As the Virginia death toll from opiates continues to rise, two big healthcare groups recently endorsed new opiate prescription guidelines aimed at hospital emergency rooms in an attempt to curb the epidemic. Jessie Knadler talks to two ER physicians in Augusta County about the guidelines, and what it’s like to work on the front lines of the drug scourge.
An emergency physician’s job is already stressful. Now add to that, patients suffering from chronic pain who come to the emergency department specifically seeking narcotics; opioids. This is something that Dr. Vicki Conti, an emergency physician at Augusta Health in Fishersville, sees daily.
“They come to the ER because we have an open door every day of the year 24/7. [They say] My doctor didn’t give it to me. It’s very hard because you don’t like to see people suffer. At the same time, you don’t want to give them something that will harm them in the long run. “
Unlike an acute injury, such as a fracture, chronic pain - that is, pain lasting longer than six months -- is much harder to treat, let alone identify: Back pain, chronic abdominal pain, headaches. These are conditions Dr. Conti and her colleagues see on a daily basis. The pain may be real for patients, but the injury doesn’t show up on any test or CAT scans and for some patients, it never goes away. Pain is also entirely subjective.
“It’s very hard for me to know and decide, am I just feeding an addiction or am I treating an acute exacerbation? “
Or both, which is all too often the case.
“It’s so hard. I mean, people that are desperate to get their opioids will do and say anything….We get very belligerent people. I’ve had to escort people out of the emergency department because they will not leave….I don’t like to do that.”
How did this happen?
In began in the 90s when pain was designated as the “fifth vital sign,” The thought at that time was that pain management was undertreated. Healthcare providers began asking patients to rate their pain. Again, pain is totally subjective. How do you accurately measure it? Doctors began prescribing opioids like oxycodone or hydrocodone to relieve patients’ suffering.
Fast forward to today when Virginia is in the midst of an opioid epidemic. It’s one of 14 states showing significant increases in the rate of opioid deaths from 2013 to 2014. Prescription opioids, as well as heroin, the use of which soared after legal opiates became harder to obtain, resulted in 801 fatal overdoses last year, up from 541 - a 48 percent increase -- in 2012.
“The philosophy back 15 years ago, we tried to treat pain until they were pain free,” says Dr. Adam Rochman, medical director of the emergency department at Augusta Health.
“That philosophy is now changing. It’s unrealistic to be pain free….some injuries are going to have pain.”
Dr. Rochman was part of a joint task force including the Virginia College of Emergency Physicians and the Virginia Hospital & Health Care Association that recently endorsed more stringent guidelines for opioid prescriptions within state hospitals’ emergency departments.
“It’s going to be a lot more difficult for chronic pain sufferers to obtain opioid prescription from the ED. Emergency physicians are encouraged to refer those patients onto primary care providers. And for patients who do get an opioid prescription? They can expect a very limited supply, typically three days.”
“Opioids aren’t a bad medicine. They’re very necessary in our society. It’s a select chronic pain group for emergency department providers…it’s a difficult population to serve and it may not be in their best interest long term to do that. So the idea is to coordinate care, to get people pain relief but do it without opioids because long term it causes more problems than it helps.”
As an example, he recounts a young patient suffering from chronic abdominal pain. She’d had multiple tests and evaluations, and none revealed a conclusive diagnosis.
“This patient is already on chronic narcotics in her mid 20s and at heavy doses and I don’t think we’re doing her any favors. The perspective I get is I see some of those patients 10, 15 years from now who’d had that same situation but I see them at the tail end of things and almost all of them to a T wish they were never on the chronic narcotics in the beginning. What is ten years going to look like for that poor girl? It’s bleak in my mind. It’s a difficult problem.”