Running a busy emergency department is hard enough, let alone when you throw drug-seeking opioid addicts and overdose victims into the mix.
America is in the middle of an epidemic of prescription painkiller and heroin abuse that’s killing thousands every month. Often, those at their worst are showing up in hospital emergency departments across the country that are understaffed and ill equipped to deal with the intricacies of pain management and drug addiction.
Virginia, for one, has been ravaged by this scourge of drug abuse, with 4,036 prescription opioid overdose deaths between 2007 and last year, according to the Virginia Department of Health. Looking to alleviate that trend, the Virginia Hospital and Healthcare Association convened a group of stakeholders in January and just last week rolled out its own list of 14 guidelines to help doctors to more carefully prescribe opioid painkillers in the ED.
The recommendations include everything from not replacing bottles of opioids that were allegedly lost or stolen, to screening patients for signs of drug abuse. Several of the guidelines overlap with what’s been recommended previously by the Massachusetts Hospital Association’s own task force, which we reported on last month.
Most crucial in the guidelines is the suggestion that hospitals designate one outpatient provider outside the ED to provide opioids for chronic pain, along with calls by the task force to better coordinate care between primary care and emergency physicians, says task force member Scott Hickey, M.D., chairman of emergency medicine at the CJW Medical Center.
“You need a chronic pain management doctor because these patients need continuity of care,” Hickey says. “Nobody gets good care if they’re seeing different doctors all the time.”
Virginia hospitals are now setting about to begin implementing these guidelines, and Sean Connaughton, president and CEO of the state hospital association, hopes they’ll quickly begin making a dent in the epidemic. Some Massachusetts hospitals, such as Beth Israel Deaconess in Plymouth, have already made their own progress, with the number of such painkillers prescribed dropping by 25 percent in the five months following implementation
Up next, Connaughton says the association plans to take a closer look at both primary care and behavioral health and how hospitals can similarly tweak practices to help curb the epidemic. He believes momentum is beginning to build in this regard, and it has started with setting aside blame and working together across the spectrum of health care to come up with solutions.
“I think there’s a recognition that we have created a problem that has to be addressed, and instead of playing the blame game or ignoring the problem, we’re just going to have to work to address this challenge straight on. I think that’s what you’re definitely seeing.”
Here are all 14 of Virginia’s recommendations to improve prescribing of opioids in the ED:
- A dedicated provider outside the emergency department should provide all opioids to treat any patient’s chronic pain.
- Administering intravenous or intramuscular opioids in the emergency department for the relief of acute exacerbation of chronic pain is generally discouraged.
- Prescriptions for opioids from the emergency department should be written for the shortest duration appropriate. In cases of diagnostic uncertainty or chronic conditions, this generally should be for no more than three days, as is consistent with national guidelines.
- Hospitals, in conjunction with emergency department personnel, should develop a process to screen for substance misuse. Those protocols should include services for brief intervention and referrals to treatment programs for patients who are at risk for developing, or who actively have, substance use disorders.
- When patients present with acute exacerbations of chronic pain, it is recommended that a summary of the emergency department care, including any medication prescribed, is communicated to the primary opioid prescriber or primary care provider.
- Emergency department providers should not dispense prescriptions for controlled substances that were lost, destroyed, stolen or finished prematurely.
- Emergency department providers should use extra caution when considering prescribing controlled substances to patients who do not have proper photo identification.
- Emergency department providers, or their designees, are encouraged to consult the prescription-monitoring program before writing opioid prescriptions for acutely painful conditions.
- Emergency department providers, in general, should not provide replacement doses of methadone or buprenorphine for patients participating in an opioid treatment program.
- Unless otherwise clinically indicated, emergency department providers should not prescribe long‐acting or controlled-release opioids, such as oxycodone, fentanyl patches or methadone.
- Emergency department providers are strongly discouraged from prescribing or dispensing buprenorphine products.
- Hospitals are encouraged to support physicians’ decisions when it is their clinical judgment that an opioid should not be prescribed even if a patient has requested a prescription.
- Emergency departments are encouraged to coordinate the care of patients who frequently visit the emergency department for evaluation of acute exacerbations of chronic pain. When possible, care coordination should include development of a patient‐specific care plan involving the emergency department, hospital and the primary care provider treating the patient’s pain‐inducing condition. Such care plans may include patient‐specific policies or treatment plans, and should include treatment referrals for patients with suspected prescription opioid abuse problems.
- Nothing in these recommendations is intended to supersede state or federal laws or regulations. Emergency departments should consider posting signs that notify patients that staff consults the prescription-monitoring program prior to prescribing controlled substances, as is required by law.