April 27, 2017
Roneet Lev, MD, is director of operations at the Scripps Mercy Emergency Department in San Diego and also chairs the Emergency Medicine Oversight Commission (EMOC) with the San Diego County Medical Society, where she coordinates and improves the care provided in 19 hospital emergency departments.
It’s fair to say Dr. Lev has her finger on the pulse of what providers and pharmacists face at the very front lines of emergent care and, today, the proper and safe use of opioids is demanding a lot of their attention. The Centers for Disease Control and Prevention (CDC) has declared an opioid epidemic for the past 5 years, noted Dr. Lev, who said problems with opioid use actually started around 2000, when the number of opioid deaths began to increase. That corresponded to a time when pain was identified as the fifth vital sign and the medical community was told to treat all pain equally and that opioids shouldn’t be reserved for cancer patients or end-of-life comfort. That’s also when the medical community began to measure the quality of care based on patients’ reported pain scores, a factor that pressured many providers into using powerful pain-control punch when a light touch would have worked.
Dr. Lev recently discussed the scope of the opioid problem in the United States and why the transparent and standardized use of opioids in community emergency departments could help solve the nationwide crisis.
How big is the issue of opioid abuse and misuse in this country?
First, we need to acknowledge that medical providers are also victims of the opioid epidemic. They received incorrect information about proper opioid use, so now it’s a matter of re-teaching them about safer ways to manage pain.
We’re now just seeing the tip of the iceberg with respect to an alarming number of opioid deaths. According to the CDC, 91 people die each day from opioid overdose. The alarming number of deaths is why the federal government says we’re facing an opioid epidemic. But in San Diego County, 250 people die each year from prescription opioids, so I prefer to call the problem a prescription drug epidemic. Most people who die from opioid use get in trouble because of a cocktail of medications, not a single pain control drug.
What can emergency department providers do to ensure opioids are used safely and effectively?
Emergency departments account for less than 5% of total opioids prescriptions. If you do a deep dive into which prescriptions people actually die from, Vicodin scripts written for patients with back pain aren’t always to blame. However, 20% of all prescribers involved in opioid deaths are emergency physicians. That indicates there’s a missed opportunity to improve prevention efforts. It means patients likely visited an emergency department before they died for treatment of some sort, and during those visits providers could have reviewed medications lists, keyed red flags in prescription drug monitoring program (PDMP) reports, looked for co-prescribing of opioids by different providers, and addressed dangerous drug-drug interactions.
Do emergency department pharmacists have a role to play in managing opioids use?
They do. In fact, pharmacists and emergency room physicians have similar roles and responsibilities in preventing the misuse of opioids. I’m part of the San Diego Safe Prescribing taskforce, which developed a guideline that pharmacists can use to talk to providers more effectively about the unsafe prescribing of opioids, because some pharmacists are reluctant to do so.
Pharmacists should contact prescribers for clarification if they see patients on the unholy trinity of an opioid, a benzodiazepine, and carisoprodol. They should also contact prescribers if patients are on more than 50 morphine milligram equivalents per day or if they notice escalating doses of opioids. Pharmacists and emergency department physicians can review medication lists with patients and have conversations about the use of opioids and benzodiazepines. They should warn patients about the dangers of taking those agents in combination and advise them to speak to their prescribing physicians about alternative treatment options.
What needs to be done moving forward to help solve the opioid crisis?
Providers must properly manage individuals who are already on opioids and improve pain management regimens so we don’t create a new group of Americans who are at risk of dying from opioid prescriptions.
Emergency pharmacists in San Diego collaborated a couple years ago to develop best practices for the safe prescribing of opioids. The program outlines the responsibilities of emergency department providers based on what some patients will try to get opioids. The recommendation states that only one physician and one pharmacist can coordinate the prescriptions for a single patient, and they must always check the patient’s medication history in PDMP reports. The guideline also states that opioid prescriptions will not be filled in emergency departments and long-acting opioids will not be used in that setting to treat acute pain.
What factors contribute to the program’s success?
A couple of weeks after the program launched, chronic opioid-seeking patients figured out which hospitals they could go to for pills and called the facilities “Candyland.” Those patients also targeted emergency department physicians who would write opioid prescriptions and called the providers “Candymen.” Those issues eventually went away when we created a community standard to which all hospitals adhered. When all of the emergency departments got on the same page—coordinated the care they provide and were transparent about how opioids would be prescribed—providers no longer had to deal with screaming and angry patients demanding powerful painkillers.