A changing landscape of opioid prescribing in emergency medicine.

Emergency Medicine providers are grappling with the dual challenges of adequately treating pain while avoiding the risks associated with opioid pain relievers. The aggressive treatment of pain with opioids for the last three decades has resulted in an epidemic of opioid use disorder and opioid related mortality. This editorial discusses the findings in a study of emergency department (ED) opioid prescribing by Yang et al. and explores the changing landscape of opioid prescribing in emergency medicine. We specifically discuss risks associated with opioid prescribing, strategies to reduce risks while improving pain management, the role of advanced practice providers in ED opioid prescribing, and the importance of further education on opioid sparing pain management strategies.

Characteristics of emergency department "doctor shoppers".

BACKGROUND: There is a need to accurately identify patients at risk for drug abuse before giving a prescription for a scheduled medication. OBJECTIVE: Our aim was to describe a subset of emergency department (ED) patients that had eight or more schedule II-V prescriptions filled from eight or more providers in 1 year, known as "doctor-shopping" (DS) behavior, to compare demographic features of DS and non-DS patients, and to determine clinical factors associated with DS. METHODS: We conducted a prospective, observational study of emergency providers' (EPs) assessment of patients with back pain, dental pain, or headache. EPs recorded patient demographics, clinical characteristics, and numbers of schedule II-V prescriptions, subset opioid prescriptions, providers, and pharmacies utilized in a 12-month period, as reported on the state prescription drug-monitoring program. χ(2) and t-tests were used to compare DS with non-DS patients on demographics; a multivariate logistic regression was performed to determine clinical factors associated with DS. RESULTS: Five hundred and forty-four patient visits were recorded; 12.3% (n = 67) had DS behavior. DS and non-DS patients were similar in sex but differed in age, race, chief complaint, and weekday vs. weekend arrival. DS patients utilized a median of 12.0 (interquartile range [IQR] 9.0-18.0) providers compared with a median of 1.0 (IQR 0-2.0) providers in the non-DS group. Reporting allergies to non-narcotic medications (odds ratio [OR] = 3.1; 95% confidence interval [CI] 1.4-6.9; p = 0.01), requesting medications by name (OR = 2.7; 95% CI 1.5-4.9; p < 0.01), and hospital site (OR = 2.0; 95% CI 1.1-3.6; p = 0.03) were significantly associated with DS. CONCLUSIONS: There are multiple clinical characteristics associated with DS in this patient population.

Prescription drug monitoring programs: examining limitations and future approaches.

Prescription drug abuse is a leading cause of accidental death in the United States. Prescription drug monitoring programs (PDMPs) are a popular initiative among policy makers and a key tool to combat the prescription drug epidemic. This editorial discusses the limitations of PDMPs, future approaches needed to improve the effectiveness of PDMPs, and other approaches essential to curbing the rise of drug abuse and overdose.

Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department.

STUDY OBJECTIVE: We compare emergency provider impression of drug-seeking behavior with objective criteria from a state prescription drug monitoring program, assess change in opioid pain reliever prescribing after prescription drug monitoring program review, and examine clinical factors associated with suspected drug-seeking behavior. METHODS: This was a prospective observational study of emergency providers assessing a convenience sample of patients aged 18 to 64 years who presented to either of 2 academic medical centers with chief complaint of back pain, dental pain, or headache. Drug-seeking behavior was objectively defined as present when a patient had greater than or equal to 4 opioid prescriptions by greater than or equal to 4 providers in the 12 months before emergency department evaluation. Emergency providers completed data forms recording their impression of the likelihood of drug-seeking behavior, patient characteristics, and plan for prescribing pre- and post-prescription drug monitoring program review. Descriptive statistics were generated. We calculated agreement between emergency provider impression of drug-seeking behavior and prescription drug monitoring program definition, and sensitivity, specificity, and positive predictive value of emergency provider impression, using prescription drug monitoring program criteria as the criterion standard. A multivariate logistic regression analysis was conducted to determine clinical factors associated with drug-seeking behavior. RESULTS: Thirty-eight emergency providers with prescription drug monitoring program access participated. There were 544 patient visits entered into the study from June 2011 to January 2013. There was fair agreement between emergency provider impression of drug-seeking behavior and prescription drug monitoring program (κ=0.30). Emergency providers had sensitivity 63.2% (95% confidence interval [CI] 54.8% to 71.7%), specificity 72.7% (95% CI 68.4% to 77.0%), and positive predictive value 41.2% (95% CI 34.4% to 48.2%) for identifying drug-seeking behavior. After exposure to prescription drug monitoring program data, emergency providers changed plans to prescribe opioids at discharge in 9.5% of cases (95% CI 7.3% to 12.2%), with 6.5% of patients (n=35) receiving opioids not previously planned and 3.0% (n=16) no longer receiving opioids. Predictors for drug-seeking behavior by prescription drug monitoring program criteria were patient requests opioid medications by name (odds ratio [OR] 1.91; 95% CI 1.13 to 3.23), multiple visits for same complaint (OR 2.5; 95% CI 1.49 to 4.18), suspicious history (OR 1.88; 95% CI 1.1 to 3.19), symptoms out of proportion to examination (OR 1.83; 95% CI 1.1 to 3.03), and hospital site (OR 3.1; 95% CI 1.76 to 5.44). CONCLUSION: Emergency providers had fair agreement with objective criteria from the prescription drug monitoring program in suspecting drug-seeking behavior. Program review changed management plans in a small number of cases. Multiple clinical factors were predictive of drug-seeking behavior.