For someone suffering from debilitating, chronic pain, prescription narcotic painkillers can make quality of life possible.
But there is also a tremendous potential for abuse and misuse.
As an emergency physician, Dr. Sharon Meieran at Adventist Medical Center in Portland sees the consequences all the time.
“Every day in the ED I see the fallout from misuse of these medications,” Dr. Meieran says. “It takes the form of overdose, addiction and suicide attempts.”
Not only do emergency doctors see the results of overdose and addiction, they frequently treat patients who see the emergency department as a source of these drugs.
While front-line emergency doctors have an obligation to evaluate patients who report pain, the doctors can’t know if these patients may already have received painkillers somewhere else and they can’t monitor patients' long-term use of the drugs.
“There is a difference between people with acute pain and pain for legitimate conditions and people who want narcotics for themselves or their friends or family,” says Dr. Wade Fox, DO, who works for California Emergency Physicians America in the emergency department at Mercy Medical Center in Roseburg.
“If you have a broken ankle or cancer and are in pain, there is no emergency physician in the Western world who is not going to treat your pain aggressively.
“But those with chronic pain — back pain, migraines, chronic abdominal pain—who’ve run out of their pain medications at the end of the month, that’s a problem more appropriately managed by a single provider, using an interdisciplinary approach — physical therapy, counseling, etc. — rather than us in the emergency department,” Dr. Fox says.
And there are those “patients” who follow a regular circuit, driving up Interstate 5, heading east on I-84, and then south on Highway 97, stopping at hospitals along the way, asking for pain medications.
“Misuse of prescription opioid medications has reached epidemic proportions,” Dr. Meieran says. “These medications, such as oxycodone (Percocet) and hydrocodone (Vicodin), are being misused at an alarming rate, and people are dying as a result. Everyone I know has some close personal connection to an individual who is affected by this public health epidemic, and they are crying out for help”
Dr. Meieran is also past president of the Oregon Chapter of the American College of Emergency Physicians, which has taken a substantial, proactive step to address this public health problem.
Effective Saturday. September 15, Oregon’s emergency physicians are adopting uniform guidelines for prescribing these medications from EDs.
Information about the guidelines will be posted in ED waiting rooms statewide, advising patients of the guidelines and explaining how they will be implemented.
Oregon has a relatively new Prescription Drug Monitoring Program to help prevent multiple prescriptions going to the same person, and Meieran says the additional guidelines will help.
"This isn't something we're doing to be punitive or to deny people treatment. It really is a huge public safety and public health issue right now and, you know, we want to be part of the solution."
The guidelines cover opioid drugs like OxyContin, Demerol and methadone. They include not prescribing to people without a valid ID, and not providing replacement prescriptions.
Federal health authorities say prescription drug abuse is the nation's fastest-growing drug problem.
Emergency room workers like Dr. Meieran say they see people who come back time and again, and have heard all the excuses for needing a new prescription.
"It's kind of like 'The dog ate my homework'. . . the dog ate their prescription. A lot of people, you know, 'I was on the bus and my prescription for OxyContin was stolen.' If we don't have the objective proof, we're not going to just issue these duplicate prescriptions."
The guidelines also suggest that emergency room workers ask questions about substance abuse, and even provide brief interventions and treatment referrals. Dr. Meieran thinks they'll be a catalyst for getting more people the help they need, even in a busy emergency room.
"You can point to the guidelines, and I've had really great conversations with people. People admit, 'Yeah, I think I'm addicted to these, and I don't know what else to do, I don't know how else to get them, I don't know how else to treat my pain,' whatever it is. So then, you can start doing something more productive."
The Oregon guidelines are voluntary. The precautions are modeled after those in other states, including Washington, where they are required by law.
“We are the No. 1 source of prescription opioid medications, and we have a responsibility to take action,” Dr. Meieran says. “For a long time, we have acted in a disjointed fashion, with the right hand not knowing what the left hand was doing. We have come together in the public interest to ensure that these medications are prescribed consistently, appropriately and responsibly.”
It is a big challenge for the emergency department team to walk the fine line between responsible prescribing and their primary objective of providing care. But the cost of doing nothing is staggering: