Drug seekers or patients in need? One ED’s solution to a perennial problem.
Pain is the most common symptom prompting one to seek emergency care (1). Over the past two decades numerous studies have addressed the inadequacy of pain management provided by the medical community (2). Oligoanesthesia is considered by some to be a public health emergency. Recognizing this issue, in 2001 The Joint Commission put into effect pain management standards engaging medical providers and hospital administrators across the country. Along with this heightened awareness to pain developed a trend towards the routine use of opioid analegesics for the treatment of moderate to severe non oncogenic pain (3).
In 2005, approximately 10 million Americans were being treated on long term opioid therapy for non cancer related pain (4). It is estimated that the average patient daily morphine milligram equivalent (MME) dosage has increased from 100 MME in 1997 to almost 700 MME in 20075. Parallel to this increase has been an almost identical increase in the unintentional overdose mortality rate6. In great part due to narcotic pain medication, the overall overdose death rate is at epidemic levels. Data from 2007 show 20 states where accidental overdose deaths exceeded either motor vehicle collision (MVC) fatalities or suicide. In some states, such as Ohio, unintentional overdose deaths exceed those from both MVC and suicide (7).
No distinct causal relationship has ever been demonstrated linking specifically the emergency department prescription of controlled substances to the current epidemic of unintentional overdose fatalities. Regardless, many emergency physicians struggle daily with concerns over the safety and appropriateness of prescribing controlled substances to patients they suspect of “drug abuse”. The nature of emergency medicine leaves it specifically vulnerable to “doctor shopping” in an environment where a prescription for 100 tabs of oxycodone can be filled for a $3+ copay and resold at a street value of $1000+ (8). What defines “drug abuse” is ambiguous, and it has been hypothesized that the majority of patients recurrently presenting to the emergency department requesting narcotic pain medication suffer from some combination of mental illness, chronic pain, and substance abusing tendencies (3).
As ED Medical Director of Carteret General Hospital (CGH), managing recurrent visit patients with acute on chronic pain requesting narcotics is an everyday reality. CGH is a 140 bed hospital whose ED evaluates approximately 42K patients a year. CGH is the only acute care medical facility in Carteret County, a rural eastern seaboard county with a residential population of 66K and a large transient group of seasonal tourists.
Of the 100 counties in North Carolina, Carteret has the third highest per capita death rate from drug overdoses. Among the 13 NC seaboard counties, Carteret County has the highest per capita controlled substance prescription rate (9). Carteret County youth report higher usage of prescribed painkillers (for non-medical purposes) than their peers throughout NC (16.3% in Carteret County compared with 7.2% for the state as a whole)(10).
It is our hope to aggressively treat pain in our emergency department. Review of CGH ED Pyxis data starting in late 2009 and following 13,407 consecutive patients visits over a 4 month period revealed a total of 83 (19 parenteral narcotic, 28 oral narcotic, 36 non narcotic) pain medication doses removed for every 100 patient visits. Although pain control is critical to our mission, our use of narcotic pain medication was a cause of frustration among many staff members who felt that we were contributing to our communities “drug abuse” problem (figure 4).
The Controlled Substance Program (CSP)
In an attempt to systematically identify patients who are not best served by receiving prescription narcotics or benzodiazepines in the ED setting, a Controlled Substance Program (CSP) was initiated. Process steps:
- ED staff were asked to anonymously nominate patients who were felt to be inappropriately utilizing the ED for controlled substances.
- All nominated cases that met at least one of the following three inclusion criteria were reviewed:
- Greater than 6 ED discharged visits in the past 12 months with subjective pain complaints
- Concern for doctor shopping on query of NC Controlled Substance Prescription Monitoring Database
- Drug related criminal history on background check
- Selected cases reviewed by multidisciplinary panel in rapid fire format (5 minutes or less per case). Each review involved synopsis of ED visits, as well as results of prescription database query, and criminal background check information. Patient identifiers remained hidden to panelists, except moderator (author, ED physician director). See figure 5 for panel participants. Please note, all panelists not present for all reviews to date, attendance ranged from 6-11 participants.
- Unanimous agreement was required for inclusion in program.
- Cases selected for inclusion in program have identifier placed next to name within EMR and patient tracking board.
- For selected patients, an attestation is included in their EMR detailing the following: (1) review process, (2) data utilized to determine inclusion, and (3) attendance roster for panel resulting in selection. This attestation is available to patients should they request their medical record.
- ED physicians / mid-levels are instructed to not prescribe controlled substances to participants without consulting ED medical director in real time (in person or via telephone). An email should be sent to medical director should participant require controlled substance during ED stay.
- Cases that are excluded are designated for review by an individualized care plan committee. No indicator is placed next to name.
Upon initially announcing program to ED staff 1/5/10, 53 patients were nominated within the first 48 hours. At that point nominations were closed until all nominated cases were reviewed. Initial 48 nominated patients were reviewed on 1/14/10 and 4/28/10. Thirty-six of the first 53 reviewed for selection had drug related criminal convictions. Query of the NC Controlled Substance Prescription Monitoring Database revealed the average patient had received 24 controlled substance prescription from 8.7 doctors in the 12 months prior to review.
For the initial 36 selected patients, ED visits 6 months pre inclusion to 6 months post inclusion dropped from 185 (average 5.1 visits per pt) to 102 (average 2.9 visits per patient). Four of the 102 visits by CSP participants 6 months post inclusion resulted in a controlled substance prescription upon d/c. Two instances were discussed with medical director (acute LE fracture, second degree burn). In the two other instances protocol was breached and medical director not notified. Twenty-seven of the 102 visits post inclusion involved the administration of narcotics during the ED stay. Upon noting this, a process addition of requiring an email to medical director whenever a controlled substance is given to CSP participant during stay was initiated (Figure 6).
Two additional CSP review panels were subsequently held (10/27/2010 and 4/12/2011). To date, a total 127 patients have been reviewed with 106 selected for inclusion. Two patients are known to have died since inclusion, both secondary to presumed unintentional overdoses.
Although the nature of this program limits access to controlled substances to a subset of patients by creating administrative hurdles, it is critical that it is not viewed as a “black list.” No specific list of patients is distributed, posted, or in any way available to ED staff. Patients are only identified as a participant in the CSP by an indicator that is visible on our ED tracking board. If an ED physician feels that a patient needs a controlled substance RX, he or she is still able to prescribe it; all that is required is additional justification or clarification through discussion with ED medical director.
It was the initial intention of the program to send a certified letter to all selected patients describing the program and providing them with a list of local pain management centers, detox facilities and crisis hotline. Senior CGH administration, while remaining exceptionally supportive of the program, felt that the message may be misconstrued by patients and potentially discourage them to access needed care. It was preferred that patients be notified in person by the ED physician on duty during a subsequent ED visit. To date, we have not been successful in having our ED physicians consistently perform this function. Anecdotally it appears that most CSP participants are aware of the program.
Maintaining the need for unanimous agreement by a multidisciplinary committee in a rapid review format ensures that the threshold for inclusion remain high. If during discussion any member had concerns regarding the appropriateness of inclusion, the patient would not be included and his or her case would be discussed in more detail by a care planning / case management group.
The use of publically available criminal background checks on patients in the context of this program was controversial. It was thought to be critical that patients have access to any records reviewed with an attestation placed in their EMR. Should a patient question his or her CSP inclusion they would have access to the information reviewed by the panel, as well as the names and positions of all panelists who anonymously selected the patient. Most found the frequency of nominations with a drug related criminal convictions (25/53, or 47%) to be alarming. While having a drug related conviction did not guarantee inclusion, not utilizing this information in making an informed judgment was thought to be imprudent.
In summary, the ultimate goal of the CSP is to best identify patients that have tragically fallen into a maladaptive pattern of medical care and are not best served by receiving controlled substances from our emergency department. The above data is a description of CGH’s operational experience with the program and clearly fraught with biases if viewed as a scientific study. Anecdotally, the program has been well received by staff and has assisted ED physicians in identifying patients with substance abuse concerns, ultimately freeing us to let pain management remain a paramount concern for all of our patients.