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Service Delivery Innovation Profile

Emergency Department and Urgent Care Clinicians Use Protocol To Reduce Opioid Prescriptions for Patients Suspected of Abusing Controlled Substances


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Snapshot

Summary

An emergency department and urgent care center that are part of a hospital system in southeastern Maine implemented a one-page, easy-to-understand protocol that physicians and nurses use to decide how to treat patients complaining about pain who may be abusing opioid medications or other controlled substances. The protocol recommends that physicians make a comprehensive effort to verify the patient's recent medication history, decline (except in rare cases) to refill prescriptions for controlled substances that have allegedly been lost or stolen, and avoid prescribing controlled substances to patients with a history of taking such medications for pain management. At their discretion, physicians and nurses provide a copy of the protocol to patients to show the basis for their decisions. The protocol has significantly reduced the proportion of emergency department patients complaining of dental pain (a common complaint used by those who abuse controlled substances) who are prescribed opioids, which in turn has led to fewer such patients presenting to the emergency department.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the proportion of patients coming to the emergency department and urgent care center complaining of dental pain who received prescriptions for opioids and the proportion of visits to these sites accounted for by patients with dental pain.
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Developing Organizations

Lincoln County Healthcare
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Use By Other Organizations

As noted, Washington, Ohio, and New York City have implemented similar protocols and guidelines.

Date First Implemented

2011
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Patient Population

Vulnerable Populations > Substance abusersend pp

Problem Addressed

Abuse of prescription opioids and other controlled substances is a serious problem in the United States, leading to a growing number of fatalities. People who abuse opioids often present to emergency departments (EDs) and urgent care centers complaining of pain that can be difficult for a physician to verify (such as dental pain, headaches, or back pain), putting physicians in the challenging position of deciding how to best treat the patient. Protocols on the use of controlled substances can help, but few organizations currently use them.
  • A growing, often deadly problem: Between 1990 and 2010, unintended deaths caused by prescription opioid overdoses quadrupled in the United States, to a level that surpasses deaths involving heroin and cocaine. This increase coincided with a near-twofold increase in the annual number of prescriptions for opioid drugs (from 120 to 210 million). The problem of prescription opioid abuse is particularly large among those 16 to 25 years old, with between 9 and 12 percent of those in this age group reporting having abused a prescription opioid (typically hydrocodone or oxycodone) in the last year.1 The State of Maine leads the Nation in prescription opioid abuse, with related deaths exceeding those from motor vehicle accidents.2
  • EDs and urgent care centers as a source of drugs for many abusers: Although definitive statistics do not exist, health experts generally believe that patients abusing opioids often go to EDs and urgent care centers in search of these drugs.3 For example, people abusing opiates (or selling them to such abusers) often go to the ED making false claims that their medication has been lost or stolen. When physicians deny their request for a refill, these patients often protest and/or lodge complaints with the hospital, which can have negative professional consequences for physicians. This type of drug-seeking behavior is extremely common in Maine EDs, with some individuals adopting increasingly sophisticated ruses designed to deceive physicians, such as using false identification and showing physicians phony x-rays.
  • Unrealized potential of protocols: Protocols and guidelines are available that detail specific actions that physicians should take when a patient is suspected of abusing opioid medications. These resources can help reduce subjectivity in the decisionmaking process and provide institutional support for the physician's decision. While some States (e.g., Washington4,Ohio5) and cities (e.g., New York City6) have instituted such protocols and guidelines, most have not.

What They Did

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Description of the Innovative Activity

An ED and urgent care center in southeastern Maine implemented a one-page, easy-to-understand protocol that physicians and nurses use to decide how to treat patients complaining about pain who may be abusing opioid medications or other controlled substances. The protocol recommends that physicians make a comprehensive effort to verify the patient's recent medication history, decline (except in rare cases) to refill prescriptions for controlled substances that have allegedly been lost or stolen, and avoid prescribing controlled substances to patients with a history of taking such medications for pain management. At their discretion, physicians and nurses provide a copy of the protocol to patients to show the basis for their decisions. Key elements of the protocol and how it is used are detailed below:
  • Recommended steps for interacting with patients suspected of abuse: Since March 2011, physicians and nurses working in the ED at Miles Memorial Hospital and in the urgent care center at St. Andrews Hospital and Healthcare Center use a one-page protocol when caring for patients they suspect of abusing controlled substances (most commonly oxycodone and hydrocodone). The protocol consists of recommended steps, including how to verify prescription history, handle refill requests, and manage pain.
    • Verifying prescription history: The protocol advises physicians to verify a patient's current medication regimen through multiple sources. Recommended sources include the patient (by conducting an interview), the patient's medical records, the patient's prior providers (through a quick phone call), existing controlled substances contracts in which patients attest that they will not seek such substances from other prescribers while under a particular doctor's care (through a search), and the State's prescription monitoring program (PMP) database, which is accessible through an electronic query. The PMP is often the best way to determine if a patient is using medication inappropriately. For example, a patient may claim to have never used hydrocodone, but the PMP may show that the patient has received multiple prescriptions for it in the last year. Such a finding indicates a strong likelihood the patient is abusing this medication or selling it to others.
    • Handling refill requests: The protocol advises that physicians not refill prescriptions for patients who claim that the controlled substance has been lost or stolen or is otherwise unavailable. Exceptions may be made in rare cases, such as if abrupt discontinuation could cause life-threatening withdrawal symptoms. In such cases, the protocol calls for doctors to prescribe at most a 4-day supply (to give the patient time to contact his or her regular physician), and to notify the patient that providing the drug in this manner is not standard practice and will not be repeated. At their discretion, physicians may report to the police patients who they believe have used deception to obtain a prescription for a controlled substance.
    • Managing pain: If circumstances suggest a patient with a new painful condition is abusing controlled substances, the protocol advises physicians to use pain management strategies that do not involve controlled substances, typically use of noncontrolled medications (e.g., nonsteroidal antiinflammatory drugs) combined with immobilization, injection of nerve blocks, or other strategies. These circumstances include patients who have visited the ED or urgent care center frequently for painful conditions in the past and/or have a history of taking controlled substances (as determined from the patient interview, medical records, and/or the PMP). In these cases, the protocol advises physicians to prescribe controlled substances on a one-time basis only and to do so in coordination with the physician managing the patient's other controlled substance prescriptions. This recommendation does not apply to patients with terminal illnesses.
  • Sharing of protocol with patients to justify decision as institutional policy: The protocol is brief (one page) and written in clear, easy-to-understand language, making it ideal for sharing with patients. Consequently, ED and urgent care center staff (often the nurse who first comes into contact with patients) give a copy of the protocol to any patient they suspect may be abusing controlled substances. They review the protocol with the patient and answer any questions he or she may have about it. If the physician's subsequent exam continues to suggest abuse and the patient still seeks the drug, the physician informs the patient that he or she is showing signs of inappropriate use of medication and goes over the protocol again, pointing to specific, relevant elements as appropriate. Sharing the protocol in this manner allows clinicians to justify their decisions to patients who protest and helps deflect any criticism by clearly demonstrating that the clinicians are following institutional policy and cannot make exceptions. It also serves as evidence that the clinicians followed standard hospital procedure should the patient later complain and/or lodge a formal complaint.

Context of the Innovation

Located in coastal Maine, Lincoln County Healthcare operates two hospitals: Miles Memorial Hospital in Damariscotta (which has an ED) and St. Andrews Hospital and Healthcare Center in Boothbay Harbor (which has an urgent care center). Lincoln County Healthcare is a member of MaineHealth, a not-for-profit health care delivery network.

ED and urgent care center staff at the two hospitals served as the primary impetus for creation of the protocol on prescribing controlled substances. Their experiences made them aware of the growing problem of opioid abuse in Maine, including the fact that in 2009 deaths from opioid abuse in Maine exceeded deaths from motor vehicle accidents for the first time, with many fatalities occurring among teenagers and young adults. Around the same time, ED leaders at Miles Memorial Hospital recognized that Maine's free, secure PMP database could serve as a reliable source of information on controlled substance prescriptions. A growing percentage of ED physicians used the database, which includes all transactions for Schedule II, III, and IV controlled substances dispensed in the State. With physicians having online access to PMP data, ED leaders believed they could create a protocol to help them reduce prescriptions for opioid medication while still providing effective pain management.

Did It Work?

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Results

The protocol has significantly reduced the proportion of ED and urgent care patients complaining of dental pain (a common complaint used by those abusing controlled substances) who are prescribed opioids, which in turn has led to fewer such patients presenting to the ED in the first place.
  • Fewer opioid prescriptions: The proportion of patients presenting to the ED and urgent care center with dental pain who were prescribed opioids fell by 17 percent after implementation of the protocol, from 59 percent during the 14 months before implementation to 42 percent during the 5 months afterward. (While the protocol applies to all patients presenting with pain and to all controlled substances, program leaders have tracked only dental pain and opioid use, since dental pain is a common ailment cited by individuals who abuse controlled substances and opioids are the most abused of these substances.)
  • Fewer patients presenting with dental pain: The proportion of ED and urgent care visits accounted for by patients with dental pain fell by 19 percent in the year after implementation of the protocol, from 26 to 21 per 1,000 visits. Program leaders attribute the reduction to word-of-mouth conversations among patients about how physicians at the two sites have cracked down on potential opioid abuse and are much less likely to prescribe controlled substances.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the proportion of patients coming to the emergency department and urgent care center complaining of dental pain who received prescriptions for opioids and the proportion of visits to these sites accounted for by patients with dental pain.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Creating protocol: Two ED physicians employed by Lincoln County Healthcare (one of whom serves as director of the ED) started developing the protocol in 2009. They began by reviewing existing protocols and guidelines on ED-based prescriptions of controlled substances used by other municipalities, adapting and condensing their key elements into a one-page, easy-to-understand document. They subsequently revised the draft based on feedback from members of several working groups: the two hospitals' monthly ED conferences attended by hospital administrators, ED physicians, and nurse managers; a team with representatives from several additional MaineHealth hospitals; and a State-level consortium of hospital leaders. In 2010, the physicians gained approval of the final draft from Lincoln County Healthcare leaders for implementation at the two sites.
  • Reviewing charts to facilitate evaluation: As part of the hospitals' ongoing quality improvement efforts, the physicians who drafted the protocol and their colleagues wanted to document its effect on prescribing patterns. To assist with this task, two ED physicians (not the authors of the protocol) volunteered to conduct chart reviews covering the period before and after implementation (January 2010 to August 2011).
  • Introducing protocol to staff: In early 2011, the two ED physicians who developed the protocol presented it at the monthly ED conferences, explaining to administrators and clinicians how it would be used. Physicians and nurse managers responded favorably, seeing the protocol as a way to support and justify their treatment decisions. Nurse managers subsequently circulated the protocol to their nurses via e-mail.
  • Rolling out protocol, ongoing improvement: The protocol officially was implemented on March 1, 2011, and has remained in use since that time. Staff periodically discuss the protocol during ED conferences, including how it might be further refined and improved.

Resources Used and Skills Needed

  • Staffing: The protocol did not require the hiring of any additional staff. The physicians and nurses who work in the two sites use it as part of their regular duties.
  • Costs: The protocol cost little to develop and implement. The physicians who developed and evaluated it did so as part of their normal job responsibilities and, in many cases, on their own time.

Tools and Other Resources

The protocol is available at: http://rx.lchcare.org. Protocols and guidelines used by EDs in other municipalities can be accessed via the sources listed in footnotes 4, 5, and 6.

Adoption Considerations

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Getting Started with This Innovation

  • Use existing resources: ED leaders considering implementing a protocol for prescriptions of controlled substances can rely heavily on existing protocols and guidelines, adapting them to suit issues specific to local circumstances as necessary.
  • Keep it simple: Whether developed in-house or adapted from elsewhere, protocols should be as concise and straightforward as possible, avoiding complex, legal-sounding language that may confuse physicians and/or patients.
  • Make sure physicians use State PMP: Before implementing this type of protocol, ED physicians need to have experience using the PMP (which most States now have). If physicians do not have such experience, ED leaders should host a training session on PMP and subsequently consider mandating its use.

Sustaining This Innovation

  • Track prescription patterns: If resources permit, EDs should monitor facilitywide rates for prescribing controlled substances to identify overall trends and changes in practice patterns and also track rates by individual doctor to identify any unusual, unjustified variations. If this type of monitoring is not possible, program leaders can consider use of informal observation, which may still reveal notable patterns. For example, nurses may be well positioned to notice when a particular physician prescribes opioids at a very high rate. The nurses can notify a senior ED physician, who can then review the protocol with the physician.
  • Look for potential enhancements: Regular ED staff meetings can be a good time to discuss ways to enhance the protocol's effectiveness. For example, staff at Lincoln County Healthcare noticed that patients increasingly used false identification in the ED and urgent care center. After discussing the situation at a meeting, ED leaders are now considering requiring patients to produce a photo identification before they can receive a prescription for a controlled substance.

Use By Other Organizations

As noted, Washington, Ohio, and New York City have implemented similar protocols and guidelines.

More Information

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Contact the Innovator

Tim Fox, MD
Director, Emergency Medicine Department
Miles Memorial Hospital
35 Miles Street
Damariscotta, ME 04543
(207) 563-4521
E-mail: tim.fox@lchcare.org

James Li, MD
Emergency Medicine Department
Miles Memorial Hospital
35 Miles Street
Damariscotta, ME 04543
(207) 563-4521
E-mail: james.li@lchcare.org

Innovator Disclosures

Drs. Fox and Li reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Fox TR, Li J, Stevens S, et al. A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Ann Emerg Med. 2013;62(3):237-40. [PubMed]

Footnotes

1 National Institute on Drug Abuse. Prescription drugs: abuse and addiction. Research Report Series. Bethesda, MD: National Institutes of Health. 2011. NIH Publication Number 11-4881. Available at: http://www.drugabuse.gov/sites/default/files/rrprescription.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
2 Nagle M. Razor's edge: prescription drug abuse in rural states now a leading cause of deaths, arrests and treatment admissions. UMaine Today. 2010;10:8-13. Available at:
https://umainetoday.umaine.edu/past-issues/fall-2010/prescription-drug-abuse-in-rural-states-leading-cause-of-deaths-arrests
/
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3 Grover CA, Close RJ, Wiele ED, et al. Quantifying drug-seeking behavior: a case control study. J Emerg Med. 2012;42(1):15-21. [PubMed]
4 Washington State Department of Health. Washington emergency department opioid prescribing guidelines. Available at: http://washingtonacep.org/Postings/edopioidabuseguidelinesfinal.pdf.
5 Ohio Emergency and Acute Care Facility. Opioids and other controlled substances (OOCS) prescribing guidelines. Available at: http://www.healthyohioprogram.org/ed/guidelines.aspx.
6 New York City Department of Health and Mental Hygiene. New York City emergency department discharge opioid prescribing guidelines. Available at: http://www.nyc.gov/html/doh/downloads/pdf/basas/opioid-prescribing-guidelines.pdf.
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Original publication: March 12, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.