How Drug Abuse Affects EDs, and What Docs Are Doing About It

Opiate overdoses, doctor-shopping by patients seeking controlled substances and opiate misuse are routine enough features of emergency department patient populations that emergency physicians have developed innovative solutions to address these medical and social problems, which are detailed in studies being presented at the annual meeting of the American College of Emergency Physicians in October.

For every fatal opiate overdose visit to U.S. emergency departments, there are 63 non-fatal opiate overdoses. Opiate overdose resulted in 106,813 ED visits in 2009, with the majority (67 percent) caused by prescription opiates. That data was reported in "Clinical and Demographic Characteristics Associated with Opioid Overdose Visits to United States Emergency Departments," by Michael A. Yokell, a third-year medical student at Stanford University School of Medicine.

"Fatal overdoses from opiates grab lots of headlines, but an equally important story is the huge volume of ER visits for opiate ODs that are not fatal," said Yokell. "Since treatment in ERs is highly effective at reducing the risk of death from overdose, more efforts should be made to ensure that all patients who need treatment for OD have safe and ready access to ERs for lifesaving emergency care."

"Doctor-shopping" patients, who had narcotic prescriptions from 10 or more providers in one year, were more likely to report an allergy to non-narcotic pain relievers, to request a narcotic by name, to have multiple visits for the same complaint and to have pain out of proportion to the physical exam. They were more likely to be white than non-white and come to the ED on weekends. The average number of medical providers these doctor-shoppers had seen in the previous year was 17, versus 1.6 for non-drug-seekers, according to "Characteristics of 'Doctor-Shopping' Patients in the Emergency Department" from Tufts Medical Center, Boston

"Knowing the typical characteristics associated with doctor-shoppers will give emergency physicians a better chance to identify patients with high risk for abuse when they come to the ER with pain complaints, " said lead study author Scott Weiner, M.D.

Emergency physicians are taking the lead in treating repeat emergency patients who visit the ED in search of narcotics.

For example, in San Diego, patients who made more than two emergency visits for alcohol, substance abuse or psychiatric problems were identified and flagged by the electronic medical record and consequently placed in non-medical detox programs, which reduced repeat emergency visits by 90 percent, from 137 total visits or 5.27 visits/week to 10 total visits or 1.67 visits/week over a 6-month period. The results are reported in "An Innovative Solution to Reduce ED Recidivism Among Substance Abuse and Psychiatric Patients" from the University of California San Diego.

"Non-medical detox in community-based social programs outside the hospital may be a prudent and cost-effective way to reduce repeat ER visits for patients who are substance abusers," said lead study author Alfred Joshua, M.D.. 

When emergency physicians and care managers in cooperation with primary care physicians set up individualized care plans for patients who were flagged as drug-seekers, the mean number of ED visits declined from an average of 7.6 per year to 2.3 per year, according to "Care Plans Can Reduce Emergency Department Visits for Those with Drug-Seeking Behavior."

"These interventions had a meaningful impact on the behavior of our drug-seeking patients, which was beneficial to both the patients and overstressed emergency departments," said lead study author Ashley Flannery, D.O., from Morristown (N.J.) Medical Center.

Troubles Connecting Systems a Major Concern for HIEs

Four years after the passage of the American Recovery and Reinvestment Act and the subsequent investment of billions of federal dollars in an e-health system, sharing patient data outside a health care system remains a significant obstacle, according to eHealth Initiative's 10th annual survey of health information exchanges (HIEs).

Today, the use of electronic health records and other electronic information systems have made data sharing within hospitals and health networks routine. However, the survey shows that health care delivery organizations are increasingly challenged by the need to interface with clinical and administrative systems outside of existing networks. Three-quarters of the 199 survey participants reported that they have had to construct numerous interfaces between different systems to facilitate information sharing, a process that is both time consuming and expensive.

"The recent challenges with insurance exchanges have helped people understand just how difficult it is to connect data, whether it's clinical, personal or administrative," said Jennifer Covich Bordenick, chief executive officer of eHI. "It's relatively simple for providers within a hospital using a single EHR to share information about their patients. The real challenge and expense is getting dozens of different systems to talk to each other." In fact, 68 organizations have had to build 10 or more interfaces with different systems, and more than 140 cited interoperability as a pressing concern.

Despite these challenges, the eHI survey shows increased confidence in HIEs as a viable, sustainable business. The new demands associated with health care reform and meaningful-use requirements have led providers to turn to HIEs for support, which is encouraging from a business standpoint and may help reduce reliance on federal funding. However, the burden of sharing data between different systems may ultimately threaten the sustainability that HIEs have worked so hard to achieve. "The use of different standards, products and approaches for managing health information means HIEs have to spend time and money to bridge the gaps," acknowledges Covich. "Any groups that rely solely on federal funding, which expires next year, will not survive."

The survey also shows that many HIEs have not yet developed ways to allow patients to enter or view their own data in the health exchanges. Only 31 organizations currently offer patients access to their information. Moreover, even simple patient engagement services, like tools for managing appointments or prescriptions, are rare. As part of the federal EHR Meaningful Use Program, patient engagement is a critical step for providers looking to receive incentive payments for using EHRs. This could change in future years, as 102 organizations reported that they have plans to offer patients access to their data.

"While it's a little disheartening to see such low patient engagement, overall I think we're in a better place than we were last year. Awareness around health care reform has helped build the business case for data sharing and engaging consumers," said Bordenick.

The key findings can be downloaded here.