Written by Christopher R. Carpenter, MD, MSc, Washington University in St. Louis School of Medicine Division of EM, Missouri ACEP Member, Emergency Medical Abstracts Facult and W. Kenneth Milne, MD, University of Western Ontario, Emergency Medical Abstracts Faculty
Reproduced with permission of Emergency Medical Abstracts from September 2016 issue
Hardly a month goes by when the topic of prescription-drug initiated illicit substance abuse leads the mass media news or pops up in one of the emergency medicine trade journals. The numbers illustrating the growth and scope of the problem in the United States (U.S.) are staggering.
- Annual Oxycontin prescriptions increased from 76 million to 207 million between 1991 and 2013, which correlates with a doubling of the number of opioid-related emergency department visits between 2004 and 2011. [CDC 2015]
- 14,000 prescription opioid-related deaths occurred in 2014 alone. [CDC 2015]
- Drug Enforcement Agency Schedule II agent prescribing in children increased from 3.6% in 2001 to 7.0% in 2010, led by hydrocodone which was Schedule III until 2014. [Mazer-Amirshahi 2014a]
- In adults, the percentage of ED visits during which an opioid was prescribed increased from 20.8% to 31.0% between 2001 and 2010, while prescribing of non-opioid analgesics were unchanged. [Mazer-Amirshahi 2014b]
- The U.S. (which constitutes 4.6% of the world’s population) consumes 98% of the world’s hydrocodone supply and 80% of the global opioid supply. [Manchikanti 2008]
- The Centers for Disease Control identified scant evidence of benefit for long-term opioid therapy for chronic pain outside end-of-life scenarios, noting that harms likely outweigh benefits. [CDC 2016]
One might reasonably question whether emergency medicine contributes significantly to these statistics. For example, a one-week cross-sectional survey of EDs across the U.S. indicated that 17% of discharged patients were prescribed an opioid and almost always in small amounts (median 17 pills) and immediate-release formulations. [Hoppe 2015] A recent editorial estimated a Number Needed to Harm of 7,864 ED visits with opioid therapy to create one new heroin abuser. [Yealy 2016] However, ED prescriptions for opioids may precede 1/3 of heroin addictions in the urban U.S. [Butler 2016] Understanding the events contributing to this epidemic is important, as is weighing the advantages and disadvantages of evolving interventions to stem the rising tide like prescription drug monitoring programs. The yin and yang of oligoanalgesia and over-prescribing opioids have been explored on EMA (October 2012: Illicitly Seeking Controlled Medications and May 2014: Opiates – Too Little, Too Much). This month’s essay will explore the current epidemiology of opioid misuse in ED settings within the context of professional society guidelines and evolving legislative efforts to reverse the devastating trend of narcotic abuse related deaths.
Defining the Ethical Quandary
Just as healthcare providers are ethically bound to provide high-quality advice, as well as courteous and timely care to their patients, patients are expected to be honest when conveying medical history to their physicians. [AMA Code of Ethics, 2016] Patients who knowingly deceive providers risk disruption of the mutual trust that is a prerequisite for efficient and cost-effective medical decision-making in the acute care environment in which those who deliver healthcare are simultaneously squeezed by credentialing organizations to avoid oligoanalgesia and dissatisfied customers on the one side with an ever-expanding outcry from news outlets, victim’s families, and legislatures to reduce opioid prescribing. Although biomedical ethics emphasize the principle of autonomy (the right of a competent individual to choose amongst reasonable medical options without coercion), society has limited any individual’s access to opioid medications for multiple reasons: dependency, compromised judgment that can imperil others via neglect or motor vehicle accidents, and unintended death via respiratory depression. Physicians are also expected to optimize the benefits of medical care (beneficence), while minimizing iatrogenic harms (non-maleficence). Therefore a balance must be struck between patient autonomy and physician judgment when evaluating options for pain control.
Barriers to Addiction Management
One ED provider concern is that physicians are encouraged to “just say no” to opioids without offering acceptable alternatives, particularly for under-insured patients who lack timely access to primary care or any access to pain medicine or rehabilitation services. Brief interventions alone are unlikely to reduce opioid abuse. [Merchant 2015] ED initiated buprenorphine treatment yields more opioid-free days and less inpatient detoxification services, but prescribing opioid antagonists requires certification that most ED providers lack. [D’Onofrio 2015] Expanding access to addiction recovery services will be essential to combat the opioid epidemic. [Volkow 2014]
Challenges Confronting Opioid Reductionists
Since many ED conditions that elicit pain are subjective (headache, abdominal pain, neuropathic pain, sickle cell crisis) without a quantifiable vital sign or lab to verify or qualify the degree of pain, some providers err on the side of the golden rule: treat others as I would be treated and assume truthfulness of each individual. Others often begin from the perspective of guilty until proven innocent – that almost every patient is in less severe pain than they report and opioid analgesia will not be prescribed. Risk factors that differentiate aberrant drug behavior from genuine pain control issues are poorly developed for chronic pain and do not exist for acute pain or ED settings.[Chou 2009, Solis 2010a, Solis 2010b] The American Society for Pain Management Nurses recommends against the term “controlled medication seeking behavior” completely due to concerns for prejudice, premature closure bias, and care access barriers. [McCaffery 2005] Early evidence indicates that Shared Decision Making to select optimal analgesia does not increase opioid prescribing and could represent an ethical middle ground for skeptical and more liberal providers, but as discussed on the March 2016 EMA essay such an approach will require time, training, and adequate acceptance by providers and patients. [Holland 2016]
Another barrier to real-time interventions that address controlled medication seeking behavior is the legal aspects surrounding medical fraud. If opioid-seeking behavior is confirmed during an episode of ED care, what is the provider’s obligation to notify law enforcement? Some hospital bylaws view such whistle-blowing as a violation of the Health Insurance Portability and Accountability (HIPAA) patient privacy. Although these situations should be discussed with individual hospital’s risk management teams, scenarios in which HIPAA might be bypassed include: 1) controlled medication seeking behavior involves theft of or tampering with prescriptions, or witnessed re-selling of the drugs; 2) the patient exhibits an imminent threat to public safety (driving away under the influence); or 3) the patient is an imminent threat to themselves. The last scenario is almost impossible to prove when the threat is avoided, but controlled medications account for 30% of drug-related deaths. [Solis 2010b]
Solutions to Reduce ED Opioid Prescribing
Common sense and medical intuition are and will likely always be the first- and best-line of defense against individuals seeking controlled substances under false pretense. Red flags for such medication seeking behavior are myriad, including: seeking different providers/institutions/pharmacies over short time, obtaining street drugs when prescriptions unavailable, theft of medical supplies, primary provider or caregiver concern for additive behavior, frequent loss of medication sought, or use of false identification. [Solis 2010b] Obviously, objective findings supporting an acute source of pain (dental abscess, acute fracture, appendicitis) mandate timely analgesia using the least potent, most effective medication. Sometimes, that medication will be an opioid, but often non-opioid analgesia is adequate so a stepwise approach is reasonable, [Oyler 2015] if pain can be frequently reassessed and more potent analgesia is provided when needed prior to discharge from the ED. ACEP Guidelines recommend that routine opioid prescribing for chronic non-cancer pain be avoided, but provide no recommendations for acute pain management. [Cantrill 2012] The CDC recently provided 12 recommendations to guide physician opioid ordering. [Schwarz 2016] Faculty-approved opioid prescribing guidelines have reduced narcotic prescribing significantly in some settings, [del Portal 2015] and one ED has taken this to the extreme with an “opioid-free emergency room” that uses alternatives like nitrous oxide, trigger-point injections, and a therapeutic harp! [Hoffman 2016]
Primary care providers and Pain Medicine specialists sometimes use a pain management contract that explicitly defines who, what, how much, when, and how controlled medications will be prescribed with consequences for patient excursions away from the agreement. [Hariharan 2007] However, many settings and patients lack access to a single primary care provider and/or pain management services. In Grand Rapids Michigan, Dr. R. Corey Waller left emergency medicine for a Pain Medicine fellowship and then developed the “Spectrum Health Medical Group Center for Integrative Medicine” in which he and his staff served as the sole primary care provider for “super-utilizers”. Their protocols included weekly face-to-face evaluations between Dr. Waller and his patients, as well as individualized care sets that appeared on the electronic medical records for ED providers if Dr. Waller’s patients received care in the ED. Those care sets included instructions to call Dr. Waller immediately (he was on-call 24/7/365) and to not prescribe opioids without first speaking to him. [Thoms 2012]
Prescription drug monitoring programs exist in 49/50 states in the U.S. (Missouri is the lone holdout). Critics of these programs note patient privacy concerns and unwarranted deterrence of appropriate opioid-prescribing by some providers. [Solis 2010b] One single-center prospective (non-randomized) study reported that a statewide prescription monitoring plan altered opioid prescribing in 41% of cases (2/3 prescribed less and 1/3 prescribed more than planned before review of the database). [Baehren 2010] In Florida, prescription drug monitoring and “pill mill laws” reduced opioid prescribing by 1.4% with similar trends noted in Texas. [Rutkow 2015, Lyapustina 2016] However, another observational study across two academic hospitals in non-geriatric adults presenting with back pain, dental pain, or headache demonstrated fair agreement (κ = 0.30) between clinician gestalt and prescription drug monitoring criteria for drug-seeking behavior and only altered intended prescribing in 9.5% of cases. [Weiner 2013]
Better understanding the role emergency medicine has played in the opioid abuse epidemic remains elusive, but a more important question is how our specialty can help reduce this plague without compromising timely pain relief for those with acute crises. Additional research is needed to improve the detection and management of opioid prescribing in the ED setting. [Solis 2010b]
- Reliability and accuracy of warning signs for controlled medication seeking behavior for acute pain in the ED.
- Ethical and effective thresholds above which ED provider notifies legal authorities about controlled medication seeking behavior.
- Reliability, accuracy, and effectiveness of existing state prescription drug monitoring programs to reduce controlled medication seeker prescribing without negatively impacting timely analgesia for legitimate pain patients.
- Effectiveness and costs of ED-initiated strategies to treat controlled medication addiction issues and behaviors.
CDC Website, Today’s heroin epidemic, July 7 2015, http://www.cdc.gov/vitalsigns/heroin/
CDC Website, Prescription Opioid Overdose Data, June 21, 2016. http://www.cdc.gov/drugoverdose/data/overdose.html
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