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In the Balance |4 June 2013

Guidelines for Opioid Prescription: Why Emergency Physicians Need Support

Hillary V. Kunins, MD, MPH, MS; Thomas A. Farley, MD, MPH; Deborah Dowell, MD, MPH

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
This article was published at www.annals.org on 9 April 2013.
  • From the New York City Department of Health and Mental Hygiene, Queens, New York.

    Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0412.

    Requests for Single Reprints: Hillary V. Kunins, MD, MPH, MS, New York City Department of Health and Mental Hygiene, 42-09 28th Street, 19th Floor, Queens, NY 11101.

    Current Author Addresses: Drs. Kunins, Farley, and Dowell: New York City Department of Health and Mental Hygiene, 42-09 28th Street, 19th Floor, Queens, NY 11101.

    Author Contributions: Conception and design: H.V. Kunins, T.A. Farley, D. Dowell.

    Drafting of the article: H.V. Kunins, T.A. Farley, D. Dowell.

    Critical revision of the article for important intellectual content: H.V. Kunins, T.A. Farley, D. Dowell.

    Final approval of the article: H.V. Kunins, T.A. Farley, D. Dowell.

    Collection and assembly of data: H.V. Kunins.

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On 10 January 2013, The New York Times reported that new guidelines would “sharply” restrict opioid analgesic prescription at New York City hospitals. That phrase is a great exaggeration of their power, as the New York City Emergency Department (ED) Discharge Opioid Prescribing Guidelines (1) are voluntary guidelines crafted by practicing emergency physicians and the New York City Department of Health and Mental Hygiene. Still, they were announced by Mayor Michael Bloomberg, which is distinctly unusual for a release of clinical guidelines. Why did emergency physicians, who are already able to prescribe opioids (or not), regardless of government backup, welcome the city's support for their recommendations?
Many physicians, including emergency physicians, are immensely conflicted about opioid analgesics. They feel accountable to patients requesting opioids for subjective pain; to guidelines and standards that imply that withholding opioids constitutes poor medical practice; and to institutions valuing patient satisfaction surveys that reward physicians for meeting patient requests, whatever they may be. At the same time, physicians are increasingly aware of the consequences of opioid use, such as overdose and addiction. They face complex and difficult decisions as they navigate the desire to relieve pain and to keep patients safe.
By several measures, adverse consequences of opioid analgesic use have increased dramatically in the United States. Deaths from opioid analgesic–related overdose increased from about 4000 in 1999 to 14 800 in 2008 (2), and associated ED visits and addiction treatment admissions have risen as well (3).
This sharp uptick in adverse consequences...
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Kunins HV, Farley TA, Dowell D. Guidelines for Opioid Prescription: Why Emergency Physicians Need Support. Ann Intern Med. 2013;158:841–842. doi: 10.7326/0003-4819-158-11-201306040-00631

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Published: Ann Intern Med. 2013;158(11):841-842.

DOI: 10.7326/0003-4819-158-11-201306040-00631

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