ERs no quick fix for pain, say Top of Utah hospital officials

Feb 25 2013 - 7:18am

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Top of Utah hospitals are seeing more people coming into their emergency rooms in the hopes of receiving painkillers. (Standard-Examiner file photo)
Top of Utah hospitals are seeing more people coming into their emergency rooms in the hopes of receiving painkillers. (Standard-Examiner file photo)

It's something emergency room physicians deal with every day -- people complain of agonizing pain.

While many of them are in true distress, others see the ER as ground zero for a quick fix.

Over the past year, emergency room physicians have written fewer prescriptions for narcotic painkillers. However, the number of people seeking them is on the rise.

"Increasing problems with narcotic dependency and accidental overdose are both local and national concerns," said Sandy Egbert, director of intensive medicine at McKay-Dee Hospital's emergency department in Ogden.

Donnagay Applonie, an emergency room case manager at Davis Hospital and Medical Center in Layton, said drug-seeking behavior is on the increase in emergency rooms, as well as throughout all areas of medicine.

According to a study by the Centers for Disease Control and the Substance Abuse and Mental Health Services Administration, from 2004 to 2008, the estimated number of emergency room visits linked to the nonmedical use of prescription narcotic pain relievers more than doubled, from 144,644 to 305,665 visits each year.

The study, using data from SAMHSA's Drug Abuse Warning Network emergency department system, found the three most frequently involved opioid pain relievers in hospital emergency rooms during that time period were oxycodone, hydrocodone and methadone.

Other painkillers such as morphine, fentanyl and hydromorphone were lower in frequency, but their usage still showed an increase.

For example, related nonmedical-use visits involving hydromorphone -- also known as Dilaudid -- rose 259 percent from 2004 to 12,142 in 2008.

Many factors can contribute to tolerance, dependency and addiction to painkillers, said Janet Smith, emergency department director at Ogden Regional Medical Center. In the majority of cases, people take the medications as prescribed and do not become addicted.

Others aren't as lucky. They might receive pain medication after surgery, build up a tolerance and become dependent.

"We treat all patients who complain of pain as if that symptom is real. Pain relief is an important factor when treating someone who is injured, needs emergency care or is dealing with a chronic disease," Smith said.

However, she added, it's important to know and respect the powers of narcotic pain medications -- and to know and respect their risks.

"No one should come to the emergency department with any expectation that they will receive pain medication," Smith said. "Misuse and abuse can cause serious medical and psychological complications."

And death.

According to the Utah Department of Health's latest figures, 432 people in the state died of drug overdoses between October 2008 and October 2009. More than half of those deaths were from prescription painkillers.

In addition, the state health department reports that, since 2000, deaths from prescription narcotics increased more than fourfold across Utah.

Several states, including Utah, have implemented new rules when it comes to dispensing pain medication.

Many doctors and emergency rooms are reserving narcotic pain medication for people with the worst pain, such as those involved in serious accidents or people with cancer. A new policy in New York City states most public hospital patients will no longer be able to get more than three days' worth of narcotic painkillers after leaving the hospital. Florida hospitals are also cracking down on the amount of narcotics dispensed in the emergency room.

At McKay-Dee Hospital, if a patient suffers from frequent migraine headaches, back pain or other musculoskeletal pain, toothaches, kidney stones or other recurrent conditions, the pain will be evaluated and non-narcotic pain medication will be offered first, Egbert said.

"Everyone has a different pain tolerance," she said. "And it takes working together with care providers and the patient. That's one of the reasons patients are asked what their pain is on a scale from 1 to 10."

But doctors are also trained to know whether a sprained ankle equals a 10, compared to someone who nearly had their arm severed in a car accident.

Emergency rooms have access to an online state database that shows any narcotic dispensed in Utah.

These prescriptions are reported to the Division of Occupational and Professional licensing, said Tyson Bigelow, a pharmacist at McKay-Dee Hospital. Clinicians can check the database to determine the type and amount of narcotic prescribed, and to see notes from previous visits.

"When our emergency physicians suspect a patient is inappropriately seeking pain medications, they refer them to a local pain management specialist," Smith said.

"We believe that patients will receive more effective and appropriate care from a physician who is trained to provide interventional pain treatments."

Applonie said patients who come to the ER frequently for pain medication may be referred to the proper programs to help them decrease their usage. Sometimes law enforcement may also become involved.

Emergency rooms are unable to represcribe medications for those who have been prescribed painkillers, Egbert said.

"If patients are receiving regular prescriptions for narcotic pain medication from their primary care provider and have lost the prescription, had it stolen or ran out early, the emergency department won't be able to supply them with a new prescription or narcotic pain medication."

When narcotics are given, experts say, it's important to use them only as directed and to discard any unused medication in the appropriate manner as soon as possible.

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