The opioid crisis is often blamed on doctors who over-prescribe the addictive painkillers to patients, who then become addicted or overdose from the powerful drugs.
But addiction can also begin in another health care setting — the emergency room.
Until the dangers of opioids became commonly known, emergency room doctors used opiates to treat pain much more aggressively, said Dr. Richard Shaffer, of Touchette Regional Hospital in East St. Louis. Doctors favored pain relief over the relatively unknown risks of misuse, abuse addiction and overdose, Shaffer said.
Opioids contributed to nearly 1,200 overdose deaths in Illinois in 2016, according to data from the Illinois Department of Public Health. Another 1,000 people died in heroin-related overdoses, according to a 2014 survey by Washington University in St. Louis. Most of those overdoses likely began with prescription drugs.
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Though drugs like Vicodin or OxyContin can treat severe pain, the strength and duration of those prescriptions can lead to a higher likelihood of addiction, a problem emergency department doctors in the metro-east are trying to avoid.
Now, those doctors, along with emergency room doctors nationwide, are changing their policies to help prevent a long-term problem that can begin in an emergency situation.
A 2017 study in The New England Journal of Medicine showed long-term opioid use was significantly more likely in patients who saw emergency room doctors who prescribed opioids at a high rate. Patients of doctors who used opioids rarely showed less long-term opioid use, according to the study.
Implementing an emergency room policy can significantly reduce opioid prescriptions, according to another study from The American Journal of Emergency Medicine.
At Touchette Regional Hospital, emergency room doctors rarely prescribe opioids at all, according to Shaffer. While illegal drugs play a “significant part” in overdose deaths, narcotic prescriptions can also be part of the problem, Shaffer said.
“The abstracted complaint of ‘pain’ is the most common visit at Touchette Regional Hospital and we practice in an area where the population is heavily afflicted with illicit drug use and drug addiction,” Shaffer said. “It is our obligation to address patients in acute pain and treat them accordingly.”
Doctors first address the type of pain a patient is experiencing before deciding if an opioid prescription is necessary.
Treating chronic pain, or pain that lasts for more than three months, with an opioid is highly discouraged in emergency rooms, said Dr. Loren Hughes, President of HSHS Medical Group, which operates St. Elizabeth’s Hospital in O’Fallon and St. Joseph’s Hospital in Highland.
Hughes is also longtime emergency room medical director for HSHS in the metro-east.
“ER providers are encouraged to use non-opioid pain meds, consider referral to pain management, and recommend alternative modes of treatment such as yoga and therapy in lieu of opioid medications,” Hughes said.
But even if a doctor prescribes an opioid, the prescription will only last for a few days and never more than a week, Shaffer said. It is also best practice to check the patient’s prescriptions against the Illinois Prescription Monitoring Program database, as well, he added.
Regardless, chronic pain is best treated by the patient’s primary care doctor, Shaffer said.
“When patients complain of chronic pain we address their immediate complaint as best as possible with non-opioid methods such as Tylenol, NSAIDS (anti-inflammatory drug), or muscle relaxers and ask them to follow up with their primary care physicians for further care,” Shaffer said.
When it comes to acute pain, most patients can be treated without opioids, Shaffer said. Traumatic injuries might warrant an opioid prescription, but doctors evaluate and risks and benefits of such a prescription before handing it out.
Treating acute pain can be complicated, too, in patients who have a history of opioid prescriptions, says Dr. Dan Normansell of Memorial Hospital in Belleville.
“If they’ve been on narcotics for a long time, it takes a larger dose to have an effect,” Normansell said. “For acute painful conditions if we need to treat, we give them the lowest dose possible for the shortest duration and for no more than seven days. If they’re still having pain, they need to follow-up with their general practitioner.”
It’s difficult to track just how much opioid prescriptions have decreased in emergency rooms, however. Charles DuMontier, vice president of Medical Affairs for Touchette Regional Hospital, said the state’s tracking system counts opioid orders.
Touchette’s in-house tracking system shows most pain medicine prescriptions are for Ibuprofen, DuMontier said.
Hospitals continue to evaluate how to avoid prescribing opioids when possible, the president and CEO of HSHS Medical Group said.
“Policies will change as new information becomes available and best practices are identified,” Hughes said.
In the meantime, doctors continue to pursue alternative treatments over prescribing opioids, said Normansell, the Memorial Hospital doctor.
“In the ER, we’re looking for any other options we have,” Normansell said. “Once people understand (chronic pain management) is not the role of emergency department, I think that helps.”
CDC guidelines for opioid prescription
The Center for Disease Control issued in-depth guidelines in 2016 on prescribing opioids for chronic paid. Three of the most important principles include:
- Non-opioid therapy is preferred for chronic pain outside of active cancer, palliative and end-of- life care. Opioids should only be used when their benefits are expected to outweigh their substantial risks.
- When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. Clinicians should start low and go slow.
- Providers should always exercise caution when prescribing opioids and monitor all patients closely. Clinicians should minimize risk to patients—whether checking the state prescription drug monitoring program, or having an ‘off-ramp’ plan to taper.