Alex M. Rosenau, DO
This article was published at www.annals.org on 9 April 2013.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0376.
Requests for Single Reprints: Alex M. Rosenau, DO, Lehigh Valley Health Network, JDMCC 214, I-78 and Cedar Crest Boulevard, Allentown, PA 18103; e-mail, firstname.lastname@example.org.
Author Contributions: Conception and design: A.M. Rosenau.
Analysis and interpretation of the data: A.M. Rosenau.
Drafting of the article: A.M. Rosenau.
Critical revision of the article for important intellectual content: A.M. Rosenau.
Final approval of the article: A.M. Rosenau.
Collection and assembly of data: A.M. Rosenau.
Rosenau A.; Guidelines for Opioid Prescription: The Devil Is in the Details. Ann Intern Med. 2013;158:843-844. doi: 10.7326/0003-4819-158-11-201306040-00632
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Published: Ann Intern Med. 2013;158(11):843-844.
More people in the United States now die of prescription drug overdose than accidental vehicular trauma (1). This startling statistic has stimulated physicians, government agencies, and various organizations to effect change through provider guidelines, patient education, and proactive legislation. Opioid analgesics, particularly oxycodone, are major contributors to this trend in preventable death.
Elected officials often erroneously point to the emergency department (ED) as a leading source of opioid prescriptions. In addition, legislative and regulatory action across the United States has called for mandatory continuing education and reclassification of hydrocodone to a schedule II drug. The mayor of New York City recently announced that public hospital emergency physicians are prohibited from prescribing more than a 3-day supply of opioids. This announcement was based on an understanding of the New York City Department of Health and Mental Hygiene's opioid prescribing guidelines (2). The guidelines as written are largely acceptable to most physicians, although, regrettably, the mayor's office did not announce them as such and seems to have limited them to ED opioid prescribing.
Taghogho Agarin, MD, MPH
April 10, 2013
Conflict of Interest:
The most compelling reason
The most compelling reason why practical guidelines are needed is that about one person died from opioid analgesic overdose every 36 minutes as of 2008, according to data from the Centers for Disease Control and Prevention. Sixty percent of these deaths are attributable to prescriptions written by physicians (1, 2.)
Practical guidelines have worked in the past, when issued from state authorities. For instance, after the introduction of a dosing guideline in the workers compensation system of Washington State in 2007, which mandated primary care physicians to consult with pain specialists if prescribing greater than 120mg/day Morphine Equivalent Dose (MED), the proportion of patients on doses greater than 120mg /day MED fell by 35% and the number of deaths decreased 50% between 2009 to 2010 (3).
Emergency room physicians and primary care physicians account for 43% of all opioid prescribed in the US (4), but some evidence suggest gaps in knowledge and practice exist. For instance, the use of urine drug testing for managing patients on opioid analgesic therapy is only done by 8% of physicians when there is demonstrable evidence for its benefits in reducing opioid fatalities ( 5). Bullet point guidelines would certainly be helpful where knowledge gap of exists.
Multiple page guidelines have been published in 2009, by the American Academy of Pain Medicine, and in 2012 by the American Society of Interventional Pain Physicians, but simple summarized, take home bullets, which are easy to follow, like the ones currently used in New York City Public Hospitals could save lives and standardize best practices across the board. The use of simplified, practical guidelines should be encouraged in other hospital networks across the country.
1. Margaret Warner, Li Hui Chen, Diane M. Makuc, Robert N. Anderson, Arialdi M. Miniño, Drug Poisoning Deaths in the United States, 1980–2008
2. Anna Lemke, M. D. Why Doctors Prescribe Opioids to Known Opioid Abusers:
N Engl J Med 2012; 367:1580-1581, October 25, 2012.DOI: 10.1056/NEJMp1208498
3. Gary Franklin, Jaymie Mai, Judith Turner, Mark Sullivan, Thomas Wickizier, Deborah Fulton-Kehoe: Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline American Journal of Industrial Medicine Volume 55, issue 4, pages 325-331, April 2012
4 .Nora D. Volkow, MD; Thomas A. McLellan, PhD; Jessica H. Cotto, MPH; Meena Karithanom, MPH; Susan R. B. Weiss, PhD Characteristics of Opioid Prescriptions in 2009 JAMA. 2011; 305(13):1299-1301. doi:10.1001/jama.2011.401
5. Howard A Heit, Dourglas L Gourlay. Urine Drug Testing in Pain Medicine: Journal of Pain and Symptom Management; Vol. 27 No. 3 March 2004
Taghogho Agarin, MD., MPH, MBA
Department of Psychiatry,
Harlem Hospital Center,
Columbia University , New York.
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