September 19, 2012 -- For someone suffering from debilitating, chronic pain, prescription narcotic painkillers can make quality of life possible. But there is also a tremendous potential for abuse and misuse. As an emergency physician, Dr. Sharon Meieran sees the consequences all the time.
“Every day in the ED I see the fallout from misuse of these
medications,” Dr. Meieran says. “It takes the form of overdose, addiction and suicide attempts.”
Not only do emergency doctors see the results of overdose and
addiction, they frequently treat patients who see the emergency
department as a source of these drugs. While front-line emergency
doctors have an obligation to evaluate patients who report pain, the
doctors can’t know if these patients may already have received
painkillers somewhere else and they can’t monitor patients' long-term use of the drugs.
“There is a difference between people with acute pain and pain for
legitimate conditions and people who want narcotics for themselves or their friends or family,” says Dr. Wade Fox, DO, who works for California Emergency Physicians America in the emergency department at Mercy Medical Center in Roseburg. “If you have a broken ankle or cancer and are in pain, there is no emergency physician in the Western world who is not going to treat your pain aggressively.
“But those with chronic pain—back pain, migraines, chronic abdominal pain—who’ve run out of their pain medications at the end of the month, that’s a problem more appropriately managed by a single provider, using an interdisciplinary approach — physical therapy, counseling, etc. — rather than us in the emergency department,” Dr. Fox says.
And there are those “patients” who follow a regular circuit, driving
up Interstate 5, heading east on I-84, and then south on Highway 97, stopping at hospitals along the way, asking for pain medications.
“Misuse of prescription opioid medications has reached epidemic
proportions,” Dr. Meieran says. “These medications, such as oxycodone (Percocet) and hydrocodone (Vicodin), are being misused at an alarming rate, and people are dying as a result. Everyone I know has some close personal connection to an individual who is affected by this public health epidemic, and they are crying out for help.”
Dr. Meieran is also past president of the Oregon Chapter of the
American College of Emergency Physicians, which has taken a
substantial, proactive step to address this public health problem.
Effective September 15, 2012, Oregon’s emergency physicians are
adopting uniform guidelines for prescribing these medications from
EDs. Information about the guidelines will be posted in ED waiting
rooms statewide, advising patients of the guidelines and explaining
how they will be implemented.
“We are the number one source of prescription opioid medications, and we have a responsibility to take action,” Dr. Meieran says. “For a long time, we have acted in a disjointed fashion, with the right hand not knowing what the left hand was doing. We have come together in the public interest to ensure that these medications are prescribed consistently, appropriately and responsibly.”
It is a big challenge for the emergency department team to walk the
fine line between responsible prescribing and their primary objective of providing care. But the cost of doing nothing is staggering:
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Prescription medications are second only to marijuana as the most abused category of drugs in the United States.
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The emergency department is the largest ambulatory source for opioid painkillers.
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The estimated number of emergency department visits involving nonmedical use of narcotic pain relievers more than doubled in just four years, 2004 to 2008.
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The number of fatalities from drug overdoses exceeds those from traffic accidents, and prescription drug overdoses represent more than half of those fatalities.
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Well over half of unintentional overdose deaths now are caused by prescription opioids, and since 2007, prescription opioids have been involved in more overdose deaths than heroin and cocaine combined.
In Oregon, as of a few years ago:
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The state had the fifth highest rate of nonmedical use of prescription painkillers. Nearly 700 poisoning deaths were associated with prescription opioids in the years 2003–2007.
Of Oregonians age 18 to 25, 17.9 percent have used prescription opioids, the highest of any state. Seven percent of Oregon 11th grade students say they’ve used a prescription drug in the past 30 days to get high.
The voluntary guidelines adopted by Oregon emergency physicians, in cooperation with the Emergency Nurses Association and the Oregon Medical Association, are modeled on guidelines other states are following, including the state of Washington, which enacted its guidelines under the mandate of a state law. It has been endorsed by the Oregon Health Authority (OHA), the Oregon Association of Hospitals and Health Systems and the Oregon Academy of Family Physicians.
“We must work together to be sure prescriptions drugs are used appropriately,” says Bruce Goldberg, MD, OHA Director. “Deaths from prescription drug overdoses are devastating to families and are preventable.”
Dr. Meieran agrees.
“As emergency physicians, we want to work in a coordinated fashion with primary care providers and others to create a system where people are treated compassionately, effectively and appropriately for their pain,” she says.
