“Cure Sometimes. Treat Often. Comfort Always”  – Hippocrates (400-ish BC)

What is doctor to do?  We have a mandate to treat pain and relieve suffering, but some of the best medications available have high abuse potential and are involved in an epidemic of unintended morbidity and mortality.

Do we as physicians prescribe too many narcotics?  Specifically do we emergency physicians prescribe more than we should? As with much else in medicine the evidence is complex and at times contradictory.  Some examples of the argument that we are not aggressive enough in the treatment of pain are the following (click on them to access links):

• Racial and ethnic disparities in pain management
• Under treatment of acute pain in the emergency department
• Under treatment of pain in elderly leads to opioid misuse
• CMS to measure timing of ED pain medication in long bone fractures

If you have spent any time looking at the news or proposed state legislation the answer would clearly be yes. There is an epidemic of deaths related to prescription drug use and misuse. The problem is stark both in terms of the individual tragedies and sheer numbers.

My goal in this piece is to lay out the problem from an emergency medicine perspective and to suggest a set of guidelines that might help my colleagues in their daily struggle to figure out what the right thing to do is for each patient. This is based on a lecture I delivered at NJ-ACEP Scientific Assembly in May 2014 (Click here for slides: The Pendulum Swings).

To start out let me disclose the following to understand my perspective:

I am a prescriber of narcotics….

• One year thru March 2014
• Cared for 2,700 patients
• 318 filled prescriptions for CDS (down from 390 year prior)
• Averaged 18 pills per script (19 in year prior)

Who rarely prescribes “Higher Potency/Longer Acting” formulations:

• 30mg Oxycodone (2 scripts)
• Morphine 15mg (1 script)
• Dilaudid 2mg (2 script)
• Oxycontin 20mg (1 script)

AND a patient who has received narcotic pain medication…

• Winter of 1988-1989
• MVC (while as EMT in ambulance)
• Femur Fracture
• Surgery x 4
• Meperidine, Morphine, Oxycodone

• Summer 2014
• “El Diablo” (kidney stone)
• 4mm UVJ
• Toradol and Oxycodone

The Modern Culture of Treating Pain

The introduction of  pain as  “The 5th Vital Sign“  in the mid-1990s coincided with an explosion of prescribing of high potency and/or long-acting narcotics. The need to measure pain was codified by the Joint Commission at the start of the 2000’s.

From an ED point of view pain scales may or may not be useful as the median pain score is an 8.

Heavy advertising especially by physicians to physicians for drugs such as Oxycontin® culminated in this being a block-busting $1Billion drug by 2001.

Eventually the FDA found the manufacturer had engaged in misleading and dangerous advertising. But by that time an epidemic had begun.

 Is this an ED Problem?

Not surprisingly the answer turns out to be yes and no….

• We make up 2-5% of all narcotics prescribed and filled.
• We generally prescribe only 15-20 doses of the lowest strengths
• However….A significant number of our  patients are “at-risk”
• AND…. Most EPs feel at least once a shift they are being manipulated for drugs

While it is easy to label certain patients as drug-seekers the reality is much more complex. It is probably more useful to approach this from a RISK perspective.  Data suggests that approximately 10% of those receiving narcotics are “at-risk”.

• Diversion
  • False names, false addresses, no actual medical complaint
• Multiple Visits for Acute Conditions
  • Toothaches, traumatic injuries, visceral organ pain
• Chronic Pain from non-specific conditions
  • Migraines, Low Back Pain, Fibromyalgia, Chronic Lyme disease, etc.
  • C1-Esterase Deficiency
• Chronic Pain secondary to specific medical condition
  • Gamut from SCD, Gastroparesis, Chronic pain after surgery
  • Headaches secondary to history of Brain Aneurysm, Recurrent Renal Colic
• Pseudo-Addicted 
  • A drug seeking behavior that simulates true addiction, which occurs in patients with pain who are receiving inadequate pain medication
• Addicted (hard to distinguish from pseudoaddiction)

A Rational Approach to Narcotic Prescribing

in the Emergency Department

The holy grail in emergency medicine has shifted from figuring out which patient with chest pain can be discharged safely to which patient can I safely give narcotics. This, of course, must occur in one of the most complex and information-challenged environments in healthcare. Physicians must balance all this with these other priorities. Here are some guidelines that could be helpful:

 When prescribing narcotics:

• Screen for substance abuse as needed
• Emphasize risks to patient
• Encourage safe disposal of left over medication
• Continue to use short-acting formulations
• Generally limit amounts to five days
• Strongly consider alternatives in patients already taking benzodiazepines
  • Greatly increased risk of death
• When practical avoid parenteral medications for exacerbations of chronic pain
• Have a higher threshold for certain conditions including dental pain, sprain

Use your State’s PMP consistently to screen for “at-risk” behavior when:

• Multiple “recent” ED visits
• Exacerbation of chronic pain
• Patient requests medications by name
• Allergies to multiple alternative medicines 
• Not from typical catchment area
• Before prescribing LA opioids for non-cancerous pain
• For more on Prescription Monitoring Programs  (PMP) see this blog:

When clinical judgement and/or data suggests “at-risk” behavior:

• Share concerns with patient
• and negotiate no CDS prescription vs. smallest amount possible
• If possible speak with primary medical doctor for coordination

If pseudo addiction suspected coordinate closely with PMD:

• Arrange appropriate follow up
• Use best judgment in terms of prescribing CDS

Establish intra-departmental protocols for the most common conditions

• Oral protocols for chronic pain exacerbations
• Common approach to repeat visits for CDS prescriptions
• Add tools to your tool box
  • Alternative therapies
  • Dental blocks

As always this is one emergency physicians opinion based on a fair amount of research and discussion. I would love to hear your opinions and questions. 

Dr. Adinaro is the out-going president of NJ-ACEP and is the Chief of Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. David can be reached via  @PatersonER . This publication represents the personal opinion of the author and does not reflect the policies of his employers.