The Opioid Prescription Epidemic: Annals of EM Resident Perspectives article

The Opioid Prescription Epidemic: Annals of EM Resident Perspectives article

opioid prescription epidemicMisuse 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

Timestamped breakdown of Google Hangout video

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

Poon SJ, Greenwood-Ericksen MB. The Opioid Prescription Epidemic and the Role of Emergency Medicine. Ann Emerg Med. 2014 Jul 11. pii: S0196-0644(14)00527-7. PMID:25017821. Free PDF

Introduction

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.

Website Title Author Type Country Date
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

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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!

  1. 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?
  2. 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?
  3. 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?
  4. 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.

Best Blog and Tweet

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

  1. 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
  2. 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
  3. 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
  4. 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
  5. 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.


Esther Choo, MD MPH

Esther Choo, MD MPH

Assistant Professor of Emergency Medicine
Assistant Professor of Health Services, Policy and Practice
Warren Alpert Medical School of Brown University
Esther Choo, MD MPH

Latest posts by Esther Choo, MD MPH (see all)

Scott Kobner
ALiEM New Submissions Editor
Medical Student
New York University School of Medicine
2014-15 ALiEM-EMRA Social Media and Digital Scholarship Fellow

Kevin Scott, MD

University of Pennsylvania, Assistant Professor of Emergency Medicine.
  • Hey Gang! Thanks for bringing this very important topic to the forefront. It is interesting to see this pendulum swing both ways within my career. Folks like Jim Ducharme have done a lot to advocate for adequate dosing of opioids to patients in pain, and yet we seem to still be reluctant to give opioids, largely because of the potential for abuse.

    Thus far, pain has been largely a subjective thing… but now with more biometric experimentation, I wonder if we will soon have some exciting new ways to actually measure pain.

    There has been a recent increase in the usage of pupillometry as a potential for measuring responses to pain (1,2). Much of the literature I can find is in French, which suggests that there may be a body of literature that I am unaware of…

    It will be interesting, therefore to see where this field goes as we head towards more objective measurements on the pain response.

    Teresa

    1. Isnardon, S., Vinclair, M., Genty, C., Hebrard, A., Albaladejo, P., & Payen, J. F. (2013). Pupillometry to detect pain response during general anaesthesia following unilateral popliteal sciatic nerve block: A prospective, observational study. European Journal of Anaesthesiology (EJA), 30(7), 429-434. http://www.ncbi.nlm.nih.gov/pubmed/23549125

    2. Larson, M. D., & Sessler, D. I. (2012). Pupillometry to guide postoperative analgesia. Anesthesiology, 116(5), 980-982. http://journals.lww.com/anesthesiology/Citation/2012/05000/Pupillometry_to_Guide_Postoperative_Analgesia.7.aspx

    • Whoops. Hit send too early:

      Q4: 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?

      At McMaster, we thought that initiating an opioid Rx was so important we now have bedside teaching and assessment of this skill. I’m thinking that this is a frequent enough occurrence that it warrants actual teaching, but contextualized teaching is probably more efficacious, in my opinion.

      • Esther Choo

        I wonder how many institutions have this kind of curriculum in place. Would be a nice question to include in a national / international survey of training programs.

  • Matt Klein

    Q3/Q4: Over my first few weeks in the ED, at least once a shift a nurse will alert me that a patient is in pain, and ask what I want to order. My response is often “What do you usually give?” As a new intern, I feel like I have a general framework of what meds to order for an asthma exacerbation, or STEMI, or a handful of other protocol-driven scenarios. Analgesia is much murkier. Most of that is probably a result of my inexperience, but there are likely other components – practice variations in my seniors/attendings, patient expectations/demands, fear of undertreating vs. oversedating. Creating formal guidelines and/or a resident curriculum would go a long way in clarifying this area for those of us who are novice providers.

    • Esther Choo

      Kudos, Matt Klein. Teaching staff have a long way to go in standardizing their practice, and probably would benefit from a curriculum as much as trainees, IMHO.

    • MGreenwoodEricksenMD

      Great comments Matt! You touch on many of the key issues – we don’t have enough formal education on opioid pharmacology and prescribing. And pain is subjective – making it challenging to create clinical guidelines. Send us your best educational ideas on teaching opioid prescribing!

    • Thanks for your response! Certainly formal guidelines and/or an established curriculum would help to alleviate some causes of the uncertainty you mention in prescribing practices.

      As a new intern, do you feel that pain management was addressed in your medical school experience? What could have better prepared you for your new role?

  • Anand Swaminathan

    Opioid misuse and overprescribing is clearly a huge issue. It’s hard to figure out exactly how to change this but there’s a couple of things I’ve noticed.

    1 – When I was training (not that long ago), I was taught to be very liberal with prescription of opiates. This wasn’t a patient satisfaction issue as we don’t really do much in the way of patient surveys at my big county hospital. I think we believed we were doing what was best for the patient. As a result, lots of patients with ankle sprains walked out the door with an Rx for 20 Vicodins. This is crazy. There’s little, if any, evidence that opiates are necessarily better than other medications for pain. In fact, in certain diseases characterized by severe pain (renal colic, biliary colic) we have decent evidence that NSAIDs are just as good. While it’s possible that the acute pain in the ED needs an opiate, that doesn’t necessarily mean the patient has to go home on an opiate. Jim Ducharme stated on a recent EMRAP that opiates don’t relieve pain, they dissociate you from it. The pain is there, you just don’t care. I haven’t read all the evidence on this but have no reason to doubt a pain guru like Jim.

    2 – It is difficult if not impossible to figure out who is “faking it” in the ED. Vital signs, how the patient looks etc doesn’t determine if the patient is in pain or not. It’s almost silly to try to figure it out. If the patient presents in pain, treat it. That doesn’t mean they need an opiate. Maybe they need an NSAID, acetaminophen, a nerve block or even ketamine. Treatment in the ED doesn’t determine outpatient treatment. You can give someone a dose of opiate and send them home with an NSAID. If you give someone with a chronic opiate abuse issue an opiate in the ED only to find out they have multiple recent opiate scripts, just don’t send them home with any more.

    3 – We do a terrible job managing patients with chronic pain. They need referral for treatment. The ED is not the place to refill or start chronic meds (in the vast majority of cases) for almost any condition and chronic pain is simply another chronic medical condition.

    4 – Everyone in whom you are concerned about chronic opiate dependence or abuse deserves a conversation from you, their physician, and referral for treatment. We wouldn’t discharge a chronic hypertensive or a diabetic without follow up. It’s easy to just give them 5-10 percs, discharge and move on to the next chart but just because it’s easy, doesn’t mean it’s right.

    Okay, no more soap box. The bottom line for me is not to waste your time trying to figure out who’s faking it. Treat pain as you see appropriate, discuss abuse if you think it’s present and refer. Lastly, they’re not narcotics. Narcotics are illegal drugs of abuse. They’re opiates. Let’s not stigmatize this more than necessary.

    • Esther Choo

      Thanks, Swami. These are all awesome points; no soap boxing detected! I need to know more about “opioids as dissociative agents.” !!?? Will investigate and report back.

      • Anand Swaminathan

        I think Ducharme meant that you are dissociated from the pain itself. New concept to me as well. The pain is still there but you don’t care. Makes sense when you’ve got the patient with abdominal pain who is sleeping after you give them 6 mg of morphine but when you wake them up they still say they are in pain.
        The point of his segment was that we should ask “are you in pain” but rather “do you want anything for pain.”

        Very aside from the discussion here but interesting.

  • Anand Swaminathan

    Q2 – I work in NY where we are required to check the PMP for every patient. The exception to this is for the provision of emergency care. Our PMP is difficult to navigate and terribly user unfriendly. This limits it’s implementation significantly.

    Honestly, I don’t prescribe a whole lot of opiates any more. If the patient has chronic pain and ran out of meds or lost their meds, I refer them back to their primary doctor or pain doc. If they have acute pain, I often try non-opiate options in the ED. Even when the patient needs an opiate acutely, they often won’t need them to go home on.

    When I do prescribe them, it’s short courses (5-10 pills) and if a patient tricks me, so be it.

  • Scott Cooper

    As a nurse who gets to work with multiple doctors in multiple settings I find that opioid prescribing or pain relief is completely biased based on the doctor being pro or con opiates. Unfortunately the patient plays only a partial role. Complications from to much NSAIDS use or APAP use is just as much a problem for patients coming into the ER. I could give a thousand examples of both. But long winded examples to docs who are already biased would make no difference. I am pro opiate, just not a short acting opiate for pain that isn’t going away. Short acting opiates are the most common to start someone on the path of misuse. Educating up front about abuse and misuse is rarely done and would probably make a difference in a good percentage of acute pain injuries or illnesses.

    • Esther Choo

      “Unfortunately the patient plays only a partial role” – This is a KEY point. We always assume the patient wants opioids, the doctor does not, and the conflict is in one direction only. I’ve found that a frank, direct discussion with patients often leads to a mutual decision to go with other modes of pain control. TY Scott!

  • Jeanmarie Perrone MD

    Great discussion this morning. I am on my way to a shift but wanted to share some of our thoughts about our ….Safe Opioid Prescribing Curriculum

    Our inaugural special session at SAEM2014 was to start
    the necessary dialogue about drafting a “Safe Opioid Prescribing” Curriculum
    for EM. The significant gap in our knowledge of pain management in acute and chronic ED situations was so well highlighted by Drs’ Sabina Poon and Margaret Greenwood-Ericksen in their Annals perspective. Rather than outlining a
    written curriculum that may or may not be adopted by CORD or the EM Model
    Curriculum, we concluded that we could tackle the knowledge gap by producing a
    few podcasts highlighting several case based challenging patient scenarios and
    hosting them on a FOAMed website or existing pain curriculum site such as Dr.
    Sergei Motov http://www.painfree-ed.com/ or others…and sharing in the FOAMed community…
    Here are some of the challenges I face in my clinical practice…What do you need to know more about?

    How to manage severe pain in a trauma patient on buprenorphine (Suboxone)?

    Neuropathic pain….you’ve made the diagnosis in the ED>…what
    are the safest treatment options?

    These may be more Opioid Prescribing 2.0—perhaps we could
    also do a primer on as Sabina said:

    “What’s in that Norco you are prescribing for pain?”

    What are the advantages of IV morphine over IV
    hydromorphone?

    Management of pain in the Elderly—do hazards of opioids outweigh hazards of NSAIDs or other agents?

  • My apologies for jumping in as a patient but I’d like to share my perspective. I am treated by my neurologist for chronic pain as a result of a connective tissue disorder (Ehlers Danlos Syndrome) that affects my joints as well as severe neuropathic pain and migraines.

    At times I use opiods for acute flare-ups (this is consistent with pain management of EDS and some of the other pain I have). As a result of convenience, I will get around one rx of 30 pills per year – this way I have “emergency pills” and don’t need to bother people as frequently. (If I go through many flare-ups, I may need more, and my neurologist will prescribe it. At one point a few years ago I was on oxycontin but realized that it was not a good idea for me.) As I live in NY, all of my information goes through the PMP. I also see almost all of my physicians in one hospital as I want as complete an EMR as possible for
    all involved.

    I am an ER frequent flyer at that same hospital. Though entirely another topic, unfortunately I pass out a great deal and then can’t stand up. I can’t get my insurance to assist me with my medical needs for that issue it seems that they would rather pay for ER babysitting.

    On one of the many occasions I wound up in the ER I did need pain medication. The preceding incident had multiple witnesses and those who brought me into the ER stated there was no way I was not in agony. Yet as a result of my frequent ER visits (with no pain meds given or requested), the attending and PA assumed I was medication seeking. Had they actually looked at medications given during those prior visits, asked me about my disorders, or looked at the state PMP, they would have seen that was not the case.

    After over four hours of my crawling around crying, it was determined that I “deserved a percoset” based on my appearance. I did have emergency percoset in my bag anyhow but was in too much pain to get to it and had nobody with me. Did I need an opiod? I don’t know – toredol might have been just as useful, but nobody gave it any consideration. (Ironically, I only once asked for pain medication…I was mostly just crying and mumbling “Ow.”)

    I find it highly concerning that anyone looks at a patient as “deserving” of pain medication or not. Despite my frequent ER visits, in recent years I have never had anything stronger than toredol given. Had the providers looked at the PMP or the medications given to me during prior visits, they would have seen that.

    Perhaps because providers are so fearful of “giving in” to those who are “medication-seeking,” they create automatic labels without looking into a situation. Yet perhaps it’s not fear, perhaps it is lack of knowledge as to what is going on with patients and the instinct to fill in the blank with a diagnosis – some diagnosis – any diagnosis rather than “I’m not sure.” I say this because I was informed by the PA that 99% of cases like mine were patients just looking for medications. I find that dubious and wonder how many patients leave with undiagnosed problems and inappropriate care.

    Perhaps if I had seen a resident rather than a PA things would have been different, perhaps not. I seriously doubt this lack of appropriate pain management was a one time occurrence based upon other patients I have seen in the ER.

    The initial labeling of patients – either by the triage nurse or whomever – without looking into their history, diagnosis, or needs is quite concerning. In this case it created very poor pain management. In other cases it has caused me other problems. Overall, it seems to me that before deciding on a treatment plan, anyone (including a nurse) treating or diagnosing a patient should look into the patient’s history, especially if it is on file, be willing to listen to what the patient says, and open to the idea that something may actually be wrong though the ER doc cannot diagnose it. That said, as a patient, I have also seen patients who I believed were simply medication-seeking. How to distinguish between the groups, I don’t know.

    Note: Many EDS and other chronic pain patients (with real diseases) do not get properly diagnosed for years and are written off as medication or attention seeking, especially as we wind up in ERs so frequently.

  • Debiegun

    Hi all,
    Kudos to my former attending Dr Choo for putting this together. Thanks to all for opening the discussion.
    I’m going to quote a series of people.
    On one hand we have the program director where I work. Andy Perron who says “the next study that shows we are good at treating pain will be the first.” So we know we under great pain in patients who need treatment. Study after study has shown it.
    On the other hand we have the kinds of experiences Drs Poon and Greenwood-Erickson note. We all have similar experiences.
    So we are left ding doubting and wondering who has real pain and how we can address it. There is no exam feature or test that can tell us. Jim Ducharme has said on prior EMRaps if you don’t believe the patient then why are you in medicine. And mostly this is true, but I don’t want to be a sucker.
    Also I disagree with Swami. If a patient has pain so severe they need an opiate in the Ed then they will probably need it at home when the first one wears off. Just because I can’t see them doesn’t mean their pain is less severe then. Rather that exactly the patient I think WILL need an opiate later.

    So I fall back on something Dr Libby Nestor taught me during residency and I teach my residents now. I don’t know who is in pain or who isn’t or how much pain. But I do know what appropriate use of the ED and opiates is. So I check the records for how often you are in the ED (it often gives other useful info too) and what meds you were given on those occasions. Then I check the PMP only if the first part raises a question. Then I draw a line in the sand it’s an arbitrary line but allows me to treat all patients fairly and equally. I will treat your pain with up to two doses of opiates in the ED and never give out an Rx more than once a quarter.

    • Debiegun

      Disqus wouldn’t let me finish.
      It’s not a perfect plan but it works and it avoids lots of arguments with demanding patients.