are prescribing an opioid don't even ask the patient if he has a history of drug addiction. I've seen it happen where a patient who is in recovery from a opioid addiction gets in an accident, is taken to the ED, and is given opioid medications without anyone asking about his prior history.”
The indications for prescribing opioids vs. nonopioid medications — and for how long — may not be as clear-cut as one might think, even in the ED. “If someone has an acute fracture and is in very severe pain, it's pretty straightforward that you need an opioid analgesic,” Dr. Volkow said. “But in other cases, it may be less obvious. It shouldn't be automatic to think of an opioid analgesic as your only option, but that appears to be what has happened based on changes in prescription practices in the past 10 years for opioids vs. non-steroidal anti-inflammatory drugs.”
The length of the prescription is another significant issue. In most cases, she said, even pain that is initially intense needs an opioid for only a few days. “How many pills should you actually be prescribing to that patient?” Dr. Volkow asked. “There are data to suggest that these prescriptions are given for longer. It's sometimes claimed that it's so the patient doesn't have to have the inconvenience of coming back to the emergency department or going to his primary care physician. But the greater the exposure to these drugs, the greater the risk of addiction.”
In the emergency department, physicians should be prescribing only short courses of opioid analgesics — less than 30 days' worth, said A. Thomas McClellan, PhD, the former deputy director of the Office of National Drug Control Policy who now directs the Penn Center for Substance Abuse Solutions at the University of Pennsylvania. “First, because you want to be sure that the patient gets linked to the primary care or specialty care person who will handle his pain management, and second, to prevent misuse or diversion,” he said.
“Long-acting opiates and long-term prescriptions, that's not something we should be doing in the ED,” said Jason Hoppe, DO, an assistant professor of emergency medicine at the University of Colorado in Denver. “But it's still happening. People will err on the side of giving patients the benefit of the doubt, refilling long-standing prescriptions and providing longer prescriptions.”
Drs. Hoppe and Wilson added that prescription drug monitoring programs are another key tool for emergency physicians to control the use and misuse of opioids. At least 34 states currently have working monitoring systems that have the capacity to receive and distribute controlled substance prescription information to authorized users like emergency physicians.
“You can't run every patient through a [monitoring program] if you're thinking of giving them an opioid; that would slow the ED down and might not be appropriate for every patient,” Dr. Hoppe said. “We still don't entirely know how to interpret the results or exactly what a high-risk profile looks like, but I think it has a lot of potential.”
Dr. Wilson added that the New York State Department of Health, for instance, now sends out notifications if patients have received multiple narcotic or sedative prescriptions from different doctors,” he said. “This is legitimate information we can put in the medical record: Patient X got 300 opioid sedative tablets from three different doctors in three weeks. That's objective data that suggest the likelihood of drug-seeking.”
The JAMA article is a good first step in addressing the problem of overprescription of opioids, Dr. Hoppe said. “It's a tough situation in the ED. On the one hand, we've been accused of undertreating pain; on the other, we're one of the main sources for abuse prescriptions that flow into the community. There was a huge push toward proper pain management, which is important, but I think the data on increased rates of abuse, overdoses, and admissions to drug treatment programs tell us that the pendulum swung too far in one direction.”