Prescribing Opioids in the Emergency Department

The management of pain, especially chronic pain, can be very difficult. It is difficult even when a physician has an ongoing relationship with a patient who suffers with chronic pain and has had the opportunity over time to evaluate the patient’s physical condition, mental status, and medical history. When physicians are seeing patients complaining of pain in an emergency department (ED), however, things become even harder.

I was thinking about this issue as I read the initial report of a task force on “prescription painkiller abuse” established by Mayor Michael Bloomberg of New York City, where I practice and live.  In January, the task force issued guidelines on the prescription of opioids in EDs. Public hospitals owned by the city will be required to follow the guidelines and the report recommended that other hospitals in the city institute them voluntarily.¹

The task force makes three major recommendations regarding the writing of prescriptions for opioids to patients who are being discharged from an ED:
1. Long-acting/extended-release (LA/ER) opioids will no longer be prescribed    
2. In most cases prescriptions for short-acting/immediate-release opioids will be limited to a 3-day supply 
3. Lost, stolen, or destroyed prescriptions will not be refilled.
   
Patients with cancer-related pain would be excluded from these recommendations.

The major reason for these recommendations is concern about prescription opioid abuse. From the point of view of providing patients optimal pain management in the ED, I believe that they also make excellent medical sense. These are procedures hospitals should already be following; guidelines from governmental agencies shouldn’t be needed.  

It makes no sense to me that physicians would even consider prescribing LA/ER opioids in an ED setting. The optimal analgesic impact of these agents requires several days to be attained. Thus, for a patient who has come to an ED with either acute pain or exacerbation of chronic pain, prescribing them would offer little immediate relief. 

For patients who come to an ED reporting that they are already taking LA/ER opioids for chronic pain and need new prescriptions, I would wonder why they didn't return to the original prescribing physician. As a covering physician in the ED, I have heard various excuses as to why this wasn't possible. The one about the medications having been lost or stolen is common. Often patients have told me that they were going to run out of medication before their next regular appointment and have been unable to contact the prescribing physician to inform them of this. 

Physicians are trained to be empathetic and to listen to and believe patients. However, I think that physicians who don't express skepticism about such stories are not providing optimal care. 

The only one of the recommendations I have any concern about is the limitation to a 3-day supply of SA/ER opioids. Patients with legitimate pain complaints, especially patients who may have suffered an injury, may require the use of opioids beyond 3 days. Furthermore, they may either be unable to obtain appointments with their physicians quickly or may not even have regular physicians with whom they can follow-up and obtain additional medication if needed. 

That said, however, the guideline is not absolute on the 3-day supply limitation. It does allow prescribing physicians in the ED some flexibility, although I didn't see anything specific to indicate under what circumstances it would be reasonable to prescribe more. It is also important to remember that not getting opioids does not mean patients are being denied access to all analgesics. For most patients, acetaminophen or an over-the-counter nonsteroidal anti-inflammatory drug will provide sufficient relief after 3 days of opioids and, for many patients, opioids are not needed at all.

I can think of no reason why hospitals throughout the country should not adopt similar guidelines. Obviously these guidelines alone are not going to resolve either prescription opioid abuse or inadequate pain management—but they are a step in the right direction.

There is one other issue regarding these guidelines that I think is important. In a New York Times story covering the issuance of the guidelines, unnamed city health officials noted that "In this era of patient satisfaction surveys, doctors were often afraid to make patients unhappy by refusing drugs when they are requested, and the rules would give those doctors some support when they suspected that a patient might be faking pain to get drugs."²

I understand this although it is somewhat disturbing that in order for physicians to do the right thing they would have to say they had no choice in the decision process. However, it does raise a very real and unresolved issue.

Several years ago I attended a conference sponsored by the Federal Government Department of Health and Human Services on patient satisfaction issues. Presenters provided examples of things that could be used to measure satisfaction such as how quickly patients who underwent surgery were able to ambulate afterward or to be discharged from the hospital.

I raised the question as to how patient satisfaction surveys would apply to drug seekers who would be very happy to say you were a good doctor if you gave them prescriptions for the drugs they wanted, no questions asked, but a lousy one if you applied appropriate concern and skepticism about doing so.

I didn't receive any answer then nor have I heard a good one since. 

References
1. New York City Emergency Department Discharge Opioid Prescribing Guidelines Clinical Advisory Group. New York City Emergency Department Discharge Opioid Prescribing Guidelines. Accessed January 11, 2013.
2. Hartocollis A. New York City to Restrict Prescription Painkillers in Public Hospitals’ Emergency Rooms. New York Times. January 11, 2013. Accessed March 3, 2013.