A recent article in Annals of Emergency Medicine involves the change in prescribing patterns when a prescription monitoring program is put in place. After reviewing past prescriptions, emergency physicians changed opioid prescribing plans for 41% of patients.
Many states have instituted prescription monitoring programs to limit potential fraud and abuse of controlled substances. In 2006, Ohio instituted a program that makes available to clinicians information about a patient’s previous controlled substance prescriptions for a specified period, including the substance prescribed, the amount and date dispensed, names of prescribers, names of pharmacies used, and different addresses used by the patient. In a prospective study at an academic emergency department (ED) in Ohio, emergency physicians evaluated a convenience sample of 179 adult patients with nontraumatic painful conditions and w ere queried about whether they would prescribe opioids before and after being provided with data from the prescription monitoring program.
During the 12 months before the ED visit, the patients filled a median of seven opioid prescriptions (range, 0–128) written by an average of 5.6 providers (range, 0–40) at an average of 3.5 different pharmacies (range, 0–20). After reviewing prescription data, physicians changed their opioid prescribing plans for 41% of patients; in 61% of cases, they prescribed fewer opioids than originally planned or no opioids, and in 39% they prescribed more opioids than originally planned. Citation(s): Baehren DF et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med 2010 Jul; 56:19.
It was curious because I was having a conversation with one of my colleagues at our national ACEP convention in Las Vegas and we spoke about the impact of this law. I can only imagine the hue and cry from the privacy advocates when this process started regarding sharing this information. Of course in my great state of Maryland we have yet to pass this type of law despite the fact that 38 states have done so.
This very experienced emergency physician told me how often he was suprised by how clever some patients were at ‘laying the game’ in order to get a narcotic prescription. I have often felt this pendulum of treating all pain, regardless of the legitimacy of the source of the pain, has swung way too far in one direction.
Don’t get me wrong here. I try and be compassionate with all the patients I see and give most the benefit of the doubt. I probably am one of the more lenient docs in my group regarding giving pain meds to patients. I am also quick to say no to someone when I believe I am being played for a narcotic script. I am, as Mary Poppins would say, firm but kind and hold my ground when that is the case.
The reassuring thing about the study was the fact that in almost 40% of the cases more narcotics where prescribed when there was a change decided by the provider after checking the database. I would call this type of system a home run for appropriate and judicious treatment of pain in the ED. I would be curious to hear others thoughts on this matter.