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Western Pennsylvania emergency rooms altering policies on painkillers

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By Richard Gazarik
Monday, Feb. 24, 2014, 10:54 p.m.
 

The bleeding man walked into the emergency room in Excela Health Westmoreland Hospital in Greensburg and said he was in pain: a concrete block had fallen on his arm.

The pain was real, but the injury was no accident, said Mark Persin, an ER physician. The man was a drug addict who had intentionally bashed himself with the 38-pound block to get a prescription for painkillers that he would sell to buy heroin, Persin said.

“Every shift, we encounter someone trying to get pain medication illicitly,” said William Jenkins, another ER physician.

As similar scenes play out in emergency rooms across the nation, driven by a surge in prescription drug addiction and overdose deaths, health care systems are restricting how they prescribe opioids.

Excela Health has instituted a new protocol for dispensing pain medication in an effort to stem opioid abuse, which is blamed for most of the record 86 fatal overdoses last year in Westmoreland County.

A patient who arrives at an Excela hospital complaining of pain is allowed only enough medication for 24 to 48 hours, Person said. There are no refills.

Physicians at West Penn-Allegheny follow a guideline that recommends no opioids to any first-time patient in an emergency room except for cancer-related pain, said Dr. Jack Kabazie, director of the West Penn Pain Institute.

“This is only a guideline. We don't prescribe on the first visit. We gather records. We take a complete history and physical, take a history of any substance abuse and screen for psychological issues,” Kabazie said. “Opioids still should be one of the last resorts.”

Mike Lynch, an emergency room physician at UPMC and director of the Pittsburgh Poison Center, said the hospital has no policy “to refuse pain medication for legitimate pain.”

“There is no one-size-fits-all rule” with diagnosing pain, Lynch said.

“It's really difficult for an emergency physician or any other physician to identify who the real patients are,” he said. “It's easier said than done. Each physician takes the responsibility very seriously to be the custodian of medications.”

The addiction rate and spike in overdose deaths prompted Excela's efforts, officials said.

Westmoreland had 285 deaths from 2010-13, according to the county's Drug Overdose Death Task Force. Allegheny County reported 718 drug overdose deaths from 2010-12, state health department statistics show.

“We, as physicians, have clearly overprescribed,” Kabazie said. “We are seeing a lot of referrals from primary care physicians who were prescribing (opioids) and no longer wish to prescribe.”

Law enforcement officials link the diversion of prescription painkillers to an increase in heroin use. An addict who is prescribed 20 Vicodin tablets can sell them on the street for $100 and buy 10 bags of heroin, which is cheaper and more potent, Persin said.

Jenkins said some addicts who seek pain medications at Excela are creative. They injure themselves, complain of nonexistent injuries or use a false name to persuade a physician to write a prescription.

“We don't know the patient. We have never met them,” Jenkins said. “They walk in off the street, and the doctors need to make an immediate medical judgment for their care. There's no blood test for pain. It's very subjective.

“It can be very challenging to determine if a person is in real pain,” he said. “We give the person the benefit of the doubt. But if a patient gets the benefit of the doubt five out of seven times, we'll refuse them.”

Using electronic records, doctors can chart how many times a patient has been to any Excela ER seeking medication for pain, he said.

“It's easier for us to monitor patients with electronic records,” Persin said. “When they're in our department, I can tell how many times they've visited an Excela ER.”

Excela has increased security in the ER and has removed patients who get angry when a doctor refuses pain medication. Jenkins said some of those patients will leave the ER, glare at the physician or argue.

“Patients are becoming bolder and bolder, and they tell you what medications they need,” he said. “They can be quite threatening to staff. That threatens the whole safety of the department. It's a very serious issue.”

Several prescription drug monitoring bills in Harrisburg are stalled in committee because of civil rights and privacy issues.

“I think it's a great idea,” Jenkins said of the measures. “It's beyond me how any doctor who takes care of patients like these don't believe it's valuable.”

Richard Gazarik is a staff writer for Trib Total Media. He can be reached at 724-830-6292 or at rgazarik@tribweb.com.

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