Misuse of prescription opioids is one of the defining health problems of our generation.  The dramatic rise of opioid analgesic prescriptions in the US and Canada has been well documented, and opioids represent the most common cause of fatal prescription overdoses. On every shift, in every emergency department in the country, physicians struggle with the concerns of patients presenting with common pain complaints. Seeking to manage their patients’ symptoms in the face of dramatically rising prescription opioid misuse and fatal overdose, emergency physicians are  challenged to distinguish those who are simply seeking pain relief, those who are seeking opioid prescriptions due to addiction, and those who fit both categories. Emergency care providers are also charged with balancing the pressures of meeting clinical care and patient satisfaction goals while fulfilling our moral obligation to provide primary and secondary prevention of opioid misuse.

Google Hangout with the Authors

[su_spoiler title=”Timestamped breakdown of Google Hangout video” style=”fancy” icon=”chevron-circle”]

Timestamp	Topic
00:00	Dr. Esther Choo launches, leads, and facilitates a great discussion with an expert panel.
00:55	Dr. Poon discusses why the paper was written and a challenging decision point from the perspective of the residents. Would an opioid prescription more benefit or harm a patient?
03:10	Dr. Poon mentions PDMP (Prescription Drug Monitoring Program), also known as PMP (Prescription Monitoring Program).
04:24	Dr. Greenwood-Ericksen: There’s very little in the EM residency and medical school curriculum dedicated to opioid prescription practice. She shares an experience from her internship year about how little guidance there is about prescribing opioids and talking to patients about pain medications
06:42	Dr. Greenwood-Ericksen talks about voluntary opioid prescribing guidelines championed by ACEP and state-based groups, working alongside with public health departments. An example from New York: avoid prescribing long-acting opioids, limiting prescription to 3 day supply, and avoiding re-writing lost/stolen prescriptions.
07:45	Dr. Choo summarizes the discussion thus far and shifts gears from resident perspective and introduces expert panelists who have also published in this field.
09:22	Dr. Juurlink advocates that we need to acknowledge that Opioid Prescriptions are an epidemic … of our own making. He mentions a 2011 BMJ commentary and that he co-authored about this. Also references a J of Med Tox commentary about PDMP by Dr. Perrone et al.
14:03	Dr. Amirshahi discusses how this epidemic impacts the Emergency Department both for in-ED care and discharge prescription medications. Recommends a 2012 J Med Tox commentary by an anonymous nurse, which led to abuse and addiction. She also references her 2014 American J of EM article about opioids and headaches.
20:55	Dr. Juurlink discusses the challenges about patient education and shared decision making about opioids.
22:18	Dr. Amirshahi shares her experiences with patient education and the challenges with especially the chronic opioid user.
23:07	Dr. Juurlink responds and clarifies that there are 2 populations – chronic opioid users and opioid naive users.
24:32	Dr. Poon shares her take home points.
25:47	Dr. Greenwood-Ericksen shares her take home points.
26:36/td>	Dr. Juurlink shares his take home points.
27:35	Dr. Amirshahi shares her take home points.
28:43	Dr. Scott Kobner (ALiEM-EMRA Social Media and Digital Scholarship Fellow, NYU medical student) talks about his perspectives as a preclinical medical student and thinks this is an opportunity for medical students to get involved with outreach and advocacy about it.
31:07	Dr. Greenwood-Ericksen thanks her collaborators.

[/su_spoiler]

On August 12, 2014 at 9 am EST, we hosted a 30 minute live Google Hangout on Air with Drs. Sabrina Poon and Margaret Greenwood-Ericksen, the authors of the Annals of Emergency Medicine Resident’s Perspective paper on the how the opioid prescription epidemic. Later this year, a summary of this blog- and Twitter-based discussion will hopefully be published back into the journal.

• Sabrina Poon, MD (@sjpoon): resident physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women’s Hospital, Massachusetts General Hospital (Boston, MA)
• Margaret Greenwood-Ericksen, MD MPH: resident physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women’s Hospital, Massachusetts General Hospital (Boston, MA)
• David Juurlink, MD (@DavidJuurlink): medical toxicologist, internal medicine physician, Division of Clinical Pharmacology and Toxicology at Sunnybrook Health Sciences Centre (Toronto, ON)
• Maryann Mazer-Amirshahi, MD: medical toxicologist, emergency medicine physician, MedStar Washington Hospital Center (Washington, DC)

Annals of EM Resident Perspective Article

Poon SJ, Greenwood-Ericksen MB. The Opioid Prescription Epidemic and the Role of Emergency Medicine. Ann Emerg Med. 2014 Jul 11. pii: S0196-0644(14)00527-7. PMID:25017821. Free PDF

Introduction

In the June issue of Annals of Emergency Medicine, Drs. Poon and Greenwood-Ericksen published a Resident’s Perspective around this issue entitled “The Opioid Prescription Epidemic and the Role of Emergency Medicine.” The paper reviews the scope of the issue and describes the quandaries faced by ED physicians attempting to balance high-quality care with safe, appropriate care–resulting in high variability in ED prescribing practices. It also discusses some of the solutions that have been proposed to stem the tide of the epidemic, including prescription drug monitoring programs, prescribing guidelines, and physician education.

Testament to the urgency and difficulty of these tasks are the number of blogs on this issue over the past year.

FOAM Discussion to Date

A comprehensive review of FOAM resources produced during the last year was conducted using the FOAMSearch platform and targeted Google searches. Since 2013, 10 blog posts and 1 podcast concerning opioid prescribing trends in the emergency department have been published as the FOAM discussion of this issue continues to evolve. For some background on the paper discussion, review any of the resources listed in the table below.

Website	Title	Author	Type	Country	Date
EM Tutorials	Oxy morons. Avoid prescribing oxycodone	Chris Cresswell	Podcast	New Zealand	7/22/14
The Poison Review	Counties in California sue manufacturers of opioid analgesics	Leon Gussow	Blog	USA	5/24/14
Emergency Medicine Literature of Note	Your Patients Will Abuse Opiates	Ryan Radecki	Blog	USA	5/19/14
Emergency Physicians Monthly	Opioids: Misuse and Abuse	Ryan Radecki	Blog	USA	5/6/14
The Poison Review	ED discharge prescriptions for opioid analgesics increased 49% from 2005 to 2010	Leon Gussow	Blog	USA	3/25/14
Emergency Medicine Literature of Note	Nonsensical Opiate Overuse in Adolescent Headache	Ryan Radecki	Blog	USA	3/2/14
The Skeptics Guide to Emergency Medicine	Drugs in My Pocket (Opioids in the Emergency Department)	Ken Milne	Podcast	Canada	11/28/13
The Poison Review	Guidelines for Opioid Prescription: do emergency physicians need support?	Leon Gussow	Blog	USA	4/9/13
The Poison Review	NYC Recommendations for Prescribing Opioids in Emergency Departments	Leon Gussow	Blog	USA	3/8/13
Emergency Medicine PharmD	Opioid related deaths	Craig Cocchio	Blog	USA	3/4/13
Emergency Physicians Monthly	NYC Limits ED Opioid Prescriptions	Kevin Klauer and Rick Bukata	Blog	USA	2/8/13

Featured Discussion Questions

The ALiEM team poses the following questions to explore current practices with MMI, and perceptions about the benefits and drawbacks of this interview format. If you have additional questions, feel free to pose them!

1. The authors cite the Joint Commission’s pain control mandate (i.e., “pain is the fifth vital sign”) and the emphasis on patient satisfaction scores as critical factors in the increase in opioid prescribing over the last decade. To what extent do these factors influence your use of opioid pain medications, both during the ED visit and upon discharge?
2. The authors discussed potential barriers to prescription monitoring programs (PMPs). In your practice, are PMPs assisting in appropriate and safe opioid prescribing practices? If not, why? If so, how?
3. Only three states have adopted formal guidelines for opioid prescribing from the ED. Do you think these are/will be helpful? Why do you think they have not been adopted more widely?
4. The authors propose a resident curriculum for opioid prescribing in the ED, including lectures, journal club, case-based learning, and simulation. What have been your experiences with formal instruction around opioid prescribing? What do you think are the most effective ways to shape physician behavior around this issue?

Please participate in the discussion by answering either on the ALiEM blog comments below or by tweeting us using the hashtag #ALiEMRP. Please denote the question you are responding to by starting your reply with Q1, Q2, Q3, or Q4.

NEW! Contest for Best Blog Comment and Tweet

Thanks to Dr. Henry Woo and his colleagues in the Twitter-based International Urology Journal Club series (#urojc) hosted by @IUroJC, we are also implementing a contest for the Best Blog Quote and Best Tweet. What, emergency physicians – competitive? No… The winners will be announced in our Annals of EM publication curating this discussion.

Additional Reading / References

1. Juurlink DN, Dhalla IA, Nelson LS. Improving opioid prescribing: the New York City recommendations. JAMA [Internet]. 2013 Mar 6 [cited 2014 Jul 28];309(9):879–80. Pubmed
2. Kahan M, Gomes T, Juurlink DN, Manno M, Wilson L, Mailis-Gagnon A, et al. Effect of a course-based intervention and effect of medical regulation on physicians’ opioid prescribing. Can Fam Physician [Internet]. 2013 May [cited 2014 Jul 28];59(5):e231–9. PMC
3. Mazer-Amirshahi M, Mullins PM, Rasooly IR, van den Anker J, Pines JM. Trends in prescription opioid use in pediatric emergency department patients. Pediatr Emerg Care [Internet]. 2014 Apr [cited 2014 Jul 28];30(4):230–5. Pubmed
4. Mazer-Amirshahi M, Mullins PM, Rasooly I, van den Anker J, Pines JM. Rising Opioid Prescribing in Adult U.S. Emergency Department Visits: 2001-2010. Acad Emerg Med [Internet]. 2014 Mar [cited 2014 Mar 27];21(3):236–43. Pubmed
5. Rosenau AM. Guidelines for opioid prescription: the devil is in the details. Ann Intern Med [Internet]. American College of Physicians; 2013 Jun 4 [cited 2014 Jul 28];158(11):843–4. Abstract

Disclaimer: We reserve the right to use any and all tweets to #ALiEMRP and comments below in a commentary piece for an Annals of Emergency Medicine publication as a curated conclusion piece for this Resident’s Perspective publication. Your comments will be attributed, and we thank you in advance for your contributions.

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