His patient was in severe pain, and Christopher Ziebell, M.D., was set to prescribe him opioids for relief. But the man was asking a few too many question: How strong were they? How many pills? What kind was he getting? Ziebell, an emergency physician, decided to consult the Texas Prescription Monitoring Program, which tracks the dispersion of controlled substances across the state. The doctor was startled to find that his patient already had been prescribed several hundred dosages of opiates in the past few months.
“I was shocked because it was a lot of medicine from a lot of different prescribers, filled at a variety of different pharmacies,” said Ziebell, who is an assistant professor of surgery and perioperative care with Dell Medical School at The University of Texas at Austin.
All across the Lone Star State, and the country, doctors are facing similar situations in their own emergency rooms, as addiction to opioids takes hold, and patients seek help. While just a small fraction of pain pills, like Vicodin or Norco, are prescribed in the ER, about 45 percent of opioids that are diverted for non-medical use originated in the emergency room.
Underlining this issue, the Centers for Disease Control and Prevention just released new data in March, showing that opioid overdoses went up by 30 percent in ERs between July 2016 and September 2017. Those who overdosed are much more likely to do so again, which is why, the CDC said, “being seen in the ER is an opportunity for action.”
Texas saw more than 2,800 drug overdose deaths in 2016, which is the year with the most recently made available data from the CDC. That represents a 7.4 percent upswing in overdose deaths from the nearly 2,600 the previous year.
With all of this in mind, the Texas Hospital Association in February released new voluntary guidelines for doctors working in the ER, aiming to curb opioid misuse and abuse. Crafted with input from state professionals in behavioral health, physician leadership and quality/patient safety, THA hopes implementation of these six recommendations can help reverse this deadly trend for its member hospitals. The ER made the most sense as a place to start, as patients present there both at the start in severe pain and much further down the stream of addiction after an overdose, said Sara González, vice president of advocacy and public policy with THA.
“What we found was that, in other states, everyone seems to start with the emergency department because it’s such a critical player in this crisis,” she said. “The ER is the place people go when someone overdoses, of course, but it’s also where people go when they’re in acute pain, which may be their first encounter with an opioid.”
In the case of Dr. Ziebell’s patient, when confronted, the man admitted that he was battling addiction. He agreed to go into an intensive outpatient program and is on a path to recovery. Checking the prescription monitoring program — as Ziebell did, but others had failed to before him — is one of the crucial steps in THA’s recommendations, and the ER physician thinks these guidelines will help move Texas hospitals in the right direction.
“The first rule in medicine is to do no harm and prescribing a medication to somebody that fuels them toward addiction is doing harm,” said Ziebell who also serves as medical director of the emergency department at Dell Seton Medical Center at The University of Texas. “I think that we all have to cooperate in figuring out the best way to minimize that kind of danger to patients, and that to me is exactly what these guidelines are designed to do. They may need to evolve over time, but the goal is a worthy one, which is to ensure that we’re helping people in the best way possible.”
Language in the guidelines is careful to note that all of this is voluntary, and each patient should be taken on a case-by-case basis and assessed at the doctor’s discretion. González stressed that Texas is not trying to dictate how physicians practice medicine, and some may look to push further with the prescribing recommendations, if desired.
“We didn’t want to limit the ability for the hospital to do what it wants to do with these guidelines,” González said. “We wanted it to be a framework and a resource, and not try to force any change on a hospital if it isn’t ready to adopt those changes. But there’s a lot of interest, clearly, and willingness on the part of our membership to do the right thing.”
Going forward, the state of Texas may not be as flexible in trying to address opioid prescribing and the hundreds of drug-related deaths that have followed here. New legislation will make dispensing the drugs more difficult for providers and the hospitals that they are a part of, going forward.
House Bill 2561, passed in the 85th Texas Legislature in 2017, requires dispensing pharmacists to send all prescription drug information to the PMP by the following business day, according to González. And beginning in 2019, all drug prescribers and dispensers must consult the PMP before dispensing opioids, along with benzodiazepines, barbiturates or carisoprodol (with an exception made for cancer patients). The hope is that these new guidelines will also help hospitals to prepare for the new legislative landscape in 2019.
Small Piece of the Puzzle
Safe prescribing in the ER is just a small piece of the puzzle to address the opioid epidemic, which also includes behavioral health, medication-assisted treatment to address substance-use disorder, and community partnerships to tackle some of the other social factors, such as joblessness and homelessness, that can exacerbate these issues.
Often, when cities and states have tried to put out the pain pill fire, those with opioid dependency will turn to heroin on the street, which is cheaper and more plentiful. Four out of every five heroin users started out by misusing prescription pain killers, one study found.
“Treatment really is the most important part of all of this and treatment availability is scarce everywhere, including in Texas,” González said. “Having enough counselors, treatment programs and funding is a huge challenge here.”
One of the next steps will need to be a focus on expanding that pipeline. That’s why, legislatively, THA’s Behavioral Health Council has asked the association to work on growing the Texas workforce to address substance-use disorder.
About 80 percent of Texas counties have too few behavioral health providers to meet patients’ needs, González noted. And nationally, by 2025, the need for addiction treatment providers will surpass the projected supply by 13 percent, resulting in a workforce deficit of almost 17,000 full-time equivalent professionals, she added.
The consequences of untreated substance-use disorder can snowball into much bigger issues for Texas hospitals, including chronic conditions, poorer health outcomes, reduced employment and more encounters with the justice system, THA noted in a one-page informational sheet to members.
To help curb that snowball, the next goal on the THA's horizon is to support HB 3083/Senate Bill 1509, which look to bolster the numbers of substance-use treatment providers and incentivize them to treat patient populations that are hurting most due to any provider shortages.
Matt Feehery, senior vice president and CEO of Memorial Hermann’s Prevention and Recovery Center, and chair of THA's Behavioral Health Council, hopes these new guidelines will help foster a conversation. In his view, ER doctors need to know the resources and assistance that are out there for them if Texas is going to solve this crisis. A provider shouldn’t cut off a patient from opioids and not have a substance-use treatment plan for what comes next.
“It’s just getting people to understand the importance and the magnitude of this problem, and how we can help change the direction. That’s the biggest thing,” Feehery said. “If we’re going to address the problem specifically in emergency departments today, then we also need to make ourselves aware of what resources are available in our communities tomorrow to help people who are struggling with alcohol and drug addiction.”