15 January 2013

Mayor Bloomberg and Narcotics

I may be just a bit late in commenting on this, but last week (which was like ten years ago in Internet time) there was a bit of hue and cry regarding Mayor Bloomberg's report on the matter of prescription drug abuse and restrictions on new prescriptions for painkillers through the Emergency Department.

Initially, I was concerned. I completely agree with the comment from the linked article: “Here is my problem with legislative medicine,” said Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians... “It prevents me from being a professional and using my judgment.” The verbiage used regarding the new rules was worrisome: restricted sharply... city policy ... will not be dispensed ... regulatory authority to impose, and the like.

I'm like most doctors in that even when I agree with the purpose of proposed rules, I quite object to interference in how I practice, to "the government coming between you and your doctor" as it was so memorably put in the past. And given that Bloomberg is getting something of a reputation for being a little dictator I was all ready to get my pitchfork and torches and head down to join the mob.

While I was getting my outrage machine up to operating temperature, I took a moment to read the official press release and the actual source document (PDF), though, and one word in the very first paragraph, notably absent from the press coverage of the proposal, jumped out at me:

VOLUNTARY

Well, that's a horse of a different color, isn't it? Doctors and hospitals are encouraged but not obligated to follow the new guidelines, and in individual cases, the doctor can freely exercise his or her judgement. I'm good with that. So what about the meat of the policy?

Key points that jumped out at me:

  • A new/improved database for tracking narcotic prescriptions and making it available to prescribing doctors.
  • Not prescribing more than a 3-day supply of most narcotics, and not at all prescribing oxycontin, fentanyl or methadone through the ER, and not refilling these meds
  • All narcotics to be electronically prescribed (to limit forged prescriptions)
  • Changing the defaults on EMRs to have lower amounts of tablets dispensed.

Frankly, these all seem reasonable, as long as physician discretion is preserved. If someone has a long-bone fracture and won't be into see ortho for a week, well then a week's worth of pain meds is reasonable, for example. In our state, we put forth some very similar guidelines in our "Seven best Practices" for reducing ER overuse and abuse.

The "guidelines" are particularly useful for a practicing doc in that it gives you permission to say "no." Currently, if I see a patient whom I suspect is "working me" for narcotics, but I don't have clear evidence to support that suspicion, I am in a bit of a bind. In such cases, there's no objective evidence of disease — back pain, neuropathy, etc — but that doesn't mean there isn't real pain. If I say no, I run the risk of patient complaints and a letter from the CEO. If I say yes, I then get bogged down in negotiations over how much and what drug. The guidelines offer a compromise: a limited supply of less potent meds. If the patient ups the ante or tries to demand more, I can point to the guidelines and explain that we have a policy, that it's not personal or judgmental, but is simply our "best practice." Even better is that there are clear guidelines against refills and treating of chronic non-cancer pain in the ER.  All this is meant to give doctors faced with a demand for narcotics the institutional backing to say no, and tacitly recognizes the fact that doctors have been complicit in creating the problem through excessive opiate use.

I note that endorsing the proposal in NYC was the New York chapter of ACEP, which is also heartening. The problem of ER abuse and prescription narcotic addiction/diversion is a real issue, and it is growing. We, as ER physicians, need to take ownership of the problem, as much as we can, and take leadership in developing measures to mitigate the problem. If we don't, then it is predictable that someone else, likely state governments, will come in and impose solutions on us -- and those "solutions" are likely to be heavy-handed, draconian, and probably ineffective.

So. from what I can tell, New York's approach seems very well-reasoned and hopefully pretty effective. I am also encouraged by an addendum that several private hospitals in the NYC area have announced that they are also going to follow these guidelines (which properly only apply to city-owned hospitals). I'm also particularly pleased that the process we went through in our state has begun to be used as a model for other states to follow!

12 comments:

  1. I have a friend who precepts residents, she has adopted a practice that makes a lot of sense to me. The first task residents have when starting a rotation with her is to sit down and register for a provider account in our state's prescription monitoring program. She the pulls prescription records for the patients they review with her until the resident's own account is activated.

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  2. Lucky you. I live in a state with a mandated prescription law that is a nightmare for the 93% of patients who don't have a drug problem in Kentucky.

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  3. All narcotics to be electronically prescribed would certainly solve the abuse problem where I work, though it'd be hard on the folks that actually need legit pain treated.

    I suppose though that all ERs in NYC are fully electronic, most big cities are I think.

    That word "voluntary" seems to clash a bit with "regulatory authority to impose". Perhaps that means it's voluntary for now but they are reserving the authority to make it mandatory?

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  4. Guidelines are ok, but they don't address the real problem, which is addiction. The doctors get legislated because that's an easy access point to control. Less easy is the patient's decision to put drugs in their mouth.

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  5. Vince, I believe the difference is in who has the authority. From what I read into it, it looks like the hospital will be required to institute the electronic prescription practice, but that the doctor has the final yay or neigh as to whether or not it's used.

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  7. I fail to understand the bugaboo that is made of oxycontin. The medicine is nothing more than timed-release oxycodone. According to at least one prescriber I've spoken to it is considered less addictive than morphine in whatever form. It's a highly useful and valuable medication.

    I'll go further and say that excessive fears of addiction to opiates are preventing many people from getting adequate treatment for severe pain. My opinion, by the way, is based on observation not theory or ideology. It's the usual story of enforcing laws against the law-abiding, the criminals being so difficult to catch and convict.

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