Guidelines for Opioid Prescription: do emergency physicians need support?

April 9, 2013, 4:00 pm

pain 5th vital sign★★★★☆

Guidelines for Opioid Prescription: Why Emergency Physicians Need Support. Kunins HV et al. Ann Int Med 2013 Apr 9 [Epub ahead of print] 

Abstract

In this article, 3 internists association with the New York City Department of Public Health tell emergency physicians why they need the recently published guidelines suggesting restrictions on opioid prescribing in emergency departments.

Despite the vaguely offensive provenance and title of the article, I found myself agreeing with much of what they say, just as when the guidelines came out I thought — although many colleagues disagreed — that they were reasonable. (To read my previous discussion, click here.)

The authors get right to the point:

Many physicians, including emergency physicians, are immensely conflicted about opioid analgesics. They fell accountable to patients requesting opioids for subjective pain; to guidelines and standards that imply that withholding opioids constitutes poor medical practice; and to institutions valuing patient satisfaction surveys that reward physicians for meeting patient requests, whatever they may be. At the same time, physicians are increasingly aware of the terrible consequences of opioid use, such as overdose and addiction. The face complex and difficult decisions as they navigate the desire to relieve pain and to keep patients safe.

They note that deaths from opioid overdose have increased almost four-fold from 1999 to 2010, a rate that parallels the increase in opioid prescriptions:

The increase followed aggressive pharmaceutical marketing that exaggerated the efficacy of opioids for chronic non cancer pain while downplaying their risks. A frequently cited 1% risk for addiction to opioid analgesics, based on short-term opioid courses in hospitalized patients, was extrapolated to justify the safety of long-term outpatient use. Pain was crowned as “the fifth vital sign,” first in the Veterans Health Administration and then throughout the health care system.

They also point out that the efficacy of opioids in treating chronic non-cancer pain has never been demonstrated.

I know that many emergency physicians objected when the NYC guidelines were first announced, bizarrely and unwisely in a news conference given by Mayor Michael Bloomberg. The original report stated that the restrictions were mandatory, at least for  NYC’s public hospitals. That is no longer the case. But my feeling is that even if the restrictions were mandatory they would not be inappropriate. The epidemic of opioid prescribing — and related addiction and overdose — has gotten so out of hand that drastic measures may be required.

An accompanying article by Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians, stresses that in the context of the entire epidemic of opioid prescriptions, emergency physicians are a very small part of the problem, writing fewer than 5% of all opioid prescriptions. He also notes that limiting emergency physicians to prescribing, at most, 3 days worth of opioids may increase return visits and exacerbate the crisis of ER overcrowding.

To read my Emergency Medicine News column on “The Dark Truth Behind Pain as the 5th Vital Sign,” click here.

Related posts:

NYC Recommendations for Prescribing Opioids in Emergency Departments

Long-Term Opioid Therapy Reconsidered: Addiction is Not Rate in Pain Patients

The money and influence behind “Pain as the Fifth Vital Sign”

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