After months of sending mixed messages on the role of emergency medicine in stemming the tide of opioid abuse, the CDC has published guidelines that could prove useful in the emergency department.
Opioid abuse is no longer merely a topic for medical discussion. It has become a public health concern of the highest magnitude, even making its way into the speeches of this year’s presidential candidates.
The numbers speak for themselves, justifying the concern. Over 10 million Americans reported nonmedical use of prescription opioids in 2014. Visits to the emergency department (ED) for misuse or abuse of prescription opioids increased 153% from 2004 to 2011. Most troubling was the rising number of deaths from opioids. There were 16,007 deaths from prescription opioids in 2012, which increased to 18,893 in 2014. During this same time period, rates of heroin use and overdose also increased. Heroin users were found to be 3.9 times as likely to report nonmedical use of opioids in the previous year compared to people that did not use heroin. Another study determined that prescription-opioid abusers were 40 times as likely to abuse heroin as compared to those without a history of prescription-opioid abuse.
In response to this epidemic, both the state and federal governments are taking active steps to combat these alarming numbers. PDMPs are implemented in every state, aside from Missouri. While their impact is still unknown in many places, pill mill laws and the PDMP in Florida may be associated with decreased rates of opioid prescribing and use. States and state-wide hospital associations including Maryland, New York, and recently Missouri released opioid prescribing guidelines. Even though EDs are only a small part of the problem, many of the guidelines are directed at or incorporate ED prescribing. In addition to state or hospital-derived policies, emergency medicine associations also released guidelines of their own. A recent study explored the impact of opioid prescribing guidelines on two large urban EDs. They described the change in prescription practices in patients discharged with dental, neck and back, and chronic pain after the dissemination of a guideline. In the 6-12 months and 12-18 months after dissemination, the rate of opioid prescriptions decreased from 52.7% to 29.8% and 33.8%, respectively. When surveyed, 84% of providers believed that their own prescribing rate had decreased, 94% believed that the overall prescribing rate decreased, and only 13% believed that the new approach had affected patient satisfaction. Nearly 75% reported less hostility from patients when opioids were withheld after the guidelines were adopted. Recently, the Center for Disease Control (CDC) drafted an opioid prescribing guideline. The Food and Drug Administration (FDA) also just announced plans in February 2016 to reassess their approach to opioid medication approval in light of increasing governmental and political pressure.
Due in part to the complexity of the issue, the government and other organizations can seem schizophrenic in their messaging to emergency providers. At times, governmental agencies openly advocate for new approaches to fight the epidemic, only then to place roadblocks in the way of other initiatives. While supporting and initiating policies and increasing funding for addiction programs, governmental agencies are also impeding some actions taken by emergency physicians. Recently, hospitals have attempted to develop the ‘oxy-free ED.’ While it has ‘oxy’ in its name, the real intent is to decrease the use of and prescribing of opioids in the ED in patients with chronic, painful conditions and change prescribing habits, not just limit prescribing oxycodone or oxycontin. These policies generally encourage better coordination of care, use of non-opioids for analgesia, and only providing the minimal amount of narcotic medication that is required to control the patient’s pain. Many parts of the ‘oxy-free ED’ are consistent with other statewide opioid prescribing guidelines. In order to be more transparent, hospitals attempted to place these ‘oxy-free’ guidelines in the waiting room. In South Carolina, the regional Centers for Medicare and Medicaid Services (CMS) was contacted for permission. Surprisingly, CMS balked. They informed the ED administration that such signs might be misconstrued as intimidating and coercive, and therefore, might be considered an EMTALA violation. Unfortunately, the same thing occurred in Ohio when their regional CMS offices were contacted about posting similar verbiage. Given the threat of an EMTALA violation, most hospitals are not going to risk large fines to post similar guidelines, even if the signs are not meant to intimidate or prevent patients from seeking legitimate care.
Patient satisfaction may also be subverting attempts to initiate guidelines. Since the movement to make pain the 5th vital sign, there is an increased emphasis to provide appropriate analgesia in the ED. While this movement was likely an appropriate response to oligoanalgesia, it has morphed into the perception that patients must have their pain controlled with opioids or other controlled medications. Whether this perception is true or not, emergency providers are concerned that implementing guidelines or policies may upset patients and negatively impact patient satisfaction scores and lead to more complaints.
Maintaining high patient satisfaction is important as it can impact reimbursement, and in some cases, the ability of an ED group to keep their contract. As part of the American Board of Emergency Medicine’s Maintenance of Certification, providers are required to complete a communication/professionalism activity, which may include collecting patient feedback such as Press-Ganey scores. While one study did not find an association between prescribing opioids in the ED and Press Ganey/patient satisfaction scores, providers are understandably worried about the impact of similar policies on patient satisfaction and patient complaints.
While some organizations are disseminating a mixed message, the release of opioid prescribing guidelines from the CDC is ultimately welcome. Although intended for primary care providers who account for nearly half of all dispensed opioid prescriptions and whose prescription rates are growing at an above average rate, large parts of these guidelines do pertain to emergency providers. Even recommendations not meant for the ED can be modified into useful information for the emergency provider.
It is important to mention that none of the guidelines are meant to be used to advocate for undertreating pain, a common concern from at least a few of my colleagues. In addition, using guidelines may make having these discussions with patients easier, and possibly more accepting, when the decision is made not to treat them with narcotics.
The guideline consists of 12 recommendations broken into three categories: determining when to initiate opioids for chronic pain; opioid selection, dosing, duration; and assessing risks and harms of opioids. Some key take home points for the emergency physician include:
- Nonpharmacologic therapy and nonopioid therapy are preferred for chronic, non-cancer pain. While providers should be allowed to prescribe opioids as they feel is appropriate, other therapies including NSAIDS, tricyclic antidepressants, gabapentin, lidocaine patches, and physical therapy should be considered
- Providers should establish realistic treatment goals. While this is directed at initiating opioids for chronic pain, there is applicability to the ED in discussing what we can realistically do to control someone’s pain. Having these conversations early in their visit can make it easier to establish a treatment plan that will satisfy both the physician and patient.
- Discuss risks of opioid therapy. It is well known that patients can get addicted even with a short-term prescription. Many patients, although not all, will appreciate if you explain this to them as your rationale for not treating them with narcotics. Risks also extend beyond addiction, including complications such as in patients with sleep apnea or those already receiving sedatives such as benzodiazepines.
- If opioids are used, they should be prescribed at the lowest dose that adequately controls pain. Extended release or long acting preparations should probably not be prescribed from the ED. Only prescribe for the shortest duration that is appropriate. This duration will likely be influenced by follow up availability. If someone has a true indication for opioids and cannot get follow up for 2 weeks, your script might be for longer than for the patient that can be re-evaluated in 3 days.
- Use a PDMP. If you live in a state with a good PDMP, consider using it before writing a prescription.
- If you suspect opioid addiction, attempt to refer your patient for treatment. Clearly, resources are currently inadequate. Hopefully if the federal and state governments continue to increase funding as promised, more resources will become available.
- Center for Behavioral Health Statistics and Quality. 2014 National Survey on Drug Use and Quality: detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.
- The DAWN report: highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2013.
- Centers for Disease Control and Prevention. Wide-ranging Online Data for Epidemiologic Research (WONDER), Multiple-Cause-of-Death file, 2000-2014. 2015 (Http://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014.pdf.
- Compton WM, Jones CM, Baldwin GT. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. N Engl J Med 2016; 374:154-63.
- Becker WC, Sullivan LE, Tetrualt JM, Desai RA, Fiellin DA. Non-medical use, abuse and dependence on prescription opioids among U.S. adults: psychiatric, medical and substance use correlates. Drug Alcohol Depend 2008;94:38-47.
- Vital signs: demographic and substance use trends among heroin users-United States, 2002-2013. MMWR Morb Mortal Wkly Rep 2015;64:719-25.
- Rutkow L, Chang HY, Daubresse M, Webster DW, Stuart EA, Alexander GC. Effect of Florida’s Prescription Drug Monitoring Program and Pill Mill Laws on Opioid Prescribing and Use. JAMA Inter Med 2015;175(10):1642-1649.
- Maryland Hospital Association. (2015). Maryland emergency department opioid prescribing guidelines. Retrieved from http://www.mhaonline.org/resources/opioid-resources-for-hospitals
- The New York City Emergency Department Discharge Opioid Prescribing Guidelines Clinical Advisory Group. (n.d.). Retrieved from http://www.nyc.gov/html/doh/downloads/pdf/basas/opioid-prescribing-guidelines.pdf
- Porth, L. (2015, November). Opioid use in Missouri: Strategy for reduced misuse and abuse. Missouri Hospital Association. http://www.mhanet.com/mhaimages/opioid/MHABoardRecs.pdf
- Cantrill SV, Brown MD, Carlisle RJ, et al. Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med 2012;60:499–525.
- The Washington College of Emergency Physicians. (n.d.). Retrieved from http://www.washingtonacep.org/postings/tm_acep_letter_final.pdf
- The Missouri College of Emergency Physicians. http://mocep.org/wp-content/uploads/MOCEP-companion-piece.pdf
- Portral DA, Healy ME, Satz WA, McNamara RM. Impact of an opioid prescribing guideline in the acute care setting. J Emerg Med 2016;50(1):21-27.
- Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007–2012. Am J Prev Med 2015;49:409–13.
- The Food and Drug Administration. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm484765.htm
- New York Times: http://www.nytimes.com/2016/02/05/health/under-pressure-fda-adds-measures-on-opioid-abuse.html?_r=0. Accessed on February 2, 2016.
- The oxy free ED: http://www.mckenziehealth.org/emergency-department. Accessed on February 2, 2016.
- Schwartz TM, Tai M, Babu KM, Merchant RC. Lack of association between Press Ganey emergency department patient satisfaction scores and emergency department administration of analgesic medications. Ann Emerg Med 2014;64(5):469-81.