Dr. James Black, medical director of the emergency department at Phoebe Putney Memorial Hospital, looks over a patient’s prescription bottle. There are methods Phoebe is currently using to help combat drug abuse in its emergency room. (Staff Photo: Jennifer Parks)
ALBANY — Drug abuse has been a big problem for emergency rooms in recent years, including in Southwest Georgia. While methods have been instituted to help curb it, experts say there is still a long way to go.
Opiate overdoses, doctor-shopping by patients seeking controlled substances and opiate misuse are routine enough features of emergency department patient populations that emergency physicians have developed innovative solutions to address these medical and social problems, a study presented earlier this month in Seattle at the annual meeting of the American College of Emergency Physicians (ACEP) has shown.
“It’s a tricky subject, because there are patients with legitimate pain who need relief and others who are doctor shopping and their primary care provider is not available,” said Dr. James Black, medical director of the emergency department at Phoebe Putney Memorial Hospital.
Officials with ACEP report that, for every fatal opiate overdose visit to emergency departments in the United States, there are 63 non-fatal opiate overdoses. Opiate overdose resulted in 106,813 emergency room visits in 2009, with the majority of them, 67 percent, caused by prescription opiates.
“Doctor-shopping” patients, who had narcotic prescriptions from 10 or more providers in one year, were more likely to report an allergy to non-narcotic pain relievers, to request a narcotic by name, have multiple visits for the same complaint and have pain out of proportion to the physical exam, officials with the ACEP said of the study ahead of its annual meeting. They were more likely to be white than non-white and come to the emergency room on weekends.
The average number of medical providers these doctor-shoppers had seen in the previous year was 17, versus 1.6 for non-drug-seekers, the study showed.
“Knowing the typical characteristics associated with doctor-shoppers will give emergency physicians a better chance to identify patients with high risk for abuse when they come to the ER with pain complaints,” said lead study author and ACEP fellow Dr. Scott Weiner.
Black said the emergency department at Phoebe often sees the same signs. The patient may claim they are allergic to almost all non-narcotic pain medications, or they may specify what drug they need and how much they need — often at unsafe levels. They will have multiple doctors from whom they have gotten a prescription as well as a generic form of the same drug, and the pain is out of proportion to what they doctor will see on the exam.
“You will have a patient who will present in terrible pain. Later on they are talking on their cell phone and when you walk in they tell you where the pain is,” he said.
Emergency physicians are taking the lead in treating repeat emergency patients who visit the emergency room in search of narcotics. An example is in San Diego, where patients who made more than two emergency visits for alcohol, substance abuse or psychiatric problems were identified and flagged by the electronic medical record and consequently placed in non-medical detoxification programs, which reduced repeat emergency visits by 90 percent from 137 total visits or 5.27 visits a week to 10 total visits or 1.67 visits a week over a six-month period, officials from ACEP said.
At Phoebe, Black said the process generally involves keeping track of the patient. When they make repeat visits, they are flagged and other hospitals in the region are alerted. They may also be put on observation, and will be educated on what their options are when it comes to handling pain — since just writing the prescription and moving on does not necessarily solve the problem.
“(We also) give them other avenues to manage pain such as (physician referrals) and detox,” he said. “Detox is done as inpatient for awhile, and they are later moved to outpatient.
“Some are not aware they have a substance abuse problem, so we educate on the difference between pain and withdraw.”
The study found when emergency physicians and care managers in cooperation with primary care physicians set up individualized care plans for patients who were flagged as drug-seekers, the mean number of emergency room visits declined from an average of 7.6 per year to 2.3 per year.
“These interventions had a meaningful impact on the behavior of our drug-seeking patients, which was beneficial to both the patients and overstressed emergency departments,” said lead study author Dr. Ashley Flannery.
Black said it is significant problem, and it is a growing problem in part because there is more awareness of it — and therefore more communication about it. Part of the blame, he said, can also be on the fact that emergency rooms are more easily accessible, and many patients believe there will be no way to check for flags in the system if they come in during the night hours.
With the economy they way it has been in recent years, he said it has not been uncommon for people to get a prescription for a certain drug and sell it on the street.
Also what may be contributing to the problem is knowledge of how overdoses are treated.
“What may be feeding the problem is that we have become decent at treating overdoses, so there is less fear it will do harm to them,” Black said. “That amount confidence is pushing the envelope. We can’t always get to them in time, or they take things we can’t treat.”
It’s an issue that can be addressed, Black said, by educating patients as well as being honest with them, and giving them options as long as they are willing to follow through on them.
Through these methods, there has been a decline of such abuse seen at Phoebe — but there is still a long way to go.
“Again, the issue is to separate need of pain management and those in chronic need,” Black said. “We are not ignoring chronic need … but going into the ER every other day is not management of chronic pain.
“We want to get folks in the hands of people equipped to (more effectively) handle it … We need to be consistent in our management, because there will sometimes be patients who come in and ask who is working that day. We need to work on having a consistent approach.”