Do Opioid Guidelines Unfairly Target EDs in War on Abuse?

Pauline Anderson

April 09, 2013

The debate over whether emergency room (ED) opioid-prescribing guidelines recently put in place in New York City are appropriate or fair continues.

Hillary V. Kunins, MD, assistant commissioner. New York City Department of Health and Mental Hygiene, squares off with Alex M. Rosenau, DO, president-elect of the American College of Emergency Physicians (ACEP), and vice chair, Emergency Department, Lehigh Valley Hospital and Health Network, Allentown, Pennsylvania, in new "In the Balance" articles in the April 9 issue of Annals of Internal Medicine.

The debate focuses on the New York City Emergency Department Discharge Opioid Prescribing Guidelines, released in January 2013. The document notes that these guidelines are meant to provide guidance on prescribing from the ED and don't relate to the use of opioids during treatment in the ED.

In the end, both authors agree that solutions are needed to the worsening problem of opioid misuse. However, whereas Dr. Kunins stresses that ED physicians need support in making appropriate prescribing decisions, Dr. Rosenau maintains that the focus on EDs is misplaced.

Immensely Conflicted

In her paper, Dr. Kunins said emergency and other physicians are "immensely conflicted" about opioid analgesics. They feel accountable to patients requesting opioids for pain relief and to standards that imply that withholding these drugs is tantamount to poor medial practice. At the same time, they're increasingly aware of the "terrible consequences" of opioid misuse, such as overdose and addiction.

Dr. Hillary V. Kunins

To tackle the problem of opioid overdoses, which is at "epidemic" proportions, "widespread changes are needed in prescribing practice among all specialties," including ED doctors, Dr. Kunins told Medscape Medical News. The current guidelines were created when emergency physicians themselves approached the city suggesting that opioid-prescribing guidelines aimed at general practitioners that were released in 2011 be adapted for the ED, she said.

Opioids, she wrote in her paper, "are not a panacea" and are less successful in providing relief than many patients and physicians assume. Evidence suggests that long-term use of opioids for noncancer pain is unsupported.

Dr. Kunins stressed that the guidelines are not meant for patients with cancer or those in palliative care.

To limit risks of opioid dependence and overdose while addressing patient's pain, physicians should prescribe these agents only when other medications are unlikely to be effective, writes Dr. Kunins. The guidelines recommend prescribing the lowest effective dose for only as many days as is needed, and suggest that most patients require no more than 3 days.

"These guidelines, like other clinical guidelines, are recommendations for best practices, but clinical judgment is also quite important to the decision-making," Dr. Kunins said.

Instead of disproportionately affecting uninsured patients who rely on the ED for primary care, as many experts fear, the guidelines will promote best practices that minimize the risk of opioids and maximize their benefits, Dr. Kunins writes. Addressing concerns over increased liability, she said the recommendations will actually reduce liability in most cases as patients are less likely to overdose when the guidelines are followed.

Dr. Alex M. Rosenau

Dr. Kunins said that to date, 19 New York City hospitals, including 11 public hospitals, have adopted the guidelines, and that the guidelines have been endorsed by the New York chapter of the ACEP. The voluntary guidelines have been heavily promoted by New York Mayor Michael Bloomberg.

In addition, many other jurisdictions have adopted, or are considering adopting, similar guidelines, including Washington state, Ohio, and possibly also north Florida, she said.

EDs Not the Problem

For his part, Dr. Rosenau said most of his colleagues don't have a problem with the guidelines themselves. But he thinks the focus would be better placed in areas where most opioid misuse takes place. "I'm taking issue with the pointing at the ED as the first and major part of the problem," Dr. Rosenau told Medscape Medical News.

New evidence shows that only 4.7% of the short-acting opiate prescriptions from 2000 to 2009 were written by ED doctors and that these physicians almost never prescribe long-acting opiates, he said.

Instead of focusing on the ED, other avenues should be pursued to tackle the problem of opioid misuse, starting with patient education, possibly using new smartphone technologies, said Dr. Rosenau. He also advocates the creation of a national electronic prescription monitoring system that would be accessed by pharmacists. Such a system, he said, would be in the best position to uncover illicit drug use.

As well, improved law enforcement could help prevent illicit distribution and abuse of narcotics. The pharmaceutical industry, too, can play a role in better tracking of the flow of opioids from pharmaceutical company to pharmacy to patients.

Dr. Rosenau maintains that there are also legitimate cases of pain that require opioid analgesics for longer than 3 days. He provided the example of a patient coming to the ED with a broken bone on the Friday before last Christmas, which fell on a Tuesday.

"We know that person is not going to get in to see an orthopod over the weekend, on Christmas Eve, on Christmas, or the next day, so it could be a whole week before they get in for definitive treatment."

Limiting the opiate supply to only a few days may lead to additional ED visits for pain relief, adding to already serious overcrowding, he writes in his paper.

He stressed that 92% of people who come to the ED come there appropriately; moreover, ED doctors represent only about 2% of the healthcare budget but tend to 130 million patients every year on a "24/7" basis.

Perhaps the ED is an easy target for solutions to the opioid prescription problem because, unlike the family doctor's office, "it's a place you go to rarely that it's a little bit less personal," said Dr. Rosenau.

Restricting opioid prescription by emergency physicians "will not solve the problem of opioid misuse," concluded Dr. Rosenau in his paper. "Clinical policies for opioid prescription must not inhibit their ability to compassionately treat patients who legitimately seek pain relief in the ED."

Dr. Kunins has disclosed no relevant financial relationships.

Ann Intern Med. Published online April 8, 2013. Kunins Abstract Rosenau Abstract