Emergency Departments (EDs) function at the interface between the medical system and the communities that they serve and thus are well positioned to identify and address public health issues. Emergency physicians were among the first specialists to recognize unsafe opioid prescribing practices within the medical system at large, to develop safer strategies in their own practices, and to adapt to address the growing problem.
Efforts to galvanize the network of EDs across an urban center can have significant impact on a potentially higher-risk, city-wide population and can rapidly change patient and provider expectations about opioid use.
Institutional support can augment grassroots efforts by improving information sharing and disseminating newer, more judicious opioid prescribing guidelines.
EDs, despite specializing in acute care, can be ideal partners and agents in developing innovative approaches to public health issues, in this case by initially addressing unsafe opioid prescribing, moving to harm reduction with naloxone, and then to increased access to MAT.
Greater attention, collaboration, and resource allocation should be focused on the ED by the health system and the public health infrastructure to effectively impact public health crises and the opioid epidemic in particular.
EDs regularly evaluate and treat acute and chronic pain, provide treatment for the majority of non-fatal overdoses, and care for patients seeking treatment for substance abuse and its complications. As such, EDs have been on the front lines as the problem of misuse of opioids (and the subsequent increase in the incidence of fatal overdoses) has grown into what is now called the opioid epidemic.
In 2011, emergency physicians were identified as one of the top 5 opioid prescribers for individuals in almost all age groups. Nationally, ED visits involving the misuse or abuse of prescription opioids increased by 153% between 2004 and 2011. In Philadelphia, the proportion of ED visits due to opioid misuse increased by 120% between 2008 and 2017, from 0.484% to 1.066%. Heroin-related deaths increased sharply beginning in 2011 and continue to rise. In 2017 alone, there were 9,300 drug-related ED visits in the city.
Emergency physicians working in Philadelphia hospitals recognized the important role that EDs played in protecting the health and safety of individuals living in communities affected by the emerging opioid epidemic. The Philadelphia Emergency Department Prescription Opioid Misuse Working Group (hereafter referred to as the Working Group) was developed to bring representatives from every area ED together to discuss opioid prescribing practices, to understand local and national trends in opioid use and its sequelae, and to identify a cadre of emergency medicine champions from each institution who could address the emerging issue of opioid misuse within their institutions.
The Working Group identified the importance of making a concerted effort not only to limit the role of EDs in the problem, but also to be part of the solution by forming a unified front in developing safe and judicious opioid prescribing guidelines for the benefit of our patients, our staff, and our city. This effort had to be balanced with the health system’s continued emphasis on pain management metrics, patient satisfaction scores, and pain assessments.
In late 2012, an initial group of six Philadelphia emergency physicians developed the idea and initial process for the Philadelphia Emergency Department Prescription Opioid Misuse Working Group. Less than 6 months later, in April 2013, delegates representing 28 EDs gathered for a half-day conference of presentations and group discussions. Each member of this group was charged with developing an institution-specific opioid prescribing guideline or policy for his or her department.
An email/online LISTSERV was created following the conference to allow for ongoing discussion and resource sharing among the delegates. In particular, the LISTSERV was used to share information about the barriers and limitations that were encountered when implementing new opioid prescribing guidelines and policies at different sites, as well as about the lessons learned at individual institutions that could promote a more streamlined process for others. Many of the EDs developed and promoted safe opioid prescribing policies aimed at limiting inappropriate prescribing and misuse.
The team included emergency physician champions who had been identified at 28 EDs in the Philadelphia metro region, including those associated with five academic medical institutions, three community hospital systems with graduate medical education residency programs in emergency medicine, and nine community hospitals.
The full magnitude of the opioid epidemic was not well described when this group first convened. Opioid use disorder and its associated morbidity and mortality had escalated in Philadelphia, as across the country, but health system and public awareness were slower to develop. Although multidisciplinary approaches recently have taken on greater urgency, the grassroots approach of the Working Group predated almost all other citywide efforts. The Working Group received little formal support, with only two of the EDs receiving internal or external funding to develop these efforts and outputs.
Since the initial meeting, 21 EDs have continued to engage, share data, and support ongoing efforts. Prior to the meeting, only four (19%) of these 21 EDs had implemented Safe Opioid Prescribing Guidelines, whereas today, all but two of the EDs have implemented such guidelines. These efforts informed the development of the Pennsylvania state-level guidelines that were released in 2014 and predated the release of Centers for Disease Control and Prevention (CDC) prescribing guidelines in 2016. Additionally, six EDs (29%) implemented individualized provider feedback for their personal opioid prescribing practices along with comparative data from other providers.
Data on the total number of ED-originated prescriptions for opioids, available from eight of the 21 EDs after implementation of the guidelines, showed a mean decrease of 37% (range: 17% to 61%) in opioid prescriptions between 2011 and 2016. While these data cannot be directly correlated to efforts of the Philadelphia Emergency Department Prescription Opioid Misuse Working Group alone, the decrease in the total number of prescriptions may indicate a heightened awareness of inappropriate or unsafe prescribing practices. Anecdotally, all institutions participating in the Working Group reported an overall decrease in the number of opioid prescriptions from their EDs.
Many of the champions from these 21 EDs who continued to participate in the Working Group expanded their efforts well beyond the focus on opioid prescribing practices. Most (86%) of the EDs went on to develop educational approaches to address the opioid epidemic for medical students, emergency medicine residents, emergency medicine faculty, and/or the larger medical community. More than half (71%) of the EDs implemented routine naloxone-prescribing protocols and, in some cases, instituted direct distribution to increase patient and community access to overdose prevention medication and strategies. Nearly one-third (29%) developed Warm Handoff processes to increase patient access to treatment after near-fatal overdoses or other serious sequelae of opioid use disorder.
Six EDs developed protocols to initiate medication-assisted therapy (MAT) induction with buprenorphine, and at least four more are currently developing protocols with the same goal. In effect, members of the Philadelphia Emergency Department Prescription Opioid Misuse Working Group implemented the CDC strategy of Prevent, Reduce, and Reverse at the same time or even before the CDC recommended it.
Many members of the initial group were recognized for their content expertise and strength in advocacy. Nearly 85% of the members of the Philadelphia Emergency Department Prescription Opioid Misuse Working Group went on to hold leadership roles within their institutions related to efforts to address the opioid epidemic, and most were involved in efforts on the city, state, and federal levels.
Many were called to serve on the Philadelphia Mayor’s Task Force to Combat the Opioid Epidemic, with one serving on the main Task Force and four serving on various subcommittees; all played a significant role in developing the final recommendations put forth by the Task Force. The members of the Working Group continue to innovate in order to advocate, increase awareness, and facilitate access to care in the face of the opioid epidemic across the city.
Where to Start
The opioid epidemic has highlighted the potential impact of emergency physicians and EDs in addressing public health issues. Any small group of health care providers who observe negative consequences resulting from common medical practices, in this case opioid overprescribing, can consider starting a focus group or task force at their institution to draft best practices.
Health system leadership should acknowledge the value of this grassroots approach and lend support. Leadership can signal support and empower providers by widely disseminating lessons learned from these grassroots efforts. Metrics such as the total number of prescriptions and adherence to recommended practices can help to build a safer environment for opioid use in the treatment of chronic pain.
The Philadelphia Emergency Department Prescription Opioid Misuse Working Group was borne from a self-identified need for greater education and a concerted effort to address a growing issue. We collaborated across ED and health system boundaries for the sake of our patients, our departments and staff, and, ultimately, our city. This approach can serve as a model for the role that EDs can play in the health of the community.