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In the Balance |

Guidelines for Opioid Prescription: The Devil Is in the Details

Alex M. Rosenau, DO
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 9 April 2013.

From Lehigh Valley Health Network, Allentown, Pennsylvania.

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, alex.rosenau@gmail.com.

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.

Ann Intern Med. 2013;158(11):843-844. doi:10.7326/0003-4819-158-11-201306040-00632
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In January 2013, the New York City Department of Health and Mental Hygiene released guidelines to help reduce the misuse of prescription opioid analgesics by establishing standards for prescribing from the emergency department. In this commentary, the President-Elect of the American College of Emergency Physicians argues that restricting opioid prescription by emergency physicians will not solve the problem of opioid misuse. Rather, closing corrupt pain centers and improving access to high-quality nonemergency care will improve the care of patients with pain.

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The most compelling reason
Posted on April 10, 2013
Taghogho Agarin, MD, MPH
Columbia University
Conflict of Interest: none

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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