Improving Outcomes, Twelve Trials of Christmas!

Day Four of Christmas – Why are we not checking the database?

Welcome to the Twelve Trials of Christmas series on EMinFocus!  This is the fourth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done.  I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM.  Some may pan out, some may not.  All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

Despite the national attention narcotic misuse has received recently, there is scant evidence on the effect of a statewide prescription monitoring program within the ED. Sadly, evidence shows class II, III, IV, V analgesic prescription rates from ED providers increased from 2001-2010, while nonopioid analgesia prescriptions remained stable.  I would be curious to see if prescriber habits have changed since the recent onslaught of naroctic overdoses in the media, especially since 49 of the 50 states have a state-wide prescription monitoring program.  Have we written for fewer tablets per prescription? Say, from 20 to 12 tabs? Are we writing for less oxycodone and more NSAIDs (or for more hydrocodone or Tramadol rather than percocet) after implementation of a statewide database?  Are we even using the tools at our disposal?  If not, then why not?  Are we too busy?  Too burned out?  Just want to “get the patient out of the ED?”  Just don’t care?  Don’t want conflict?  Is there an difference between MDs, PAs, and NPs?  What about level of experience?  Does type of workplace (urgent care, office, ED) matter?  Do we think we can actually spot the addict – because multiple studies show we suck at it.

In New York state, all urgent care centers, ambulatory surgery centers, private practices, dental offices, and clinics are required to check the database  if writing for 5 days of narcotics.  Sadly, ED’s are not required to do this. NY actually makes it easy – while providers must register, they can designate another person to check the database.  I’ve heard of urgent care centers having the triage nurse checking the database before they see the provider.  Sadly, I’ve seen colleagues write for “a few days” to get the patient through “until their pain doctor sees them in 2 days” – despite this being a known red flag for substance abuse.

All providers are in a unique position – the patient that has an extensive database history also needs your help.  Rather than be confrontational, we can sit down, explain you are concerned about their recent prescription pattern, and would like to offer them help if they feel as though they need it.  If they decline, I still refer them to detox on their discharge papers.

So, I would like to see if providers are changing practice since implementation of a statewide prescription monitoring database, and if not, then why.  There is hope, interventions show we can change  (though durability is a separate issue). As a provider, if you are not interested in checking the database for every prescription you write, consider moving to Missouri, the only state without a database, also known as America’s drug store.

ACEP opioid policy: www.acep.org/content.aspx?id=88197

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