Debate rages over restrictions on ED painkiller prescriptions

Dueling articles published online today in the Annals of Internal Medicine present opposing views of how moves to restrict opioid prescriptions in hospital emergency departments will affect care.

Alex M. Rosenau, D.O., maintains a three-day drug supply--the amount to which ED doctors at public New York City hospitals are now restricted--may not be enough for patients to obtain follow-on care, he writes in the article "Guidelines for Opioid Prescription: The Devil Is in the Details."

Rosenau, president-elect of the American College of Emergency Physicians, notes emergency physicians write fewer than 5 percent of prescriptions for immediate-release opioids and even fewer for extended or long-acting opioids. Policies intended to restrict opioid abuse "must not inhibit (physicians') ability to compassionately treat patients who legitimately seek pain relief in the ED," he writes.

"Closing corrupt pain centers and improving access to high-quality, nonemergency care will improve the care of patients with pain," he adds. "Restricting opioid prescription by emergency physicians will not solve the problem of opioid misuse."

Rosenau calls for a national system automatically identifying opioid prescription and dispensing by pharmacy, patient and physician.

Meanwhile, the New York City Department of Health and Mental Hygiene argues its guidelines, announced in January, will help "conflicted" emergency physicians make difficult decisions, according to a companion commentary, "Guidelines for Opioid Prescription: Why Emergency Physicians Need Support."

"They feel accountable to patients requesting opioids for subjective pain; to guidelines and standards that imply that withholding opioids constitutes poor medical practice; and to institutions valuing patient satisfaction surveys that reward physicians for meeting patient requests, whatever they may be," the authors write.

ED visits and admissions for addiction treatment have risen along with deaths from opioid analgesic overdoses, the Health Department notes. And both come as sales of opioid analgesics increased from less than 2 kilograms per 100,000 Americans in 1999 to 7 kilograms in 2010.

The commentary authors claim there's no evidence to support the long-term use of opioids for noncancer pain. When they are needed, they contend, lower doses and shorter courses will reduce risk.

To learn more:
- here's the abstract for Rosenau's article
- read the NYC Health Department commentary abstract

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