- Emergency physicians see first-hand the devastating consequences of drug misuse and abuse.
- More people in the United States die of drug overdose than motor vehicle crashes. [i]
- According to an American Journal of Preventive Medicine study (2015), the largest percentage drop in opioid-prescribing rates between 2007 and 2012 occurred in emergency medicine (-8.9%) [ii]
- Emergency physicians typically prescribe only a few narcotic pills at a time — enough to last until a patient can see an outpatient medical provider.
- Pain management remains one of the top reasons people legitimately seek emergency care. There is no objective test for pain.
What are opioids?
Opioids are a type of prescription narcotic medications that relieve pain. They can reduce the intensity of pain signals the reach the brain. These medications include Vicodin, codeine, oxycodone, (also OxyContin), Percocet, morphine and other related drugs. The most common diagnoses associated with opioid pain reliever prescribing are back pain, abdominal pain and extremity fracture or sprain. [iii] These kinds of drugs are used safely when the doctor’s instructions are followed carefully. They become most dangerous and addictive when taken with methods to increase the euphoric effects, such as snorting or injecting crushed pills, or combing the pills with alcohol and other drugs.
How serious is the prescription opioid abuse problem in the United States?
Every day, more than 40 people die in the United States from overdose of prescription painkillers. That’s more than 16,000 deaths a year. It has more than quadrupled since 1999. [iv] Nearly 60 percent of drug overdose deaths involved prescription drugs. In 2011, improper use of prescription drugs led to 1.4 million ER visits in the United States.[v] The Centers for Disease Control and Prevention (CDC) has classified prescription drug abuse as an epidemic.
Over two million people in the United States suffer from substance abuse disorders related to prescription opioid pain relievers.[vi] While there has been a decrease in the use of some illegal drugs like cocaine, data show that nearly one-third of people ages 12 and older who used drugs for the first time in 2009 began using a prescription drug non-medically. [vii] Opioid analgesics are a major contributor to this trend in preventable death.
The total number of drug-related emergency visits nearly doubled from 2004 to 2010. Of those visits, about half — or 2.3 million — involved misuse or abuse of prescription drugs. Emergency visits involving misuse or abuse of prescription drugs increased by 115 percent between 2004 and 2010, from 626,472 visits in 2004 to 1,345.645 visits in 2010. By contrast, ER visits for illicit drugs increased by only 18 percent during the same period.[viii]
Illegal narcotic diversion for profit and illicit use, as well as accidental overdose and inadvertent addiction, are potentially preventable causes of death. [ix]
According to the White House Office of National Drug Control Policy, some who misuse prescription drugs, particularly teens, believe these substances are safer than illicit drugs like cocaine and heroin, because they are prescribed by health care professionals and dispensed by pharmacists.
What does opioid prescribing in the emergency department look like?
Emergency physicians’ first responsibility is to the patient and to relieving suffering. There is no objective test for pain. Pain management is a major reason for why many patients go to emergency rooms with up to 42 percent of emergency department visits being related to painful conditions. [x]
Sometimes the availability of an outpatient, office-based medical appointment can be upwards of a week from the point of the patient’s initial emergency visit, so emergency physicians will often prescribe a few pain pills to help control pain until the patient can see his or her doctor.
Emergency physicians write fewer than 5 percent of all immediate-release opioid pills [xi] prescribed. According to a study in Annals of Emergency Medicine, only 17 percent of patients discharged from the emergency department were given prescriptions for opioid pain relievers. The study also concluded that nearly all of these prescriptions were immediate-release formulations and an overwhelming majority of them were small pill counts.[xii]
There are multiple pressures on emergency physicians to address patient pain while also working to prevent opioid abuse and addiction. [xiii]
What do emergency physicians recommend to help address opioid abuse?
Emergency physicians have worked to educate the public and their peers about drug abuse, both nationally and at the grass-roots level. They have spoken to community groups, reporters and policy makers about the effects of prescription drug abuse on their communities and their patients.
Prescription drug monitoring programs (PDMP) can be effective and emergency physicians generally support their use. As for 2015, PDMPs are available in 49 states with the exception of Missouri.[xiv] Emergency physicians can look up a patient to see if they have a record of drug-seeking.
Dedicated drug-seekers can be creative about feeding their addictions, and it is important that emergency physicians be able to provide adequate pain medication to patients who legitimately need it. Some emergency physicians warn that mandatory drug monitoring programs could have the unintended consequence of inhibiting their ability to provide pain relief to patients who legitimately need it. In addition, some research shows that access to prescription drug monitoring program data actually increases the amount of pain medication emergency physicians prescribe to about half their patients.
Because the issue is so complex, it is essential that emergency physicians be involved in developing policies about these programs. Lack of funding has impeded the actual implementation of the monitoring systems in some states.
Pharmacies need a national system that automatically identifies opioid prescription and dispensing by pharmacy, patient and physician. The patchwork of state and municipal regulations has not yet evolved into a consistent and effective approach to opioid abuse.
Physicians can use these monitoring systems to augment their professional judgment and knowledge of the individual patient to choose the most appropriate pain relief for the situation. The more accessible these databases and tools are, the more they will be used successfully.
What can be done to decrease prescription opioid abuse?
First and foremost we must education patients, from health class in elementary school to the internist and family practitioner’s office. At the pharmacy, where these medicines are dispensed, patient education can take place via package insert and pharmacist – patient interaction. Patients are understandably very afraid of pain and can be resistant to trying non-opiate pain relief first, even though it can be extremely effective. All physicians should be urged to educate their patients about non-opiate pain relief options and encourage their use first, before turning to opiate pain relief.
Enforcement is also critical to preventing the illicit distribution and abuse of narcotics. The Drug Enforcement Administration and some state district attorneys’ offices have addressed this issue with renewed vigor. For example, Florida has closed nearly 254 “pain clinics” [xv] (also called “pill mills”), many along the South Florida Rte. 95 corridor. Clearly, our criminal justice system has a mandate to eliminate illicit diversion and corrupt pain clinics (pill mills) and to prosecute criminally corrupt physicians. We must correctly target these sources of the problem.
The pharmaceutical industry has a role to play, too. The graph of overdose deaths parallels the graph of pills dispensed over the last 15 years. Annual estimates of national opiate demand can be more accurately determined in concert with the DEA. Distribution from pharmaceutical house to pharmacy to patient would benefit from a better tracking system.
[i] Warner M, Chen LH, Makuc DM, Anderson RN, Minino AM. Drug poisoning deaths in the United States, 1980-2008. NCHS Data Brief. 2011: 1-8 [PMID: 22617462]
[ii] American Journal of Preventive Medicine, 2015, “Trends in Opioid Analgesic – Prescribing Rates by Specialty, U.S., 2007-2012, http://www.ajpmonline.org/article/S0749-3797(15)00089-6/abstract
[iii] Annals of Emergency Medicine, 2015, “Opioid Prescribing in a Cross Section of U.S. Emergency Departments, http://www.annemergmed.com/article/S0196-0644(15)00233-4/abstract
[iv] Centers for Disease Control and Prevention, 2015, Injury Prevention and Control: Prescription Drug Overdoses
[v] Annals of Epidemiology, “Multiple ER Visits Linked to Risk of Prescription-Drug Overdose Death,” http://www.nlm.nih.gov/medlineplus/news/fullstory_152550.html
[vi] National Institute on Drug Abuse, Prescription and Over-the-Counter Medications, 2014, http://www.drugabuse.gov/publications/drugfacts/prescription-over-counter-medications
[x] Annals of Emergency Medicine, “Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department”, 2012, http://www.acep.org/workarea/DownloadAsset.aspx?id=88197
[xi] Food and Drug Administration, “Outpatient Prescription Opioid Utilization in the U.S., Years 2000-2009. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/AnestheticAndLifeSupportDrugsAdvisoryCommittee/UCM220950.pdf
[xii] Annals of Emergency Medicine, “Opioid Prescribing in a Cross Section of US Emergency Departments, 2015, http://www.annemergmed.com/article/S0196-0644(15)00233-4/fulltext
[xiii] Annals of Emergency Medicine, “Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department”, 2012, http://www.acep.org/workarea/DownloadAsset.aspx?id=88197
[xiv] The New York Times, “Missouri Alone in Resisting Prescription Drug Database,” July, 2014, http://www.nytimes.com/2014/07/21/us/missouri-alone-in-resisting-prescription-drug-database.html?_r=0
[xv] Florida Medical Examiners Reports 2007-2011
(Last Updated 2016)