In the ER: Too Much or Too Little Pain Medication?
Do we as physicians prescribe too many narcotics? Specifically do we emergency physicians prescribe more than we should? As with much else in medicine the evidence is complex and at times contradictory. Some examples of the argument that we are not aggressive enough in the treatment of pain are the following:
Racial and ethnic disparities in pain management
Under treatment of acute pain in the emergency department
Under treatment of pain in elderly leads to opioid misuse
CMS to measure timing of ED pain medication in long bone fractures
If you have spent any time looking at the news or proposed state legislation the answer would clearly be yes. There is an epidemic of deaths related to prescription drug use and misuse. The problem is stark both in terms of the individual tragedies and sheer numbers.
The CDC has some great graphics that show the scope of the problem:
where drugs come from
So where does emergency medicine come in? How big of a source of narcotics and other controlled substances are we? During a meeting with officials involved in the PMP they stated that 340,000,000 tablets of narcotics are prescribed in the State every year. That seems like a lot but how much knowingly (more on that later) comes from emergency physicians?There really is no good published data. But I have my own….
CaptureAccording to the Practitioner Self-Lookup (See Tip Box below) in the last 12 months my patients have filled approximately 300 prescriptions (4,599 tablets) for narcotics in pharmacies in the State of NJ. The average was for 15 pills of a 5mg oxycodone compound. During that time period I treated about 3,000 patients over 1200 clinical hours (almost exclusively adults).
If emergency physicians throughout the state have similar experiences than we account for 2-4% of narcotics prescribed. Hardly the likely source of most diverted or abused narcotics. From my own personal experience non-selective use of the PMP (checking everyone) is low yield (less than 8%) in terms of identifying at-risk patients. But that does not mean we don’t have a role in reducing abuse.
emergency signNJ-ACEP is actively involved through both the Board of Directors and also an ad-hoc Opiate Task Force. As mentioned earlier we met with officials from the Division of Consumer Affairs to give our constructive suggestions on how to improve the NJ PMP (njrxreport.com). This included:
More frequent updating of information (currently twice a month)
Ability to communicate with other prescribers about at-risk patients
Significant improvements to the user interface.
We are also advocating for our physicians and our patients as legislation regarding opioid prescribing and mandatory use of the PMP are brought forward. While our formal position has not completely coalesced here are some major elements:
As emergency physicians we are on the front lines of treating the devastating effects of drug abuse (including prescription medications).
Selected use of the NJ PMP can be effective in identifying patients at risk of prescription drug abuse and diversion.
Mandatory use in the acute care setting would be cumbersome, low yield and targeted at only a small percentage of narcotics prescribed.
Increased resources to treat both addiction and pseudoaddiction are needed in our State.
Programs that remove unused controlled substances from medicine cabinets (in NJ Project Medicine Drop) are vital and need to be expanded.
As with many of our patients lack of access to appropriate care (primary care, pain management, palliative services) causes those with chronic pain to seek piecemeal treatment in the emergency department.
We will continue to update you throughout the year as more information becomes available. As always we want to hear your thoughts.
Dr. Adinaro is the president of NJ-ACEP for 2013-14 and is the Chief of the Adult Emergency Department at St. Joseph’s Regional Medical Center in Paterson, NJ. He is also the current editor of this blog and the series: “Year of Confusion…Year of Opportunity: 20 Things Changing Emergency Medicine”. Dr. Adinaro can be reached via @PatersonER and his personal blog: PatersonER.com.
This publication represents the personal opinion of the author and does not reflect the official policy of NJ-ACEP or the American College of Emergency Physicians. You can contact us here.