Misuse of prescription opioids is one of the defining health problems of our generation. The dramatic rise of opioid analgesic prescriptions in the US and Canada has been well documented, and opioids represent the most common cause of fatal prescription overdoses. On every shift, in every emergency department in the country, physicians struggle with the concerns of patients presenting with common pain complaints. Seeking to manage their patients’ symptoms in the face of dramatically rising prescription opioid misuse and fatal overdose, emergency physicians are challenged to distinguish those who are simply seeking pain relief, those who are seeking opioid prescriptions due to addiction, and those who fit both categories. Emergency care providers are also charged with balancing the pressures of meeting clinical care and patient satisfaction goals while fulfilling our moral obligation to provide primary and secondary prevention of opioid misuse.
Google Hangout with the Authors
On August 12, 2014 at 9 am EST, we hosted a 30 minute live Google Hangout on Air with Drs. Sabrina Poon and Margaret Greenwood-Ericksen, the authors of the Annals of Emergency Medicine Resident’s Perspective paper on the how the opioid prescription epidemic. Later this year, a summary of this blog- and Twitter-based discussion will hopefully be published back into the journal.
- Sabrina Poon, MD (@sjpoon): resident physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women’s Hospital, Massachusetts General Hospital (Boston, MA)
- Margaret Greenwood-Ericksen, MD MPH: resident physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women’s Hospital, Massachusetts General Hospital (Boston, MA)
- David Juurlink, MD (@DavidJuurlink): medical toxicologist, internal medicine physician, Division of Clinical Pharmacology and Toxicology at Sunnybrook Health Sciences Centre (Toronto, ON)
- Maryann Mazer-Amirshahi, MD: medical toxicologist, emergency medicine physician, MedStar Washington Hospital Center (Washington, DC)
Annals of EM Resident Perspective Article
In the June issue of Annals of Emergency Medicine, Drs. Poon and Greenwood-Ericksen published a Resident’s Perspective around this issue entitled “The Opioid Prescription Epidemic and the Role of Emergency Medicine.” The paper reviews the scope of the issue and describes the quandaries faced by ED physicians attempting to balance high-quality care with safe, appropriate care–resulting in high variability in ED prescribing practices. It also discusses some of the solutions that have been proposed to stem the tide of the epidemic, including prescription drug monitoring programs, prescribing guidelines, and physician education.
Testament to the urgency and difficulty of these tasks are the number of blogs on this issue over the past year.
FOAM Discussion to Date
A comprehensive review of FOAM resources produced during the last year was conducted using the FOAMSearch platform and targeted Google searches. Since 2013, 10 blog posts and 1 podcast concerning opioid prescribing trends in the emergency department have been published as the FOAM discussion of this issue continues to evolve. For some background on the paper discussion, review any of the resources listed in the table below.
|EM Tutorials||Oxy morons. Avoid prescribing oxycodone||Chris Cresswell||Podcast||New Zealand||7/22/14|
|The Poison Review||Counties in California sue manufacturers of opioid analgesics||Leon Gussow||Blog||USA||5/24/14|
|Emergency Medicine Literature of Note||Your Patients Will Abuse Opiates||Ryan Radecki||Blog||USA||5/19/14|
|Emergency Physicians Monthly||Opioids: Misuse and Abuse||Ryan Radecki||Blog||USA||5/6/14|
|The Poison Review||ED discharge prescriptions for opioid analgesics increased 49% from 2005 to 2010||Leon Gussow||Blog||USA||3/25/14|
|Emergency Medicine Literature of Note||Nonsensical Opiate Overuse in Adolescent Headache||Ryan Radecki||Blog||USA||3/2/14|
|The Skeptics Guide to Emergency Medicine||Drugs in My Pocket (Opioids in the Emergency Department)||Ken Milne||Podcast||Canada||11/28/13|
|The Poison Review||Guidelines for Opioid Prescription: do emergency physicians need support?||Leon Gussow||Blog||USA||4/9/13|
|The Poison Review||NYC Recommendations for Prescribing Opioids in Emergency Departments||Leon Gussow||Blog||USA||3/8/13|
|Emergency Medicine PharmD||Opioid related deaths||Craig Cocchio||Blog||USA||3/4/13|
|Emergency Physicians Monthly||NYC Limits ED Opioid Prescriptions||Kevin Klauer and Rick Bukata||Blog||USA||2/8/13|
Featured Discussion Questions
The ALiEM team poses the following questions to explore current practices with MMI, and perceptions about the benefits and drawbacks of this interview format. If you have additional questions, feel free to pose them!
- The authors cite the Joint Commission’s pain control mandate (i.e., “pain is the fifth vital sign”) and the emphasis on patient satisfaction scores as critical factors in the increase in opioid prescribing over the last decade. To what extent do these factors influence your use of opioid pain medications, both during the ED visit and upon discharge?
- The authors discussed potential barriers to prescription monitoring programs (PMPs). In your practice, are PMPs assisting in appropriate and safe opioid prescribing practices? If not, why? If so, how?
- Only three states have adopted formal guidelines for opioid prescribing from the ED. Do you think these are/will be helpful? Why do you think they have not been adopted more widely?
- The authors propose a resident curriculum for opioid prescribing in the ED, including lectures, journal club, case-based learning, and simulation. What have been your experiences with formal instruction around opioid prescribing? What do you think are the most effective ways to shape physician behavior around this issue?
Please participate in the discussion by answering either on the ALiEM blog comments below or by tweeting us using the hashtag #ALiEMRP. Please denote the question you are responding to by starting your reply with Q1, Q2, Q3, or Q4.
NEW! Contest for Best Blog Comment and Tweet
Thanks to Dr. Henry Woo and his colleagues in the Twitter-based International Urology Journal Club series (#urojc) hosted by @IUroJC, we are also implementing a contest for the Best Blog Quote and Best Tweet. What, emergency physicians – competitive? No… The winners will be announced in our Annals of EM publication curating this discussion.
Additional Reading / References
- Juurlink DN, Dhalla IA, Nelson LS. Improving opioid prescribing: the New York City recommendations. JAMA [Internet]. 2013 Mar 6 [cited 2014 Jul 28];309(9):879–80. Pubmed
- Kahan M, Gomes T, Juurlink DN, Manno M, Wilson L, Mailis-Gagnon A, et al. Effect of a course-based intervention and effect of medical regulation on physicians’ opioid prescribing. Can Fam Physician [Internet]. 2013 May [cited 2014 Jul 28];59(5):e231–9. PMC
- Mazer-Amirshahi M, Mullins PM, Rasooly IR, van den Anker J, Pines JM. Trends in prescription opioid use in pediatric emergency department patients. Pediatr Emerg Care [Internet]. 2014 Apr [cited 2014 Jul 28];30(4):230–5. Pubmed
- Mazer-Amirshahi M, Mullins PM, Rasooly I, van den Anker J, Pines JM. Rising Opioid Prescribing in Adult U.S. Emergency Department Visits: 2001-2010. Acad Emerg Med [Internet]. 2014 Mar [cited 2014 Mar 27];21(3):236–43. Pubmed
- Rosenau AM. Guidelines for opioid prescription: the devil is in the details. Ann Intern Med [Internet]. American College of Physicians; 2013 Jun 4 [cited 2014 Jul 28];158(11):843–4. Abstract
Disclaimer: We reserve the right to use any and all tweets to #ALiEMRP and comments below in a commentary piece for an Annals of Emergency Medicine publication as a curated conclusion piece for this Resident’s Perspective publication. Your comments will be attributed, and we thank you in advance for your contributions.