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April 12, 2016 Published in Health, Top Stories

Virginia Hospitals Develop New Prescribing Guidelines To Combat Opioid Abuse

(Courtesy Photo)

(Courtesy Image)

A task force established to examine ways to reduce opioid abuse, particularly related to emergency room prescribing practices, has developed a set of recommendations to help guide hospital emergency departments in an era when prescription drug misuse has become more prevalent. The task force was created by action of the Virginia Hospital & Healthcare Association’s Board of Directors in January, 2016. Work over the next several months by representatives from VHHA-member organizations and the Virginia College of Emergency Physicians produced 14 recommendations for setting general standards on opioid prescribing in Virginia hospitals’ emergency departments, which in 2014 had nearly 3.6 million patient visits.

The recommendations address specific instances in which emergency department personnel should exercise caution in prescribing opioids for treating chronic pain. They advise prescribers to dispense medications for the shortest time possible. They encourage greater communication between emergency department prescribers and patients’ primary care physician. They discourage the practice of providing replacement prescriptions, and advise caution when dispensing medication to patients without photo identification. They encourage providers to consult the Prescription Monitoring Database before making opioid prescriptions. They discourage the prescription of long-acting and controlled release opioids. And they encourage hospitals and emergency department providers to use clinical judgment regarding prescription decisions and care coordination to help patients appropriately and safely manage pain.

“Virginia’s hospitals, health care community, law enforcement apparatus, and elected leaders all recognize the importance of working to ensure that medications prescribed to patients are taken as intended, not misused,” said James B. Cole, President and CEO of Virginia Hospital Center and Chairman of VHHA’s Board of Directors. “Combating improper use of prescription medications is not a new effort by Virginia’s local hospitals and health systems. That has long been a consistent focus of health care providers. Given the current climate, VHHA’s members felt it appropriate to redouble those efforts on behalf of the patients and communities we serve, and the entire Commonwealth.”

The task force recommendations arrive at a time when considerable attention is focused on opioid use in this country. The U.S. Centers for Disease Control and Prevention recently released a set of guidelines for prescribing opioids for chronic pain. Opioids are commonly prescribed as pain medication. Common types include codeine, fentanyl, hydrocodone, hydrocodone/acetaminophen, hydromorphone, meperidine, methadone, morphine , oxycodone, oxycodone and acetaminophen, and oxycodone and naloxone. The CDC estimates that 20 percent of patients who visit physician offices with non-cancer pain symptoms or pain-related diagnoses receive an opioid prescription. In Virginia, state and local law officials have engaged on this issue. During the 2016 General Assembly session, legislation intended to combat prescription drug misuse won bi-partisan approval

“VHHA’s members are dedicated to the well-being of Virginia and Virginians,” said VHHA President and CEO Sean T. Connaughton. “Achieving that takes many forms: treating ailing patients and educating the community about healthy behaviors, supporting the economy through jobs and investment, clinical research to combat illness, and proactive steps to respond to community health challenges as they arise. That approach is reflected in the decision by Virginia’s hospitals to establish a task force to address prescription opioid misuse and the recommendations that effort has produced.

Representatives from the following hospitals, health systems, and organizations were among those who made vital contributions to the task force in developing the recommendations: Augusta Health, Carilion Clinic, Clinch Valley Medical Center (LifePoint Health), HCA Virginia Health System, Inova Health System (Virginia Emergency Medicine Associates), Johnston Memorial Hospital (Mountain States Health Alliance), Sentara Healthcare (Sentara Albemarle Medical Center, Sentara Medical Group, Sentara Princess Anne Hospital, VCU Health (VCU Community Memorial Hospital, VCU Medical Center), Virginia College of Emergency Physicians, and Virginia Hospital Center.

Virginia Hospital Emergency Department Opioid  Prescribing Guidelines 

In January 2016, the VHHA Board of Directors established a task force on Prescription Opioid Abuse that was charged with finding ways to combat opioid abuse, and developing prescribing recommendations to guide hospital emergency departments. Representatives from VHHA member organizations and the Virginia College of Emergency Physicians jointly developed 14 recommendations that provide a general standard on opioid prescribing within Virginia hospitals’ emergency departments.

Guidelines

1.. A dedicated provider outside the emergency department should provide all opioids to treat any patient’s chronic pain.

2. Administering intravenous or intramuscular opioids in the emergency department for the relief of acute exacerbation of chronic pain is generally discouraged.

3. Prescriptions for opioids from the emergency department should be written for the shortest duration appropriate. In cases of diagnostic uncertainty or chronic conditions, this generally should be for no more than three days, as is consistent with national guidelines.

4. Hospitals, in conjunction with emergency department personnel, should develop a process to screen for substance misuse. Those protocols should include services for brief intervention and referrals to treatment programs for patents who are at risk for developing, or who actively have, substance use disorders.

5. When parents present with acute exacerbation of chronic pain, it is recommended that a summary of the emergency department care, including any medication prescribed, is communicated to the primary opioid prescriber or primary care provider.

6. Emergency department providers should not dispense prescriptions for controlled substances that were lost, destroyed, stolen, or finished prematurely.

7. Emergency department providers should use extra caution when considering prescribing controlled substances to parents who do not have proper photo identification.

8. Emergency department providers, or their designees, are encouraged to consult the Prescription Monitoring Program before writing opioid prescriptions for acutely painful conditions.

9. Emergency department providers, in general, should not provide replacement doses of methadone or buprenorphine for patients participating in an opioid treatment program.

10. Unless otherwise clinically indicated, emergency department providers should not prescribe long‐acting or controlled release opioids, such as oxycodone, fentanyl patches, or methadone.

11. Emergency department providers are strongly discouraged from prescribing or dispensing buprenorphine products. 12. Hospitals are encouraged to support physicians’ decisions when it is their clinical judgment that an opioid should not be prescribed even if a patient has requested a prescription.

13. Emergency departments are encouraged to coordinate the care of patients who frequently visit the emergency department for evaluaƟon of acute exacerbation of chronic pain. When possible, care coordination should include development of a patient‐specific care plan involving the emergency department, hospital, and the primary care provider treating the patient pain‐inducing condition. Such care plans may include patient‐specific policies or treatment plans, and should include treatment referrals for patients with suspected prescription opioid abuse problems.

14. Nothing in these recommendations is intended to supersede state or federal laws or regulations. Emergency departments should consider posting signs that notify patient that staff consults the PMP prior to prescribing controlled substances as is required by law.

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