PLEASE NOTE: THIS RESOLUTION WILL BE DEBATED AT THE 2012 COUNCIL MEETING. RESOLUTIONS ARE NOT
OFFICIAL UNTIL ADOPTED BY THE COUNCIL AND THE BOARD OF DIRECTORS (AS APPLICABLE).
RESOLUTION:
16(12)
SUBMITTED BY:
Arizona Chapter
SUBJECT:
Development of Guidelines for the Treatment of Chronic Pain
PURPOSE: Support state autonomy to establish guidelines for treatment of patients with chronic pain who present
to the ED requesting significant doses of narcotic pain medications or other controlled substances, including the
establishment of referral networks to existing pain treatment centers.
FISCAL IMPACT: Budgeted staff time.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
WHEREAS, It is recognized that the Emergency Department is often viewed as a place to obtain
prescription medications for painful conditions which may or may not be chronic; and
WHEREAS, It is recognized that ACEP has recently published guidelines for the prescribing of narcotic
pain medications for patients in emergency departments, but the policy does not address the frequently returning
patient requesting or requiring additional pain medication; and
WHEREAS, Some states are legislating that providers follow certain steps prior to prescribing narcotic
pain medications which could be considered unreasonable in a busy emergency department; and
WHEREAS, ACEP recognizes narcotic addiction and overdoses are a real and legitimate issue that must
be handled appropriately and should be done by the providers for the providers instead of waiting for it to be
legislated; and
WHEREAS, ACEP supports the use of statewide and interstate prescription monitoring programs to
determine appropriateness of narcotic prescribing, even in small amounts; and
WHEREAS, Many emergency physicians are feeling the strain from patient satisfaction scores,
performance productivity metrics and good sound medicine and often forced to prescribe medications to patients
that they feel uncomfortable doing so as there are few resources to support their decision to not refill strong pain
medications; therefore be it
RESOLVED, That ACEP supports each state having the autonomy to establish guidelines or protocols
that provide for the treatment of patients with chronic pain who present to the Emergency Department requesting
significant doses of narcotic pain medications or other controlled substances. Important in the treatment is the
establishment of a referral network to existing pain treatment centers that are better suited to follow a patients
narcotic prescribing and maintenance of records.
Background
This resolution asks the College to support state autonomy to establish guidelines for treatment of patients with
chronic pain who present to the emergency department (ED) requesting significant doses of narcotic pain
medications or other controlled substances, including the establishment of referral networks to existing pain
treatment centers.
Resolution 16(12) Development of Guidelines for the Treatment of Chronic Pain
Page 2
In 2004, ACEP developed a CME monograph, Pain Management in the Emergency Department, that reviewed
available management options and provided additional information to assist emergency physicians in improving
ED pain management.
The ACEP policy statement, “Optimizing the Treatment of Pain in Patients with Acute Presentations,”
http://www.acep.org/Content.aspx?id=48089, notes that pain categorization (eg, chronic/persistent) is helpful in
choosing appropriate interventions such as referral for long-term pain management to other providers or to pain
treatment centers. The policy states that “chronic repeat visits to non-continuity of care providers can be
addressed through social service interventions, care plans in conjunction with primary care physicians, and
analgesic contracts for emergency pain relief.” This is a joint statement by ACEP, the American Pain Society, the
American Society for Pain Management Nursing, and the Emergency Nurses Association.
The ACEP policy statement, “Electronic Prescription Monitoring,” http://www.acep.org/Content.aspx?id=82648,
supports the use of electronic prescription monitoring systems that ensure access to legitimate use of controlled
substances, protect patient privacy, provide liability protection for the practitioner, are voluntary, minimize
burdensome requirements on the physician, have linkages to other locations, are easily accessible and navigable
by practitioners around the clock, are not used to evaluate physician’s practice, and allow physicians to monitor
their own prescribing patterns and to identify potential unauthorized use.
The 2012 ACEP “Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the
Emergency Department” addresses four critical questions: (1) the utility of state prescription drug monitoring
programs in identifying patients at high risk for opioid abuse; (2) use of opioids for acute low back pain; (3)
effectiveness of short-acting schedule II versus short-acting schedule III opioids for treatment of new-onset acute
pain; and (4) the benefits and harms of prescribing opioids on discharge from the ED for acute exacerbation of
non-cancer chronic pain. This guideline acknowledges the increase in opioid deaths, recognizes the difficulties
emergency physicians face in treating pain appropriately while avoiding adverse events, identifies the literature
(and lack of literature) related to the four critical questions, and offers some guidance on prescribing opioids at
ED discharge for acute pain and acute exacerbation of non-cancer chronic pain. At the same time it recognizes the
importance of the individual physician’s judgment, and provides information for individuals and groups such as
state chapters to work within their states and institutions to develop opioid guidelines appropriate for their
locations. This clinical policy was funded by the Centers for Disease Control and Prevention, National Center for
Injury Prevention and Control, Division of Unintentional Injury.
This clinical policy is available on the ACEP Web site, http://www.acep.org/clinicalpolicies/, was highlighted in
several communications to the membership, and will publish in Annals of Emergency Medicine in October 2012.
The guideline identifies some of the state and chapter activities that have already occurred related to opioid
prescribing in the ED. The guideline was also distributed to all ACEP chapters and to The Joint Commission for
their information.
ACEP offers resource information for all chapters and serves as the central data collection center for sharing
information, such as state activities related to opioid prescribing. ACEP supports chapter efforts to pursue critical
state legislative initiatives such as ensuring patient access to emergency medical care. The ACEP State
Legislative/Regulatory Committee has been given an objective to identify and disseminate to chapters existing
exemplary state legislation or regulations related to pain medicine prescribing in the ED.
The ACEP Washington and Oregon Chapters, working with other organizations within their states, have
developed statewide ED opioid prescribing guidelines. The Florida College of Emergency Physicians has
developed guidelines about chronic nonmalignant pain management in the ED that have been adopted at
numerous hospitals in Florida. The ACEP Ohio Chapter provided input into the Opioids and Other Controlled
Substances Prescribing Guidelines for Ohio and endorsed the guidelines. The ACEP Kentucky Chapter
developed an informational guidance document on narcotics and sedatives usage in the ED for use in Kentucky.
Successful policies related to narcotic prescribing and established discharge planning regimens that more
effectively manage pain control in a North Carolina hospital ED are being expanded into a statewide rollout of a
chronic pain initiative.
Resolution 16(12) Development of Guidelines for the Treatment of Chronic Pain
Page 3
Multiple states, such as Oklahoma, Louisiana, and Missouri have Medicaid lock-in programs that require patients
to go to one provider and one pharmacy for opioids. Most states have enacted or considered legislation related to
opioid prescriptions. At least eight states require physicians to report to their prescription drug monitoring
programs. At least nine states require CME related to pain management.
In New York State, legislation (S.5720-A/ A.8320) was introduced that would have created an on-line real time
reporting system to monitor prescribing and dispensing of certain controlled substances. The ACEP New York
Chapter submitted comments in opposition to the legislation and sought an amendment to waive the reporting and
monitoring requirements for emergency physicians providing all emergency care in the state, as they believe this
legislation would have impeded patient flow and care.
Kentucky enacted controlled substance legislation that includes CME requirements for practitioners, specific
documentation and database query requirements before prescribing, and the allowance of an increased, diverse
array of persons and entities that may file complaints against practitioners for alleged inappropriate controlled
substance prescribing. In addition, if an emergency practitioner is investigated for inappropriate prescribing of
controlled substances, a pain specialist is obtained to opine on the emergency practitioner’s prescribing practices.
On July 9, 2012, the FDA approved a risk evaluation and mitigation strategy (REMS) for extended-release (ER)
and long-acting (LA) opioid medications. The REMS will require ER/LA opioid analgesic companies to make
training available for health care professionals who prescribe ER/LA opioid analgesics on proper prescribing
practices and to distribute educational materials to prescribers and patients on the safe use of these medications.
The REMS training is not mandatory for prescribers. However, the Administration is pursuing legislative changes
for a mandatory training program on responsible opioid prescribing practices that would be linked to DEA
registration.
ACEP Strategic Plan Reference
Enhance emergency care through federal and state policy initiatives.
Fiscal Impact
Budgeted staff time to provide support and share information with state chapters to assist them in their efforts to
develop guidelines and referral networks appropriate for their state.
Prior Council Action
Amended Resolution 29(10) Prescription Electronic Monitoring adopted. Supported creation of a policy regarding
the use of web-based prescription monitoring programs in every state, that utilization of the prescription
monitoring program be at the practitioner’s discretion, that physicians not be required to submit information to
prescription monitoring programs or to report potential prescribed medication abuse to the authorities, and that
ACEP support re-authorization of federal funding for the National All Schedules Prescription Electronic
Reporting (NASPER) system and adequate funding for intra-state linkages of databases with access by practicing
physicians.
Substitute Resolution 22(09) Patient Satisfaction Surveys adopted. Directed ACEP to disseminate information to
educate members about patient satisfaction surveys including how emergency physicians armed with more
knowledge can assist hospital leaders with appropriate interpretation of the scores and encourage hospital and
emergency physician partnership to create an environment conducive to patient satisfaction.
Substitute Resolution 21(04) Pain Control adopted. Directed ACEP to study the JCAHO requirements for pain
assessment and treatment as it relates to the ED and provide information and feedback to the JCAHO with regard
to their pain management requirements.
Resolution 16(12) Development of Guidelines for the Treatment of Chronic Pain
Page 4
Prior Board Action
June 2012, approved Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the
Emergency Department.
October 2011, approved policy statement “Electronic Prescription Monitoring.”
October 2010, adopted Amended Resolution 29(10).
June 2009, approved policy statement “Optimizing the Treatment of Pain in Patients with Acute Presentations.”
October 2009, adopted Substitute Resolution 22(09).
March 2004, approved policy statement, “Pain Management in the Emergency Department.” This policy was
rescinded in 2010 since the information was contained in the “Optimizing the Treatment of Pain in Patients with
Acute Presentations” policy statement.
October 2004, adopted Substitute Resolution 21(04).
Background Information Prepared By: Rhonda Whitson, RHIA
Clinical Practice Manager
Reviewed by: Marco Coppola, DO, FACEP, Speaker
Kevin Klauer, DO, EJD, FACEP, Vice Speaker
Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director