The regulation announced January 10 will put stringent restrictions on emergency physicians’ opioid prescribing practices
Last month, New York City mayor Michael Bloomberg cut the proverbial ribbon on a plan aimed at combatting opioid prescription drug abuse in the big apple. The guidelines, which will be rolled out in all 11 of the City’s public hospitals, state that the emergency departments will not prescribe long-acting opioid painkillers; can only prescribe up to a three-day supply of opioids; and will not refill lost, stolen or destroyed prescriptions. Although the Mayor lacks the authority to impose the new guidelines on private hospitals, their voluntary participation has been requested.
This recent development follows previous actions in Utah and Washington State, both with similar goals. As the prescription drug abuse problem continues to worsen in the United States, emergency physicians are likely to see more local and state governmental intervention. These top-down tactics raise many questions. Will some patients elect to present to a private hospital? If patients seeking narcotic analgesics begin to visit private hospitals instead of the public hospitals, will this result in pressure for the private facilities to participate? Will their efforts fall victim to the law of unintended consequences? Only time will tell.
The press conference announcing the new regulation accurately recited well-known statistics on the prescription drug epidemic. Health Commissioner Thomas Farley quoted that about two million prescriptions are written for opioids every year in New York City, which amounts to one for every four people. About 40,000 New Yorkers are already dependent on painkillers and need treatment. Painkillers were involved in 173 accidental overdose deaths in New York City in 2010, a 30 percent rise from five years earlier.
While these statistics are alarming, some physicians have expressed concern that they lack one critical element: a clear causal relationship between emergency department prescribing statistics and the epidemic. Officials could not say, for instance, how many prescriptions were written at emergency rooms.
The task force in charge of New York’s new opioid regulation also initiated the creation of “NYC RxStat,” which will track public health and patient safety data.
“RxStat provides us with a truly unique opportunity to design the most effective strategies to reduce prescription drug abuse and its consequences,” said NY/NJ HIDTA Director Chauncey Parker. “By combining the knowledge resources of the key public health and public safety partners, RxStat creates a platform where we can use timely and accurate data to quickly identify emerging drug trends and then coordinate our response.”
Mayor Bloomberg garnered support for the new regulations from key stakeholders including the Health and Hospitals Corporation and the New York Chapter of the American College of Emergency Physicians.
“These guidelines will help emergency department physicians strike a balance between easing a patient’s pain and discomfort while helping to ensure that medications that can be abused are not over prescribed,” said Dr. Stuart Kessler of New York ACEP.
“Given the important role that emergency departments have in the management of patients with pain, it is important that we maintain our ability to provide pain relief while keeping perspective on protecting the public health,” said Dr. Lewis Nelson, professor of emergency medicine at the NYU School of Medicine. “The recognition that this problem can be addressed with a broad effort across emergency departments provided the initial step in addressing this important issue.”
Despite the buy-in that Bloomberg achieved prior to the landmark announcement, there are still influential physicians, such as Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians, who fear the slippery slope that this move could represent.
“Here is my problem with legislative medicine,” said Rosenau. “It prevents me from being a professional and using my judgment.”
Although it is certain that the prescription drug abuse epidemic is a critical public health issue in the United States, there appears to be little consensus among physicians on how to address it. Is legislative medicine the answer? Has organized medicine failed to address a problem it has created? Is the ED the source of the problem? While these questions remain murky, what is clear is that no one knows the daily realities of emergency care quite like emergency physicians. Therefore, we need to be at the table, discussing the problem, contributing our experiences and coming up with real-world solutions.
The new opioid emergency department prescription guidelines, which hospitals can choose to display in emergency departments, clarify that:
1. Emergency departments will not prescribe long-acting opioid painkillers such as extended-release oxycodone, fentanyl patches or methadone.
2. In most cases, emergency departments will prescribe no more than a 3-day supply of opioid painkillers.
3. Emergency departments will not refill lost, stolen or destroyed prescriptions.
The posters also include tips to reduce unintended harms of opioid painkillers. The poster is available in English, Spanish, Chinese and Russian. The 11 emergency departments of the New York City Health and Hospitals Corporation, which operates all of the City’s public hospitals, have agreed to adopt these guidelines. The Health Department is encouraging private hospitals to adopt these guidelines as well.