The Opioid Prescription Epidemic and the Role of the Emergency Medicine - Water Cooler Recap

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The Opioid Prescription Epidemic and the Role of the Emergency Medicine by Poon S & Greenwood-Ericksen M in Ann of Emer Med 2014    

Pinto, K from https://www.flickr.com/photos/kokopinto/1744766359/ https://creativecommons.org/licenses/by-sa/2.0/

Pinto, K from https://www.flickr.com/photos/kokopinto/1744766359/ https://creativecommons.org/licenses/by-sa/2.0/

80% of heroin users start by abusing prescription medications – this is OUR problem         

Prescription medication overdose is now the leading cause of death from injury and the number of deaths from drug overdoses has increased every year since 1999. Estimates suggest between 6 and 12 million Americans receive prescription drugs either without prescription or without the intent of relieving pain. This article focuses on the ED provider’s role in this epidemic and offers strategies for improving training and education surrounding these medications. While heroin abuse tends to draw more attention, it is important to note that 80 percent of heroin users started their addiction by using prescription medications. Given pain in a variety of forms is the most common reason patients present in ED, the prescription drug epidemic directly effects ED residents and faculty and places pressure on us as a profession to develop better training, guidelines, and understanding regarding the appropriate treatment of pain.  

There is a lack of guidelines regarding opioid prescribing practices for ED providers.  

Surveys of ED physicians demonstrate a lack of uniformity in prescribing patterns. This makes producing consensus guidelines or statements on a national level difficult.  On a local level, some state ACEP groups and private physician groups have developed guidelines for ED opioid prescribing that focus on avoiding prescriptions for long-acting opioids and refusing to provide refills for controlled substances that were lost, destroyed or stolen. These guidelines also recommend screening for opioid abuse and prescribing no more than 3 days’ supply of opioid analgesics. States vary on their mandatory usage of a prescription drug monitoring program, but all guidelines recommend utilizing these databases when available in the ED.

Residents are not formally taught how to prescribe opioids responsibly.                 

The authors suggest that the problem may lie in the lack of training regarding opioid prescription practices for residents. Surveys show that ED residents feel under-prepared to safely prescribe opioids, especially for the management of chronic pain. Research from primary care residencies demonstrates that focused training on these issues corresponds to increased resident comfort with prescribing pain medications. The 5-hour didactic presented by the article includes education on the pathophysiology of pain; opioid related death and injury; a focus on back pain, dental pain, and headache treatment; and small group discussions and simulations of patient encounters for pain medications. 

 We know there is a problem but how do we find time to explain to patients why opioids are not always the answer?    

The discussion had on The Water Cooler mirrors many of the same concerns raised in the article, with the focus being on the lack of consistency in prescribing patterns between physicians. Especially amongst the resident comments, it seems that a consistent prescribing pattern for X disease process (the department wide pattern of no opioids for dental pain was used as a successful example) provides a framework for both conversations with patients and a guide for junior residents to develop a consistent prescribing pattern within their own practices. A simple “it is not my practice to prescribe X for problem Y” was suggested as a way to initiate conversation with patients. Residents acknowledged the importance of communicating the dangers of opiates but often do not have the time to have this conversation with their patients.

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