Prescription for Safe Use of Opioid Painkillers

	Dr. Stuart Kessler

HHC is one of the first adopters of voluntary guidelines for the safe prescription of opioid painkillers in New York City emergency rooms, as recently announced by Mayor Michael R. Bloomberg. Dr. Stuart Kessler, Emergency Department Director at Elmhurst Hospital Center, worked with the Mayor's Task Force that issued the guidelines to fight an increase in opioid abuse and prescription drug-related overdoses. Dr. Kessler, who is also on the Board of the New York State Chapter of the American College of Emergency Physicians, tells us more about the guidelines.

Why do we need these guidelines?

The problem of addiction, overdose and deaths associated with the use and abuse of prescription narcotics needs to be addressed. Between 2004 and 2010, the rate of opioid painkiller-related emergency department visits nearly tripled in New York City. In 2010, prescription painkillers were involved in 173 unintentional overdose deaths in New York City, a 30 percent increase from 2005. The guidelines are designed to reduce prescription drug abuse and overdose by encouraging ER doctors to be judicious in writing prescriptions, provide patient education, and refer patients to a primary care physician and to treatment for substance abuse when needed.  The guidelines will also help  prevent an excess supply of opioid painkillers in the community. We know that three out of four people abusing painkillers get them from medications leftover from prescriptions.

Why focus on  emergency rooms? Aren't people getting these drugs from private doctors too?

The emergency room is where people end up if they are sick from abusing opioids or have overdosed. But it's also where people are more likely to come if they are trying to get a prescription for opioids that they don't really need. But eventually these or similar guidelines need to be applied to all areas where these drugs are prescribed.

Give us an example of a patient you treated who misrepresented their pain and need for these drugs.

We recently had a patient who came into the emergency room and said he had a certain medical condition and was in serious pain.  I don't want to name the condition out of respect for the many people who really do have this disease and experience intense pain frequently. But this person said he had lost his prescription medication, was in severe pain, and couldn't see his doctor because it was the weekend. This patient requested pain medication in the emergency department and a prescription for narcotic pain meds to take at home. (Sometimes individuals say their doctor is away on vacation). It turned out that after a careful review of the medical records, he had been our patient before, we were able to determine that he didn't have the condition he claimed to have. We spoke to him regarding this situation and offered him counseling if he had an addiction problem.  Needless to say he did not get a prescription.

How will you ensure patients who are really in pain get the help they need?

Painkillers provide relief for people who are in significant pain, and we are committed to providing pain relief to the people who need it.  In the emergency department, clinicians must talk to the patient, get a careful medical history, and examine the patient, and then make an informed decision about whether to prescribe medication, and which and how much medication to use. If the decision is to use an opioid pain medication, it is likely that the patient will get a three day supply of pills at the time of discharge from the ED.  The patient will likely be instructed to follow up with with their primary care physician or a specialist MD.  If they are still in need of further prescription pain medication they can be reassessed at their next physician appointment or they can return to the ED. We might also recommend non-narcotic medication, such as acetaminophen (Tylenol), ibuprofen (Advil) or naproxen (Aleve). We don't want anyone to suffer or have discomfort.

What are the guidelines?

Our emergency departments will no longer prescribe long-acting opioid painkillers such as extended-release oxycodone, fentanyl patches or methadone. In most cases, we will prescribe no more than a 3-day supply of opioid painkillers, and we will generally not refill lost, stolen or destroyed prescriptions. 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 NYC Health Department is encouraging private hospitals to adopt these guidelines as well.

What are some tips for the safe use of pain medication?

Pain medications are safe and effective when you use them as directed by your physician, so follow the instructions carefully. Do not use more than directed or more often than directed. Don't share pain medication with anyone else, since a dose that is safe for you could be dangerous or even deadly for someone else. See your doctor regularly. All patients treated with opioids for pain require monitoring for signs of addiction, and to determine when these drugs are no longer needed. If there are medications left over from your prescription that are no longer needed then safely dispose of them in a timely manner.

What can I do to keep my properly prescribed painkillers away from children and others in my home?

You should always store prescription drugs where children and teens can't get them. Throw out old or unused medicines and encourage your friends and family to do the same. A new NY State law will soon provide for new ways for patients to dispose of unused pills.

HHC has adopted the guidelines but private hospitals can opt out. So why bother?

The New York City guidelines are endorsed not only by HHC but by the New York State Chapter of the American College of Emergency Physicians, but these guidelines are voluntary. Many physicians already use the guidelines in their practice.  Some private hospitals already follow similar guidelines, and we expect that many will follow. HHC hospitals have 1.2 million ER visits a year. A lot of people come through the doors of our emergency rooms. By getting the message out, we can have an impact.

April 2013