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Emergency Docs Use EHRs, PMPs to Help Drug-Seekers

 |  By jcantlupe@healthleadersmedia.com  
   October 17, 2013

Physicians encountering patients seeking oxycodone and other pain medications in the emergency department are using electronic medical records and prescription monitoring programs to identify doctor-shopping patients and to get them help.

An emergency department patient asks for a pain medication by name, saying he is allergic to other non-narcotic drugs. And the pain is so severe, the patient says, nothing else seems to work.

That scenario, usually a weekend occurrence, is among the red flags physicians should consider when facing one of the most pressing and continual healthcare issues: the doctor-shopping, drug-seeking patient, Scott Weiner, MD, MPH, FACEP, an emergency physician at Tufts Medical Center in Boston, MA, tells me.

Physicians have long tried to deal with the doctor-shopping phenomenon, often linked to patients seeking opioid analgesics, including morphine, oxycodone, and methadone, drugs associated with abuse.

Often, these patients go from physician to physician seeking drugs that can feed an addiction. But there have been few studies about patients who go to the Emergency Department for drugs once their doctors' offices are closed, or they are worried their personal docs may get suspicious.

For drug-seeking patients, overcrowded EDs may seem like easy targets because, in part, emergency physicians are dealing with so many matters that they may not be as attuned to potential manipulations.

Weiner evaluated doctor-shopping ED patients who had narcotic prescriptions from 10 or more providers in a year. These patients went to the doctors a lot. The average number of providers that the doctor-shoppers had seen in the previous year was 17, as opposed to 1.6 for those who aren't drug seekers, Weiner says.

In the abstract to an upcoming paper presented last weekend at the American College of Emergency Physicians Weiner acknowledges that in the ED, "recognition of patients that have aberrant drug-related behaviors is difficult" in part because physicians "do not have a high sensitivity or positive predictive value for detecting drug-seeking patients."

More than ever, physicians need to see through the differences, especially because the "Physicians might place too much weight on gestalt or stereotyping and need to rely on more objective criteria such as a patient requesting an opioid by name," Weiner wrote last July in the Annals of Emergency Medicine .

Drug-seeking behavior at the ED has been defined in various ways, he says, but includes patients who had seen at least 4 providers in 12 months before an ED evaluation. Drug overdose death rates in the U.S. have more than tripled since 1990, and "have never been higher," according to the Centers for Disease Control and Prevention. The misuse and abuse of prescription painkillers were responsible for more than 475,000 ED visits in 2009, a number that nearly doubled in five years.

"Treatment of pain is an essential responsibility of emergency practitioners," Weiner wrote in this month's AEM report. "However, many studies have demonstrated that pain is poorly controlled in the ED and for patients discharged from the ED with a painful condition."

The problem has been especially troublesome for those physicians in the ED who are seeing these patients for the first time. And sometimes, the situation doesn't seem clear-cut, Weiner says.

"You could be going to see your primary care doctor; you might be going to your orthopedic surgeon; you might be seeing a couple of residents; and you could easily have four or more prescriptions and more providers and get them legitimately," he says.

A flurry of abstracts of academic papers released last week at the American College of Emergency Physicians conference in Seattle, show the importance of electronic medical records to track drug-seeking patients and what's more, to get them help.

One of those successful programs is being developed in San Diego. There, University of California San Diego researchers found that patients who made more than two ED visits for alcohol, substance abuse, or psychiatric problems "were identified and flagged by electronic medical records, and placed in non-medical detox programs."

As a result, ED repeat visits were reduced from 137 or (5.27 per week) to 10 total visits or (1.67 visits per week) over a 6-month period, according to Alfred Joshua, MD, an emergency medicine specialist at the University of California, San Diego.

A major national effort to track drug-abusing patients has been carried out in individual state prescription monitoring programs, which collect, monitor and analyze prescribing and dispensing data submitted by pharmacies. About 42 states have PMPs that are operational, and seven more have pending legislation for such programs, according to the Alliance of States with Prescription Monitoring Programs.

Tracking is uneven, however, because different states don't cover all scheduled drugs. Still, the Prescription Monitoring Program has been effective for a hospital such as Tufts Medical Center, Weiner says.

"That has made a big difference," Weiner adds. "Now on a statewide basis, I can see where patients had their prescriptions filled. Before I had to use my own judgment. I would think, 'Oh, I think this guy is a drug seeker. No, I don't think this guy is a drug seeker.'' I could have been entirely wrong."

In fact, ED physicians do almost as well on their own as prescription monitoring programs.

Weiner reviewed 544 patient visits to emergency departments at two healthcare facilities in a year between June 2011 and June 2013. He compared the "emergency provider impression of drug-seeking behavior" and data from the Prescription Drug Monitoring Program. Generally, there was "fair agreement" between emergency providers' impression of drug-seeking behavior, and what was found in prescription drug monitoring program data, Weiner wrote.

Physicians are getting a good sense of who would be a drug-abuser or not. But the prescription monitoring programs have the data that helps in talking to patients, Weiner says. Supported by data, doctors can show proof of their drug-taking practices.

"It makes the patient aware that we are aware" of the drug-abusing potential he or she may have, Weiner says. "We can tell [a patient] 'you told me you didn't have these prescriptions, and the data base says you have 20. What's going on? That can start the screening and that can lead to interventions."

Still, it's unfortunate that the Prescription Monitoring is limited in the amount of data it can capture, Weiner says. Emergency department physicians are taking steps toward getting a handle on drug-abusing practices, but they are still far from where they want to be, Weiner says.

"We're at the stage of dealing with (the drug-abuse issue), just at the point of identifying the problem."

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Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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