New FHC Policy Outlines ED Protocols for Prescription Medications

PINEHURST – Hospital emergency departments are on the front lines of a national crisis involving the misuse and abuse of prescription medications. The emergency departments at the three FirstHealth of the Carolinas hospitals are no exception.

With the recent adoption of a new policy on emergency department administration of narcotic and sedative medications, however, FirstHealth has taken an important local step toward combating a problem with staggering social and economic implications accompanied by an alarming toll in human lives.

The policy affects the emergency departments at Moore Regional Hospital in Pinehurst, Richmond Memorial Hospital in Rockingham and Montgomery Memorial Hospital in Troy. It will also affect the emergency department at a new FirstHealth hospital that is scheduled to open in Hoke County this fall.

“This is a community effort to clean up the prescription narcotic abuse problem that is taking place,” says James O. Lewis, M.D., medical director of the Emergency Department at Moore Regional Hospital. “It’s a community health issue, and this policy is what we feel is best for our community.”

The new policy establishes guidelines (protocols) to be followed by emergency department personnel when a presenting patient claims to be in acute pain but is found after a thorough medical evaluation not to have an emergency medical condition. According to the policy, these patients will no longer be treated with Drug Enforcement Agency-controlled Schedule II, III or IV substances such as Percocet, OxyContin and Vicodin.
Patients who frequently visit emergency departments seeking pain relief will be designated as having a “chronic pain syndrome” and so categorized if they have visited an emergency department for a pain condition more than twice in a 30-day period or more than six times in a year.

A search of the North Carolina Controlled Substance Reporting System (NCCSRS) that indicates a patient is a frequent user of narcotics will result in the same designation. (A Web-based prescription monitoring system, the NCCSRS allows registered dispensers to review a patient’s controlled substances prescription history. North Carolina-dispensed prescriptions for controlled substances are reported to an NCCSRS database that is updated weekly.)

Emergency department patients who are designated as having chronic pain will be encouraged to follow up with their primary care provider (if they have one) or given a list of area physicians or clinics that are accepting new patients (if they don’t).

“We want patients with chronic pain to get their prescriptions from a single provider,” Dr. Lewis says.

Some patients may also be referred to other services, such as pain management, acupuncture, chiropractic or physical therapy, and will be given information on FirstNavistar (FirstHealth’s online database and call center for health care and community-based resources in the Sandhills).

“(Physicians) will only use prescription narcotics when (they) have exhausted every other option,” says Michael Antil, M.D., a specialist in internal medicine with Pinehurst Medical Clinic and a member of the FirstHealth task force that developed the emergency department policy.

According to Dr. Lewis, the “legitimate acute pain” of injury, trauma and terminal illness, for example, will not be affected by the policy.

“We are here to provide compassionate pain management for those in need as well as a viable alternative for those with chronic pain or addictions,” he says.

Despite the fact that the identification and treatment of pain has been a component of medical care for centuries, frequently prescribed high-potency medications too often wind up being used by people other than those for whom they were intended, says Fernando Cobos, M.D., addiction specialist with FirstHealth Behavioral Services.

“We have seen a huge increase in access to these medications,” Dr. Cobos says. “The new FirstHealth model will afford patients the opportunity to think about recovery as we provide substance abuse treatment as part of our continuum of care.”

The following statistics may help provide a better understanding of the magnitude of the prescription medication abuse problem:

• In North Carolina, unintentional overdose from prescription medications accounts for nearly three deaths a day with the highest mortality occurring in adults between the ages of 45 and 54 who were using medications prescribed by their own physician. (N.C. State Center for Health Statistics)
• The abuse of prescription narcotics is the number one drug problem in the nation and in North Carolina. (N.C. State Bureau of Investigation)
• The number of overdose deaths (from prescription medications) is now greater than the total number of deaths from heroin and cocaine combined. (Centers for Disease Control and Prevention)

“Every 19 minutes, one person dies of overdose,” Dr. Lewis says. “It has surpassed car accidents.”

Cheryl Batchelor, R.N., director of FirstHealth’s Care Transition Clinic, facilitated the multidisciplinary Narcotics Prescribing in the ED Task Force that included representation from the following FirstHealth services: all three hospital emergency departments, Behavioral Services, pain management, primary care, hospitalist program and pharmacy as well as the corporate attorney and the Patient Family Advisory Council.

Also represented were Pinehurst Medical Clinic, Moore County Sheriff’s Office, Sandhills Community Care Network and the Moore County Drug Prevention Program.

Scott G. Kirby, M.D., of the North Carolina Medical Board, a recognized expert on the responsible prescription of controlled substances, attended a meeting to share information on improper prescribing as well as on appropriate care for pain patients.

An inspiration for the initiative was Project Lazarus, a nonprofit drug overdose prevention program that encourages community response to pain management. The aim of the statewide program is to address the challenges of prescription medication abuse through a partnership involving Community Care of North Carolina, the North Carolina Hospital Association, local hospitals and emergency departments, primary care doctors, faith-based programs and law enforcement.

Although ultimately approved by FirstHealth’s administration and full medical staff, the Moore Regional Hospital Board of Trustees and the FirstHealth Board of Directors, the task force was “physician-led, because the essence of the problem is in the hands of providers with prescription authority,” Batchelor says. “Being made aware of the extent of the problem was the driver for us.”
 
One of the people providing information to the task force was Chief Deputy Jerrell Seawell of the Moore County Sheriff’s Office. Before his recent promotion, Seawell was a captain in the Sheriff’s Office Narcotics Unit, where he enforced drug laws while observing the community impact of prescription medication misuse and abuse.

He calls the misuse of prescription medications “a huge problem, not only here but across the nation.”

Health care is especially vulnerable to the problem, Seawell says, because controlled medications – unlike cocaine, methamphetamines and other high-profile substances –  are legal when physician-prescribed. This encourages “doctor-shopping” by abusers who move from physician’s office to physician’s office and emergency room to emergency room in search of pills that may later be misused or sold on the street.

Compounding the problem, says Seawell, is the fact that many abusers, especially young people, often don’t understand the addictive nature of the medications, making education and prevention an important part of the enforcement process.

He calls the new FirstHealth policy “a great start in this direction.”

“It’s very important for everybody to know what is going on and to put appropriate measures in place,” he says. “We all need to take action.”

Emergency department signage and media releases will be used to communicate the message of the FirstHealth policy, which task force members hope will set the standard for all providers of health care in the community.

Dr. Antil expects the policy will make physicians and other dispensers of legally prescribed controlled substances more cautious and more informed during these patient interactions.

“I hope physicians will be much more uniform and more circumspect in how they prescribe these medications,” he says. “This is a system-wide problem, and every type of physician has to be a part of the solution. I hope it will help all our community medical providers speak and act similarly when dealing with patients with chronic pain and drug dependency. The best course of action is often not to just prescribe more controlled substances, but to get these patients back to their medical homes and tied into the appropriate counseling/support/drug treatment programs.”