When a patient comes into the emergency department at Stanford Hospital complaining of severe pain and seeking medication, second-year emergency medicine resident Casey Grover, MD, takes note of several factors. Does the patient ask for a medication by name? Has he been to the ED at least three times within the past week? And most telling of all, is he complaining that his pain is something like 20 on a scale of 1 to 10, and asking for medication parenterally?
Just one of those factors is enough to spur Dr. Grover to take an extra few minutes to search California's Controlled Substance Utilization Review and Evaluation System (CURES), the state's online prescription drug monitoring program. CURES is one of about 40 state-based prescription drug monitoring programs that make their data available online to doctors like Dr. Grover who are struggling to differentiate patients with legitimate pain from those seeking prescription drugs to feed an addiction or for drug diversion.
The prescription drug abuse epidemic is one of the chief challenges facing emergency departments today. A new report from Trust for America's Health and the Robert Wood Johnson Foundation in May found that poisoning, primarily by prescribed opioid pain medications, now causes more deaths in the United States than car crashes.
And a study first published online by the Journal of the American Medical Association found that prescription opioid addiction is skyrocketing in a particularly troubling group — pregnant women. The study estimated that the number of pregnant mothers using opioid drugs jumped fivefold, and the number of infants born with neonatal abstinence syndrome nearly tripled between 2000 and 2009.
“When you have so many people coming in complaining of vague, ill-defined pain syndromes, it's hard as an ER physician to treat patients compassionately,” admitted Hallam Gugelmann, MD, a third-year emergency medicine resident at the University of Pennsylvania. “Pain is a horrible thing to face, and we need to be able to still treat patients for pain, but the fact is that we are actively creating addicts and even killing people by giving too much of this medication.”
Emergency physicians must also be wary of patients who are diverting their medications for street sale. The website StreetRx.com takes direct reports from street buyers on how much they paid for a diverted prescription medication, and with the exception of the ADHD medication Adderall, virtually all of its reports are on opioids. The site recently published reports of single oxycodone pills selling for between $5 and $10.
Dr. Grover and several colleagues published a case-control study in January that quantified several predictive factors that helped them examine the relative frequency of specific behaviors among drug-seeking patients visiting the ED as compared with ED patients overall. (J Emerg Med 2012;42:15.) The strongest predictors of drug-seeking behavior were:
* Requests for parenteral medication and personal assessment of their pain as higher than 10 on a 1-to-10 scale. (None of the patients in the control group demonstrated either of these behaviors, resulting in a calculated odds ratio of infinity.)
* Three or more visits in seven days (OR 30.8).
* Asking for medication by name (OR 26.3).
* Asking for medication refill (OR 19.2.)
On the other hand, describing an allergy to a nonnarcotic medication like Tylenol was only slightly more prevalent (3.2) among drug-seekers than the general ED population. The study has its limitations, Dr. Grover said. “There's unfortunately no gold standard for the diagnosis of drug-seeking, so we did the best we could to identify our 152 cases. The hospital has a case management program for people with problematic ED use, and we took all the patients in that program that had been identified as having problems with prescription medications, as well as those who had been referred for chemical dependency and people who had known substance problems as identified by CURES/PDMP.”
The confidence intervals were also very wide, and the patients were only matched for age, gender, and the general time period of their visit to the ED. They were not matched by complaint so the control patients included all comers to the ED, such as those with shortness of breath or suspected miscarriage.
“Still, I use these factors to help hone my suspicions or better characterize the person's risk of having a problem with prescription medications,” Dr. Grover said. “If someone tells me they have an isolated allergy to Motrin and they need something different, I might not check PDMP/CURES, but if they demonstrate some of the higher-risk behaviors, I will go look it up.”
Most emergency physicians agree that statewide prescription drug monitoring programs are an essential tool to help quell prescription drug abuse and drug-seeking behavior in the EDs while still treating legitimate pain.
Insufficient Pain Management
Emergency physicians at the University of Toledo changed their planned clinical management of pain patients in 41 percent of cases after accessing the Ohio Automated Rx Reporting System (OARRS), according to a study published online in the Annals of Emergency Medicine. (2012;56:19.) Although in the majority of these cases (61%), the doctors ended up prescribing less medication than originally planned, or none, in the other 39 percent the physician actually decided to prescribe more medication.
The doctors ended up prescribing no or less medication than originally planned in the majority of these cases (61%), but actually decided to prescribe more medication in the other 39 percent.
“The more you work in the ER, the more likely you are to get jaded and think someone is just seeking medication, when in fact this study shows that you may find with a prescription drug monitoring program that there are people who aren't having their pain treated sufficiently,” said Dr. Gugelmann. “A [monitoring program] can not only help you tailor your prescribing, it can help you avoid perpetuating the epidemic of misuse while identifying those in need of addiction treatment referrals.”
Such programs are in place or in the works in most states, and Dr. -Gugelmann noted that administrative factors hamper physicians from using them in some places. He had access to North Carolina's prescription drug monitoring program as a medical student, and said it was a great model for helping EPs identify the medications -patients were already taking and for -determining whether giving them more would contribute to a problem, he said.
Now an emergency medicine resident in Pennsylvania, he said he felt hamstrung by that state's policies. “Here, the drug monitoring program is only accessible to law enforcement,” Dr. Gugelmann said, “so there's no way for me to identify what drugs people are already on without a lot of work that you can't do at 3 a.m.”
Limiting monitoring program information in that way “makes it completely ineffective for public health purposes,” said Richard Denisco, MD, MPH, a program official with the National Institute on Drug Abuse's (NIDA) Services Research Branch. “It turns the drug -addiction problem into a legal problem, and we know that that's not -effective.”
NIDA recently funded a study to assess the effectiveness of prescription drug monitoring programs, Dr. DeNisco said. “The trick is to stop giving this medication to the people who don't need it while still providing it to the ones who do, and there's no doubt that monitoring plans could play a great role in improving the situation.”
Florida has one of the nation's worst prescription drug abuse problems – 16.5 drug overdose deaths per 100,000 people, according to the Centers for Disease Control and Prevention. (See FastLinks.) It's estimated that seven people die in the state every day from prescription drug overdoses, and the state finally enacted its own prescription drug monitoring program, accessible to physicians, last year.
Two major hospitals in the Orlando area — Florida Hospital and Orlando Health — have used that program's launch as the impetus for developing a coordinated chronic pain management plan. “Independently, physicians from the two hospital systems have been noticing a trend over the last several years in the use of emergency departments for treating chronic, nonmalignant pain,” said Josef Thundiyil, MD, MPH, the associate program director of the emergency medicine residency at Orlando Health and an assistant professor of emergency medicine at the University of Florida College of Medicine. “It became a real concern.”
The hospitals are the two largest health care systems in Orange County, representing more than a dozen emergency departments within the region. They announced the new policy in January, calling for doctors to help educate their patients about the dangers of addiction and abusing prescription drugs. It also calls for physicians to refer patients to primary care physicians for proper management of chronic pain and to connect them with community resources that can help with prescription drug addiction.
The new policy would have been almost impossible without a prescription drug monitoring program, Dr. Thundiyil said. “Emergency physicians want to err on the side of treating pain. A monitoring program allows us to get a sense for what might be harmful prescribing patterns. For example, say that a patient comes in asking for a prescription for back pain. Before we would just have treated them. But now we're finding that some people come in anywhere from daily to three times a week for refills, so we're making the extra effort to just give them a limited or no refill to get them through the acute phase and then connect them with outpatient community resources and a pain management specialist.”
Dr. Thundiyil noticed a change in ED patterns almost immediately. “Within a few weeks, the patients who had been coming in regularly were provided with outpatient referrals,” he said. “We've also noticed that overcrowding from chronic nonmalignant pain issues has been relieved, and we haven't seen the escalating levels of aggression related to demanding pain medication that we had seen previously.”
Taking a more active role in curtailing prescription drug abuse has also opened up communication among emergency physicians and their patients. “It can become very easy to just refill someone's prescription and send them on their way. But the realization that this discussion opened up is that there are people dying in epidemic proportions in our state, and if we don't discuss opiate addiction with our patients, we are indirect contributors to this problem,” he said. “Some of our patients are resistant to this discussion, but many are very open to saying, ‘I don't want to be on this anymore. I don't know how I ended up here, and I want off it.’ I think it's been very positive, and I've been surprised at how fast the results appeared.”
Emergency physicians should also acquaint themselves with the substantial body of evidence that indicates that prescription opioids are not the best choice of therapy for chronic pain, Dr. Gugelmann suggested. He pointed to Physicians for Responsible Opioid Prescribing, an independent organization, as a useful resource. (See FastLinks.) “To treat pain, we need to use all the tools we have and not just focus on opiates,” he said.
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* The CDC's policy report on prescription painkiller overdoses is available at http://1.usa.gov/MAEW9V.
* Read more about Physicians for Responsible Opioid Prescribing at www.supportprop.org.
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