New York Opioid Crisis: How to Prescribe Safely

Roneet Lev, MD, emergency medicine physician and President of Independent Emergency Physicians Consortium

Year over year, New York’s opioid crisis is deepening. Every seven hours, someone dies of a drug overdose in New York City.1 Statewide, overdose deaths—the majority from opioids—surged to 1,374 in 2016, up from about 937 overdose deaths the year prior.2

The quantity of opioid prescriptions in New York is equally startling. Nearly 28 million opioid drug prescriptions were dispensed statewide between 2014 and 2016. That’s about 468 prescriptions per every 1,000 people.3 This is particularly unfortunate when considering that accidental poisoning—primarily related to prescription opioids—was the leading cause of unintentional death in New York State last year, according to the National Safety Council. In fact, more New Yorkers die of drug overdoses than homicides, suicides, and motor vehicle crashes combined.1

While opioid medications can be effective pain management tools when used appropriately and in the proper setting, the risk of potential unintended consequences increases when the patient’s condition lasts longer than three months. In many of these cases, more opioid medication does not necessarily result in better pain management.  These scenarios also present physicians with unique liability concerns associated with prescribing opioid medications.

As we move forward with treatment plans—both as healthcare providers and as patients—we need to reevaluate how we can work together to combat prescription opioid-related risks, and in turn, continue to bolster patient safety and improve the practice of medicine.

First and foremost, communication is paramount, and the data agree: Studies have shown that building a strong doctor-patient rapport can help to reduce some of the risks that contribute to medical malpractice suits. Safer prescribing is rooted in having critical —and often difficult—conversations with patients, including educating the patient about opioid treatment, gaining informed consent, and following up for monitoring.

To help reveal some of the situations and care settings in which physicians prescribing opioids might be most at risk, The Doctors Company reviewed 1,770 claims that were closed between 2007 and 2015 in which patient harm involved medication factors.4 In 272 of these claims (15 percent), the medications in question were narcotic analgesics. Of the claims tied to outpatient settings, 82 percent of patient allegations for these claims involved improper medication management or treatment, wrong dose, and wrong medication. Of final diagnoses in these claims, 84 percent included poisoning by methadone, heroin, and opiates/narcotics NOS, or drug dependence.

Patient contributing factors—including noncompliance with the treatment plan, failure to follow physician instructions, and failure to keep or make follow-up appointments—appeared in 39 percent of claims, and communication factors appeared in 32 percent of claims.

The prevalence of communication factors reaffirms that incomplete or unclear communication can compromise patients’ ability to understand the doctor’s instructions and, especially in the case of pain medications, also make them feel as if the doctor doesn’t care about their issues or concerns. Neither physicians nor patients should take communication for granted by assuming they are on the same page. Take the extra time to discuss the risks associated with prescription opioid treatment, as well as what it means to take the medication properly, and ascertain that it is a true dialogue—both clear and mutually understood. In that same vein, address the importance of responsible possession of opioid prescriptions, ensuring the medication does not fall into the wrong hands.

Additionally, opioid prescriptions and refills can become difficult to manage when there are “too many cooks in the kitchen.” A proposed solution: ONE doctor and ONE pharmacy should prescribe controlled medication given for three months or more, whether for dental pain, fractures, fibromyalgia, cancer, anxiety, or ADHD. If a physician sees a patient for the third month of a controlled medication, starting a medication agreement could help to reduce risks if they plan on continuing this therapy.

Remember that while opioid withdrawal is uncomfortable, it is not life-threatening. New patients who present to a new pain specialist should not immediately be given such potent pain medications without the completion of thorough back-end research and assessment to guide the pain specialist’s recommendations. It may take longer than hoped to place the patient on a regular regimen, but the patient’s safety is well worth that time.

And finally, try to give the benefit of the doubt. Don't immediately label a patient as a drug seeker simply because they return repeatedly for the same pain complaint. It could instead be a situation of missed diagnosis—and providers should treat this patient like any other, which includes taking a detailed history (including medications), conducting a thorough physical examination, and searching for anything that may have been missed during previous care encounters.

We can all agree on one thing: we are losing too many New Yorkers to the growing opioid crisis, but the situation is not entirely out of our control. Through stronger communication, we can reduce risks for both providers and patients—and do our part to put patient safety first. Get more safe prescribing resources at NYC Health Overdose Prevention Resources for Providers and learn more about effective doctor-patient communication at The Doctors Company.


References

  1. Unintentional Drug Poisoning (Overdose) Deaths Quarters 1 and 2, 2017, New York City. http://www1.nyc.gov/assets/doh/downloads/pdf/basas/provisional-overdose-report-second-quarter.pdf. Accessed May 7, 2018.
  2. Opioid-Related Data in New York State. New York State Department of Health. Feb. 2018. www.health.ny.gov/statistics/opioid/. Accessed March 16, 2018.
  3. Opioid analgesic prescription rate per 1,000 population. New York State Department of Health. Apr. 2017. https://www.health.ny.gov/statistics/opioid/data/p22.htm. Accessed March 18, 2018.
  4. Troxel DB. Analysis of medication-related claims from The Doctors Company. The Doctor’s Advocate. First quarter 2017. http://www.thedoctors.com/KnowledgeCenter/Publications/TheDoctorsAdvocate/Analysis-of-Medication-Related-Claims-from-The-Doctors-Company. Accessed March 21, 2018.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

05/18