Last month, New York City mayor Michael Bloomberg cut the proverbial ribbon on a plan aimed at combatting opioid prescription drug abuse in the big apple. The guidelines, which will be rolled out in all 11 of the City’s public hospitals, state that the emergency departments will not prescribe long-acting opioid painkillers; can only prescribe up to a three-day supply of opioids
The regulation announced January 10 will put stringent restrictions on emergency physicians’ opioid prescribing practices
Last month, New York City mayor Michael Bloomberg cut the proverbial ribbon on a plan aimed at combatting opioid prescription drug abuse in the big apple. The guidelines, which will be rolled out in all 11 of the City’s public hospitals, state that the emergency departments will not prescribe long-acting opioid painkillers; can only prescribe up to a three-day supply of opioids; and will not refill lost, stolen or destroyed prescriptions. Although the Mayor lacks the authority to impose the new guidelines on private hospitals, their voluntary participation has been requested.
This recent development follows previous actions in Utah and Washington State, both with similar goals. As the prescription drug abuse problem continues to worsen in the United States, emergency physicians are likely to see more local and state governmental intervention. These top-down tactics raise many questions. Will some patients elect to present to a private hospital? If patients seeking narcotic analgesics begin to visit private hospitals instead of the public hospitals, will this result in pressure for the private facilities to participate? Will their efforts fall victim to the law of unintended consequences? Only time will tell.
The press conference announcing the new regulation accurately recited well-known statistics on the prescription drug epidemic. Health Commissioner Thomas Farley quoted that about two million prescriptions are written for opioids every year in New York City, which amounts to one for every four people. About 40,000 New Yorkers are already dependent on painkillers and need treatment. Painkillers were involved in 173 accidental overdose deaths in New York City in 2010, a 30 percent rise from five years earlier.
While these statistics are alarming, some physicians have expressed concern that they lack one critical element: a clear causal relationship between emergency department prescribing statistics and the epidemic. Officials could not say, for instance, how many prescriptions were written at emergency rooms.
The task force in charge of New York’s new opioid regulation also initiated the creation of “NYC RxStat,” which will track public health and patient safety data.
“RxStat provides us with a truly unique opportunity to design the most effective strategies to reduce prescription drug abuse and its consequences,” said NY/NJ HIDTA Director Chauncey Parker. “By combining the knowledge resources of the key public health and public safety partners, RxStat creates a platform where we can use timely and accurate data to quickly identify emerging drug trends and then coordinate our response.”
Mayor Bloomberg garnered support for the new regulations from key stakeholders including the Health and Hospitals Corporation and the New York Chapter of the American College of Emergency Physicians.
“These guidelines will help emergency department physicians strike a balance between easing a patient’s pain and discomfort while helping to ensure that medications that can be abused are not over prescribed,” said Dr. Stuart Kessler of New York ACEP.
“Given the important role that emergency departments have in the management of patients with pain, it is important that we maintain our ability to provide pain relief while keeping perspective on protecting the public health,” said Dr. Lewis Nelson, professor of emergency medicine at the NYU School of Medicine. “The recognition that this problem can be addressed with a broad effort across emergency departments provided the initial step in addressing this important issue.”
Despite the buy-in that Bloomberg achieved prior to the landmark announcement, there are still influential physicians, such as Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians, who fear the slippery slope that this move could represent.
“Here is my problem with legislative medicine,” said Rosenau. “It prevents me from being a professional and using my judgment.”
Although it is certain that the prescription drug abuse epidemic is a critical public health issue in the United States, there appears to be little consensus among physicians on how to address it. Is legislative medicine the answer? Has organized medicine failed to address a problem it has created? Is the ED the source of the problem? While these questions remain murky, what is clear is that no one knows the daily realities of emergency care quite like emergency physicians. Therefore, we need to be at the table, discussing the problem, contributing our experiences and coming up with real-world solutions.
The new opioid emergency department prescription guidelines, which hospitals can choose to display in emergency departments, clarify that:
1. Emergency departments will not prescribe long-acting opioid painkillers such as extended-release oxycodone, fentanyl patches or methadone.
2. In most cases, emergency departments will prescribe no more than a 3-day supply of opioid painkillers.
3. Emergency departments will not refill lost, stolen or destroyed prescriptions.
The posters also include tips to reduce unintended harms of opioid painkillers. The poster is available in English, Spanish, Chinese and Russian. The 11 emergency departments of the New York City Health and Hospitals Corporation, which operates all of the City’s public hospitals, have agreed to adopt these guidelines. The Health Department is encouraging private hospitals to adopt these guidelines as well.
Reporting by Drs. Kevin Klauer and Richard Bukata. Write in with your thoughts to [email protected]
Drs. Kevin Klauer and Richard Bukata unfairly characterize New York City’s ED opioid prescription guidelines as “top-down tactics,” and ACEP president-elect Alex Rosenau similarly characterizes the policy as “legislative medicine.” These scare tactics misleadingly overlook a key aspect of the guidelines: they are completely voluntary. Far from being “stringent restrictions,” they are simply suggestions. The only impact they will have is that emergency physicians will have one more arrow in the quiver when faced with a drug-seeking patient demanding an inappropriate prescription.
This example demonstrates, as with most other problems in health care, that EM is the “safety net” that fixes things. It’s what we do! If everything worked perfectly in the world, we would be an unnecessary specialty. The NYC guidelines were written by EPs and are designed to help reduce abuse and overdose deaths. As Dr. Trueger wrote, they are just guidelines, not mandates. I do not view this as legislative medicine. I applaud NYC for taking action. EM likely didn’t cause the problem, but we can be a proactive part of the solution.
The management of pain in the ED has always been complex for many reasons not the least of which is that we, emergency physicians, did not do the best job in addressing it. It was accepted and commonplace to hear the screams of procedures, the moans of the renal colic patients, and the faces of those in legitimate pain looking back at us from their gurney on a daily basis. We are now seeing a new problem of prescription opiate abuse and overdose. In NYC the thought is that emergency departments and emergency physicians are where this problem should be addressed and where “guidelines” restricting opiate prescriptions will ameliorate this problem. I think not! I would ask when was the last time you, as an emergency physician, sent a patient out from the ED with a prescription for 120 tablets of Vicodin? I see that kind of prescription frequently when I access the Michigan Automated Prescription Service (MAPS) computer where I can get a list of all scheduled drugs prescribed to a patient. I often see patients who receive several such huge prescriptions in a single month as they “shop” physicians. Personally I have never prescribed those sort of amounts and I have never given a patient a “3 month” supply of their Lortab or oxycodone. I don’t think I am the problem in this issue nor do I think other emergency physicians, at least that that I know of, are the problem. Emergency physicians don’t as a rule prescribe the amounts of controlled substances often given out by other physicians. So, with all due respect to Dr. Trueger I disagree with his characterization of Dr. Rosenau and I feel that NYC’s opioid guidelines are actually legislative medicine targeted at the wrong group of physicians – I would suggest that internists and family practitioners agree to similar guidelines and then there will be a dent in this problem. In the meantime I want to be free to use my professional judgement and continue to prescribe the 15-25 Vicodin I routinely do, the 3-5 fentanyl patches from time to time, the occasional oxycodone, and sometimes long acting opiates in a cancer patient where I think it is appropriate. Frankly, I have been essentially following the NYC guidelines on my own for years and for the most part I see my colleagues doing very much the same. As Dr. Weiner points out we did not cause the problem and to a small extent we can be part of a proactive solution. But, we should emphasize that even if all emergency physicians strictly adhere to the NYC guidelines it will only dent the problem is a very small way.
Dr. Walters: I appreciate your thoughtful reply, and I wholeheartedly agree that a) the ED is not a major part of the problem when it comes to opioid prescriptions b) most ED docs are very reasonable when it comes to opioid prescriptions and c) we should be free to prescribe 25 vicodins or 5 fentanyl patches if we see fit. But the guidelines expressly allow you to do so. The guidelines are purely voluntary, and we are free to use our professional judgement on a case-by-case basis. If anything, these guidelines HELP us deal with patients who demand more in opioids than we are willing to give — now there is a useful backstop for emergency docs to point to. Our hands are not being tied.
As an ED provider I would like to ask that we ALL take a look at our personal behaviors. Far too often I see peers and colleagues giving out prescriptions to patients well known for addiction and/or disruptive behaviors…with a common theme statement being “hey, I just want them out of here and I don’t really care- I just need to get my kid through college”, or “I didn’t make the problem and I’m not going to fix it- so I might as well give them what they want”….
Truly? This is our “DO NO HARM” in action? Again, I suggest we each ask ourselves if we are really doing “ALL WE CAN” to assist our patients in the short and long term…we all can have an impact this issue- the question is how much effort are we each willing to put into it?? And for who’s benefit are we really doing it??
“Has organized medicine failed to address the problem IT HAS created?”This statement suggests that many young physicians are not aware of the history of this problem
It is quite clear that the Joint Commission on Hospital Accreditation had role to play in creating this problem. A very big role. Above is a reference to their 101 page statement on pain management published in 2001 . Hospitals and doctors were expected to adhere to this version of the truth about opioids.Among other things the statement proclaimed:
1. A patient’s statement of pain is subjective and should be accepted as truth even when they do not “appear” to be in pain.
2. The Objective documenation of the measurement of pain is required. Using a 1-10 scale of pain intensity is encouraged and recommended highly by the American Pain Society which the JCHA quotes and endorses.
3 Long term acting opioid pain meds are encouraged
4 Patients usually do not become addicted to Rx for pain with opioids unless they have a prior hxn of addiction
5 Pain can be real even without evidence of physical disease and needs to be treated.
6 “Pseudoaddiction” can be created by physicians failing to treat pain adequately and forcing patients to display “drug seeking behavior” in an attempt to get their “real” pain treated.
Another government agency, the VA, published similar guidelines and opinions at that time.