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