In the midst of a national opioid overdose and abuse epidemic, researchers have found that voluntary guidelines aimed at reducing opioid prescribing in emergency room settings have an immediate and sustained positive impact.
In a study published in the January issue of the Journal of Emergency Medicine, researchers examined the impact of voluntary opioid prescribing guidelines introduced in January 2013 at Temple University Hospital and Temple University Hospital-Episcopal Campus in Philadelphia.
With emergency rooms being a major source of opioid prescribing for minor conditions and noncancer-related chronic pain, the voluntary guidelines call for “more judicious prescribing on the part of physicians.” Among its many recommendations, the Temple University guidelines urge emergency physicians to prescribe the least addictive medications when possible, avoid long-acting opioids, refrain from prescribing opioid refills and prescribe only enough medication to last until an appropriate follow-up date.
According to study author Daniel del Portal, MD, FAAEM, an assistant professor of clinical emergency medicine at Temple University Lewis Katz School of Medicine, the study is the first to examine the impact of such prescribing guidelines in an emergency room setting. Del Portal also noted that the two Temple emergency departments participating in the study care for a significant number of opioid overdose patients.
“The guidelines were issued in large part because doctors felt they were in a tough position: They didn’t want anyone to be in pain, but we also know we’re contributing to a supply of opioids that are being misused or abused and leading to more fatal overdoses,” del Portal told The Nation’s Health. “It was clear that emergency rooms had to do more.”
To determine the impact of the voluntary prescribing guidelines, del Portal and his fellow study authors examined records for adult emergency room visits between January 2012 and July 2013 for dental, neck, back or unspecified chronic pain. Among the more than 13,000 patient visits examined, the rate of opioid prescribing dropped from nearly 53 percent before the guidelines to about 30 percent immediately following introduction of the guidelines. Twelve to 18 months after the guidelines had been introduced, the opioid prescribing rate remained significantly lower at about 34 percent, the study found.
In addition to examining the guidelines’ prescribing impact, researchers also surveyed emergency room physicians on how they felt the guidelines impacted care. All 31 eligible physicians took the survey, with 100 percent saying they supported the use of an opioid prescribing guideline. In addition, 84 percent felt that their own opioid prescribing had decreased, and 94 percent believed the emergency departments’ overall opioid prescribing rate had decreased. Only 13 percent reported that they believed the guidelines had impacted patient satisfaction, and 97 percent said the guidelines helped facilitate patient-provider discussions when opioids were being withheld. Nearly 75 percent reported less patient hostility after the guidelines were in use.
“I think physicians were hungry for this type of tool,” said del Portal, who also serves as the assistant director of clinical operations at Temple University Hospital and Jeanes Hospital, also in Philadelphia.
Del Portal noted that physicians are often under enormous pressure to satisfy patients, and so the guidelines offer a consistent way to explain opioid prescribing decisions to patients. In other words, del Portal said, the guidelines help transform what often becomes a “personal negotiation” between a provider and patient into a matter of hospital protocol.
“It helps the conversation go from ‘I won’t do this for you’ to ‘We don’t do this for this problem,’” he said.
Del Portal noted that the “spirit” of the guidelines is likely translatable to other hospitals and medical settings. He added that Pennsylvania does not have a prescription drug monitoring program, which allows health care providers to check a patient’s prescription history in an effort to prevent drug diversion and abuse. However, he said that while such programs are useful tools, they are also time-consuming, expensive and not standardized from state to state. In contrast, guidelines such as those at Temple are much easier to integrate into practice.
“We don’t pretend that these guidelines will solve the bigger problems of the opioid epidemic,” del Portal said. “That will require simultaneous efforts beyond what one hospital or one system can do. But this study shows that we do have tools that are effective.”
According to the Centers for Disease Control and Prevention, the amount of prescription painkillers prescribed in the U.S. has nearly quadrupled since 1999. And since 2000, the rate of deaths from drug overdoses involving opioids has gone up 200 percent. CDC is now in the process of finalizing new guidelines for prescribing opioids for chronic pain.
For the study, visit http://www.jem-journal.com/article/S0736-4679%2815%2900621-6/fulltext. To learn more about CDC’s proposed guidelines, visit www.cdc.gov/drugoverdose/prescribing/guideline.html.
- Copyright The Nation’s Health, American Public Health Association
