Drugs in the ER
Opioid use and misuse for non-cancer pain is a challenge for emergency department physicians, the health care system and society. There are some disturbing trends reported by the Center for Disease Control (CDC) over the last few years. Between 1991 and 2010 prescriptions for opioid analgesics increased from 75.5 million to 209.5 million according to the National Institute of Drug Abuse (NIDA). This was followed by an increase in abuse and overdose. The CDC estimates that narcotic pain relievers now cause or contribute to nearly three out of four prescription drug overdoses and about 15,000 deaths per year.
The Joint Commission on Accreditation of Healthcare Organizations made pain “the fifth vital sign” in 2001 and raised the awareness of oligoanalgesia in the emergency department. Some have questioned having a subjective sign of pain as a vital sign (Skeptical Scalpel). We can objective measure a heart rate or blood pressure but how to we accurately measure someones pain?
In the US, emergency department physicians started being evaluated and compensated by means of patient satisfaction with emergency department pain control. This provided a misguided incentives for giving out opioids. Emergency department physicians are among the most frequent prescribers of opioids. (Volkow et al. JAMA 2011).
The SGEM touched on this issue in Episode #55: Drugs in My Pocket. This was part of the SGEM Journal Club initiative and recorded at the home of evidence based medicine, McMaster University.
American College of Emergency Physicians published practice guidelines regarding opioids in 2012. They suggest that opioid use be carefully individualized and time-limited. Here are some of their recommendations (Level C):
- Physicians should avoid the routine prescribing of outpatient opioids for a patient with an acute exacerbation of chronic non-cancer pain see in the ED.
- The Prescriber should consider the patient’s risk for opioid misuse, abuse or diversion.
- If opioids are prescribed on discharge, the prescription should be for the lowest practical dose for a limited duration.
Dr. Michael Barton does a holiday parody video for his emergency department. Check out his videos called My Boss is a CEO and My Best Press-Ganey Score Yet.
Click to watch video
This year Michael tackled the issue of opioids use and abuse using the Taylor Swift song We are Never, Ever Getting Back Together. Click HERE to watch the video on YouTube.
I think he did a good job balancing the difficulties face by both the patients and physicians. He ends the video with a written message summarizing the issue:
- The non-medical use and abuse of prescription drugs is a serious public health problem.
- Medical providers need to continue to address this issue while avoiding the tendency to prejudge and react with irritation from the fear of being manipulated by “drug seekers”.
- Patients’ presenting to the ED with pain-related complaints should be evaluated without bias and with consideration of the underlying cause of their pain.
- And we need to help our patients understand that although we may not provide them with narcotic pain medication at their visit, we will always try to help them.
To learn more about prescription drug abuse visit the National Institute on Drug Abuse website.
Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.