When Hany Atallah, the chief of emergency medicine at Grady Memorial Hospital, started in the Grady emergency room 13 years ago, he typically saw one or two drug overdoses a month. Now he sees them all the time.
A particular problem is the cutting of heroin with fentanyl, which is 100 times as potent as morphine, he said. Patients hooked on prescription painkillers also use forged prescriptions (requiring a call to law enforcement) or repeatedly hit ERs to demand refills, Atallah said.
Prescription pill abuse has become an epidemic, and if people get hooked on the pills but can’t get them anymore, sometimes they turn to street drugs such as heroin, he said.
“Doctors naturally don’t want their patients in pain,” he said, noting that doctors also face patient satisfaction scores related to pain. “Across the system, it’s easier to treat with opioids. We don’t necessarily do a great job of warning about opioids.”
Grady is among the health systems re-evaluating their opioid prescription habits. Atallah said his department is working on a report about how many opioid prescriptions are coming out of the emergency room and how often regular ER visitors are leaving with prescriptions.
The use of electronic medical records helps respond to the problem of overprescription, he said. Doctors can include notes to draw other health care providers’ attention to opioid concerns and even recommend against additional opioid prescriptions.
States have taken that approach a step further by establishing prescription drug monitoring websites, enabling physicians to find patients’ prescription histories. Those electronic records can lead a doctor to have a tough conversation with a patient, Atallah said. “I know you think you need a prescription. I’m happy to get help for you.”
One important distinction is between chronic and acute pain. Opioids aren’t as effective as exercise and anti-inflammatories against chronic pain, Atallah said, and some doctors try to treat even acute pain with nonopioids.
“If you come in with a broken leg, opioids are appropriate. They’re not appropriate for two months,” Atallah said. A typical prescription might be 10 to 15 tablets, not 30, he said. “Most important is what else we can do to control the pain. There are plenty of good options.”
Some patients with a history of opioid addiction refuse any painkillers for fear of getting hooked again, which Atallah said he understands. But he also sees patients who have heard about the addiction epidemic and, despite no history of problems, are wary of taking any opioids.
“We have to be careful about overdoing it,” Atallah said. While there probably are too many opioid prescriptions being written by primary care physicians and emergency rooms across the country, there’s also a danger of causing an epidemic of pain by overreacting. “We have to be careful the pendulum doesn’t swing too far.”