Opioid Prescribing in the Emergency Department

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Deaths in the US caused by opioid overdose have increased nearly 10 fold in the past 10 years with opioid analgesics responsible for more deaths annually than both motor vehicle crashes and suicides combined. Nearly all prescription drugs involved in overdoses come from prescriptions as opposed to pharmacy theft, however, once prescribed and dispensed prescription drugs are often diverted to people using them without prescriptions. In 2012, US healthcare providers wrote 259 million prescriptions for opioid medications despite more than 100 individuals dying each day from an overdose of prescription painkillers. Pain is a major symptom of patients presenting to the emergency department with nearly 42% of ED visits related to painful conditions and opioid prescribing in the emergency department has nearly quadrupled in the past decade. In 2009, emergency medicine ranked third amongst all specialties in terms of number of opioid prescriptions, writing approximately 12% of total opioid prescriptions. In response to this significant rise in opioid prescribing, the American College of Emergency Physicians released a 2012 policy statement recommending the judicious use of opioid medications in non-cancer patients. Despite these recommendations, many hospital emergency rooms do not have individual policies regarding prescribing practices. In our urban community hospital in Denver, Colorado, we propose to reduce opioid prescribing in the emergency department by creating a policy to limit outpatient prescriptions. The policy will include a provision that providers will not prescribe opioids to patients currently receiving these medications from another prescriber or if they have been prescribed opioids from another facility within the past month.

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3 Responses to “Opioid Prescribing in the Emergency Department”

  1. dscordi1 Says:

    As an Emergency Physician, this is a topic near and dear to me. Opiate abuse is a serious issue. The Joint Commission focus on pain from the late 90’s and the increasing pushes for good patient satisfaction scores have driven bad medical practice. Narcotics for the treatment of chronic pain is poorly proven and is potentially harmful.

    Few would argue that a patient a broken arm can have a few days of a narcotic pain medicine for his acute injury. However, this same patient may end up taking daily narcotics for years because he develops chronic pain at this site. We, as physicians and as a society, need to refocus on non-narcotic analgesia.

    Adherence to the policy that ACEP has provided is a reasonable start, however, addressing the other major prescribers (Primary card, Pain Management and Surgery) is just as important if not more, since they often write for more pills and higher doses than ED physicians will.

    This a topic that can not be ignored and must be addressed by the houses of medicine, surgery, the American Medical Association, the DEA, and FDA.

  2. kwells32014 Says:

    This is a great post! As a physician, particularly as a young physician still in residency this issue is one I am very cognizant of. Our surgery patient’s would often undergo very extensive operations that would require opiate narcotics for treatment. I would always encourage taking the medication for the first 24-48, sometimes 72 depending on the severity of the operation and incision. However, I would always try to recommend alternatives to opiates such as intermittent Advil or Tylenol (depending on their opiate). This is such a difficult aspect of medicine because pain is real, but how aggressive should we be? I think the job that the ACEP and many other medical organizations are doing to research and improve this aspect of medicine is wonderful.
    Just as I was completing medical school in Georgia, Georgia created a Prescription Drug Monitoring Program, and I know in Ohio where I was in residency we also had a similar online database that allowed for monitoring of a patient’s current prescription usage and which physician’s were prescribing this medication (http://medicalboard.georgia.gov/sites/medicalboard.georgia.gov/files/imported/GCMB/Files/GCMB-PDMP0713v2.pdf). I hope all states will go to this type of monitoring system, and I think the physicians who prescribe opiates non-judiciously should also be held accountable as irresponsibility on our behalf has contributed to the problem.

  3. cvshirley Says:

    Since pain is one of the most common reasons for visits to the emergency department, this is an extremely important topic to discuss. As a clinical pharmacist in the emergency department, I have continued to see inappropriate narcotic prescribing practices among ED physicians as well as consulting services that see patients in the ED.

    And as mentioned in the original post, patient satisfaction scores have significantly influenced the rise in narcotic use in the ED. Many factors influence the choice of treatment and use of narcotics, such as physician perception of the patient, differences in pain experiences based on patients’ race and gender, type of pain. At the academic institution where I work, we have continued to focus on ED resident education regarding narcotic use, especially in chronic pain patients who present to the ED, in which more narcotics are often resulting in more harm than relief. As mentioned in other comments, in the last few years Virginia has also promoted it’s Prescription Monitoring Program that will hopefully continue to help ED physicians with appropriate prescribing of narcotics.

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