As the prescribing practices of emergency providers come under enhanced scrutiny, watch for red flags of drug-seeking behavior
Use the opportunity of an ED visit to identify, intervene with youth at risk for overdoses, misuse
Every day emergency providers are faced with the difficult challenge of caring for patients who require treatment for pain while also endeavoring to identify those patients who are at risk for substance abuse so that they can be steered toward non-opiate treatment alternatives or, perhaps, addiction counseling. And such decision making is under enhanced scrutiny because as opioid and sedative prescriptions have continued to increase in recent years, so have deaths from the overuse of these powerful drugs. The Centers for Disease Control and Prevention in Atlanta, GA, reports that deaths from opioid medication overdoses alone have reached epidemic proportions in the United States.
In the absence of a prescribing or medical history, there is no question that emergency providers often struggle with making the right call. "A huge percentage of patients come in with pain complaints. We want to do the right thing for patients, and we want to treat their pain, but there are definitely some patients who have addiction problems who, frankly, come into the ED to use us for a prescription to meet their addiction needs," explains Scott Weiner, MD, MPH, FACEP, an emergency physician at Tufts Medical Center in Boston, MA, and the director of clinical research in the Division of Emergency Medicine at Tufts University School of Medicine. "Currently, there is not a good way of detecting those patients or determining who is at risk."
The result is that such decisions are often based on what a provider’s impressions are as opposed to hard data or evidence. "What I have noticed is that there is a lot of heterogeneity between my colleagues and myself [regarding these types of decisions]," says Weiner. "I think that is just normal because people have different senses of who is exhibiting drug-seeking behavior and who isn’t, so I really think we need more objective criteria to determine the patients who are at risk."
Consider characteristics of drug seekers, abusers
To obtain those data, Weiner and colleagues decided to look at the characteristics of patients who had obtained 10 or more schedule II-V prescriptions from 10 or more providers in a given year, and they compared them with patients who used fewer providers and prescriptions. The idea was to work toward developing a risk profile that providers could rely on when treating patients who present to the ED with pain, much as they use risk scores when evaluating patients with cardiac problems, explains Weiner. "A low-risk patient might still have cardiac disease, but we know it is a very unlikely situation. And a high-risk patient might not have cardiac disease, but we know to be very careful with that patient because they have all these risk factors," he says.
If providers were armed with information about the characteristics of patients who have what Weiner refers to as aberrant drug-related behaviors, they might be better able to tailor their treatment decisions, he observes. "For patients who are high risk, you might pursue alternative treatments that are not opiate, and you might spend more time counseling and screening before you write a prescription," he says.
After poring over about 18 months of data culled from ED patient encounters at two academic medical centers in Boston, MA, the researchers found that drug-seeking patients were more likely to be white than non-white, and they were also more likely to:
• request a narcotic by name;
• have multiple visits for the same complaint;
• report an allergy to non-narcotic drugs;
• have pain out of proportion to the exam;
• come to the ED on weekends.
Throw out preconceived notions
Researchers also derived findings about clinical decision making from an earlier research endeavor in which Wiener and colleagues compared ED physician impressions of drug-seeking behavior with objective criteria from a state prescription drug monitoring program.1
"The emergency providers thought that men were more likely to be drug seekers than women, but it was obviously the reverse. The finding was pertinent because shortly after the paper came out the CDC came out with a report saying that women were at much higher risk of overdose death from opiates," explains Weiner. The message to providers is to just be a little bit more careful with women, adds Weiner.
He also points out that the researchers found no difference in age between drug seekers and non-drug seekers, suggesting that any preconceived notions that providers have on that aspect should probably be thrown out.
One other finding was that emergency physicians tended to put a lot more weight on patients with a suspicious history or pain symptoms that they found to be out of proportion to the examination than did the prescription drug monitoring program data. This is a concern, says Weiner, because these criteria are subjective. "It is just a call to tone down a little bit on the gestalt and rely more on other factors," he says.
One of the more intriguing findings from the study was that once emergency physicians were able to compare their impressions regarding the patients with hard data from the prescription drug monitoring program, they changed their prescribing in about 10% of the cases. But this resulted in the physicians actually prescribing opioids for more patients than originally planned. The net result was that 6.5% of patients received an opioid prescription and 3% did not receive a prescription, a prescription that was previously planned.
View ED visit as an opportunity
While ED providers clearly need to be careful when prescribing opiates or sedatives, experts suggest they also have an important role to play in identifying young people who are engaging in the non-medical use of these powerful drugs. One new study suggests that non-medical prescription opiate use (NPOU) and non-medical prescription sedative use (NPSU) are a common occurrence among adolescents, and that the ED is advantageously situated to implement screening and intervention efforts.
As many as one in 10 adolescents who presented to the ED between September 2010 and September 2011 reported that they engaged in NPOU or NPSU within the past year, according to research conducted at the University of Michigan Medical Center in Ann Arbor.2
Further, researchers report that many of these patients had easy access to prescription medications. Among the 185 participants who reported NPOU, nearly 15% reported that there was a prescription at home for an opioid, and of the 115 patients who reported NPSU, there was a prescription at home for sedatives. (Also, see "Young male athletes at heightened risk for use, misuse of opioid medications," p. 8.)
The data present a clear opportunity for EDs to intervene with these patients, according to investigators. "What we have found in other studies and in practice for many years is that youth and adults are more forthcoming than one would expect when asked questions about how much they are using an assortment of different medications and drugs," explains Rebecca Cunningham, MD, a co-author of the study and an associate professor of emergency medicine at the University of Michigan. "And often there is an opportunity to figure out that someone has actually tripped over from misuse to real dependence on a medication, and that another strategy would be more appropriate."
Consider SBIRT screening
Cunningham notes that some experts believe that all patients who present to the ED should undergo screening in a process referred to as Screening Brief Intervention and Referral to Treatment, or SBIRT. "That is one way to use the opportunity of an ED visit to collect information on people who may be having problems in many other aspects of their lives, and provide them with that opportunity for intervention and referral while they are seeing the physician for other reasons," she observes. The SBIRT process has thus far been primarily used to address problem drinkers, but Cunningham believes it could be effective with respect to NPOU and NPSU as well.
Cunningham also advises that ED physicians may or may not be the best people to actually carry out screening. "It can be done in many other ways, and perhaps should be incorporated into the EMR technology that is in place in EDs," she explains. "Further, those EDs that are forward-thinking increasingly have dedicated personnel who focus on providing health behavior interventions."
Such a strategy can become cost-effective if it reduces hospital utilization, says Cunningham. "If you reduce repeat visits by providing a brief intervention or brief screening during an ED visit, then you will ultimately save your hospital money, " she explains. "There have been multiple studies showing that SBIRT is cost-effective to hospitals."
Patients who report NPOU or NPSU also tend to be at risk for other things such as alcohol use, dating violence, requiring public assistance, or having failing grades, observes Cunningham. Consequently, screening and intervention have the potential to pick up and potentially alleviate numerous problems.
Researchers at the University of Michigan Injury Center in Ann Arbor are now testing the efficacy and feasibility of offering an ED-based, 30-minute counseling intervention to young adults who are at risk for an overdose, have already had an overdose, or have reported misusing prescription medications in the past. "Overdose is becoming the leading cause of death among this population in Michigan and in other states, surpassing motor vehicle crashes," says Cunningham. "There is a lot of downtime in the ED, and that gets people focused on harm reduction."
The approach is aimed at getting people to recognize that they are having problems, and to identify places, times, or ways they are misusing that might put them at risk for an overdose; they will then be provided with referrals and next steps to take when they leave the ED, explains Cunning-ham.
Develop tools, resources
Weiner acknowledges that identifying patients who are at risk for medication abuse or dependency is only half the battle. Providers also need to have tools and resources at their disposal so that these patients can take the next step. Simply having a discussion with patients about their drug use can be challenging.
"If I see a patient I am concerned about, I will print out their profile from the prescription drug monitoring program [PDMP], and I will bring it into the room and share it with the patient," says Weiner. "It is really their information, so they have a right to be looking at it, too."
The patient reactions from this approach can vary quite a bit. "Some people walk out right away, some people deny [the information on the report], and some say there must a mistake," explains Weiner. "But there is a subset of patients for whom it is useful to realize that they have a problem, and to show them on paper, with objective evidence, that there is a problem."
In these cases, Weiner can make referrals for detoxification or refer patients back to their primary care physicians for counseling. The options are limited, he says. But even more challenging is trying to assess outcomes — which are critical to devising a complete solution to the problem, says Weiner. Consequently, Weiner and colleagues are working with the state of Massachusetts to see if they can get access to this data.
"The key word is outcomes," he says. "We need to know what happens to patients in order to know how best to use the [PDMP, clinical data, and screening] tools, and that is what my next steps are about," he says.
- Weiner S, Griggs C, Mitchell P, et al. Clinical impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department. Ann Emerg Med. 2013;62:281-289.
- Whiteside L, Walton M, Bohnert A, Blow F, Bonoar E, Erhlich P, Cunningham R. Nonmedical prescription opioid and sedative use among adolescents in the emergency department. Pediatrics 2013;132:825-832.
- Rebecca Cunningham, MD, Associate Professor of Emergency Medicine, University of Michigan, Ann Arbor, MI. E-mail: email@example.com.
- Scott Weiner, MD, MPH, FACEP, Emergency Physician, Tufts Medical Center, and Director of Clinical Research, Division of Emergency Medicine, Tufts University School
of Medicine, Boston, MA. E-mail: firstname.lastname@example.org.