NYC restriction of ED narcotic prescribing

[aggiedoc2010]

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Per the New York Times: http://www.nytimes.com/2013/01/11/nyregion/new-york-city-to-restrict-powerful-prescription-drugs-in-public-hospitals-emergency-rooms.html?hp&_r=1&

Some of the most common and most powerful prescription painkillers on the market will be restricted sharply in the emergency rooms at New York City's 11 public hospitals, Mayor Michael R. Bloomberg said Thursday in an effort to crack down on what he called a citywide and national epidemic of prescription drug abuse.

...patients will no longer be able to get more than three days' worth of narcotic painkillers like Vicodin, Percocet, OxyContin, as well as Fentanyl patches and methadone

Will this give emergency physicians a better way out (i.e. "I can't by law give you narcotics"), or is this just more interference into physican practice by the government even on a local level?

Is it possible that we might see this expand in the future to more cities/ states or the national level?

 

[BADMD]

F**K Bloomberg.

I get why they want to do it. However I can write as many or a few narcs as I think is appropriate. Call me when he gets an MD. He should stick his nose in Big Gulp.

 

[southerndoc]

I routinely write 45 Norco's and Percocet's when someone has a fracture. I get annoyed when docs reset an ankle fracture and then send someone out with 10 pills.

 

[Cerberus]

3 days is pretty cheap for someone with something real like a fracture. I don't think most ED docs need daddy Bloomberg to tell us how to prescribe medications. It's not at all surprising that a megalomaniac like Bloomberg would think he knows enough about medicine to tell us how to prescribe though.

 

[deleted109597]

Hey, it's repeat business. Because those fractures will have to come back in 3 days for a refill. It's another paying visit. WIN!

Also, 3 days by what criterion? 2 tabs q4? q6? 5s, 10s? Oxys or MS Contin? What about palliative patients?

 

[SoCuteMD]

Hey, it's repeat business. Because those fractures will have to come back in 3 days for a refill. It's another paying visit. WIN!

Also, 3 days by what criterion? 2 tabs q4? q6? 5s, 10s? Oxys or MS Contin? What about palliative patients?

It's not a paying patient in a NYC city-run hospital, and the docs are mostly salaried anyways. Just another med refill taking up a bed.

 

[RustedFox]

It's not a paying patient in a NYC city-run hospital, and the docs are mostly salaried anyways. Just another med refill taking up a bed.

This this this this. OMG this.

When I was a student, I had buddies rotating at NYC city-run gigs. I visited.

Maaaan.. what a wasteland.

No idea how anything gets done. None.

 

[deleted206819]

I'm at a non-HHC hospital in NYC and we're joining up in this effort. We're already hitting high numbers of boarded patients, patients in the ED at one time, and overall daily volumes since Hurricane Sandy. And now the mayor adds this to the mix ... oh brother.

I'm heading out of NYC once I'm done with residency. I hear Texas is nice.

 

[The Buff]

Also at an NYC non-HHC shop. Can't get out fast enough. RF is right--Most NYC ED's are wastelands where little to nothing gets done due to supreme overcrowding, 70% boarding, problematic/demanding patients, unionized nurses, and now daddy Bloomberg. #lessthansixmonths

 

[deleted109597]

It's not a paying patient in a NYC city-run hospital, and the docs are mostly salaried anyways. Just another med refill taking up a bed.

But with Obamacare, they're all paying!

I kid.

 

[geauxg8rs]

I posted in the Pain forum on this. It is a nanny state intrusion into medicine once again. If they wanted real change they could outlaw press gainey surveys being tied to salary/job performance. Let doctors be doctors, this is not applebees.

My question was similar to the ones posted here. The article talks about cancer and palliative care exempted. But what about fractures, sicklers, ie people with real pain? It once again will hurt the poor and people with real pain the most. Also will likely lead to a nurse with a white coat/clip board watching over doctors. Hey doctor you cannot give that fracture patient 4 days worth of q6 hour medication, but if you write it for 3 days of q 2hours you can give the same amount of pills. More nonsense will come of it.

It is like Bloombergs soda ban. If someone works outside and likes his sugary drinks he will just have to buy two smaller drinks rather than one large one. Not a problem for rich fat cats on wall street but hurts the construction worker.

 

[Rendar5]

I posted in the Pain forum on this. It is a nanny state intrusion into medicine once again. If they wanted real change they could outlaw press gainey surveys being tied to salary/job performance. Let doctors be doctors, this is not applebees.

My question was similar to the ones posted here. The article talks about cancer and palliative care exempted. But what about fractures, sicklers, ie people with real pain? It once again will hurt the poor and people with real pain the most. Also will likely lead to a nurse with a white coat/clip board watching over doctors. Hey doctor you cannot give that fracture patient 4 days worth of q6 hour medication, but if you write it for 3 days of q 2hours you can give the same amount of pills. More nonsense will come of it.

Eh, fracture pain I can understand, but most people with real pain that is not improving by 4 days out should be seeing outpatient doctors or returning to the ED. The only people I'm writing out for day 4 or more of around the clock narcotics are cancer/palliative care patients and occasionally fracture patients. That list doesn't include most chronic pain patients or sicklers, who generally have someone I can call to have them arrange for a longer term Rx.

 

[geauxg8rs]

The point being who is better at making these decisions. You or the nanny state?

 

[RustedFox]

Eh, fracture pain I can understand, but most people with real pain that is not improving by 4 days out should be seeing outpatient doctors or returning to the ED.

I don't disagree, but there are so pitifully few docs out there on the whole. I recently moved to a new city, tried to find a simple PCP for the wifey. "New patient? 4-6 weeks wait, at least." was the pretty much unanimous answer that we got.

Its just not a realistic solution.

 

[WilcoWorld]

If this were applied to all EDs and not just public hospitals, I would only be bothered (rather than infuriated). But to apply it to public hospitals only will cripple those who treat the underserved and widen the class divide.

-Hospitals and docs are held to satisfaction metrics, which are only interpreted relative to others. So, when public hospitals can only give 3 days of pain meds for your real pain, but the private place down the road can give however many the doc feels is indicated, who will get the better score? Better scores means better funding. Better funding will likely lead to better scores, which will lead to better funding, which will...you get the point.

-Also implicit in this is the thought that only poor people are drug addicts. I'm pretty sure "Mother's Little Helper" was not written about NYC medicaid patients.

 

[Cerberus]

If this were applied to all EDs and not just public hospitals, I would only be bothered (rather than infuriated). But to apply it to public hospitals only will cripple those who treat the underserved and widen the class divide.

-Hospitals and docs are held to satisfaction metrics, which are only interpreted relative to others. So, when public hospitals can only give 3 days of pain meds for your real pain, but the private place down the road can give however many the doc feels is indicated, who will get the better score? Better scores means better funding. Better funding will likely lead to better scores, which will lead to better funding, which will...you get the point.

-Also implicit in this is the thought that only poor people are drug addicts. I'm pretty sure "Mother's Little Helper" was not written about NYC medicaid patients.

I think most hospitals in the city that are not public, will voluntarily abide by this rule so as to avoid the influx of drug seekers who heard that at hospital Y they'd give bigger scripts for narcs.

 

[Flopotomist]

Is there data suggesting that the prescription narcotic problem is due in a disproportionate amount to ED provider prescriptions? In the abscence of such data, this is a solution in search of a problem.

If I feel a pt is abusing the system, or "drug seeking" I already have a powerful tool to employ. The word "no."

Treating people the way we would want our loved ones treated is important here. If a terminal patient (non-cancer) or a patient with a fracture, or a sickle cell pt (whom I believe is legit) or any other myriad of patients with real needs for opiates presents to the ED it is absurd to restrict what I can prescribe.

 

[Birdstrike]

(Will be edited and reposted later. Somewhere.)

 

[GeneralVeers]

As doctors we've shown an unsurprising lack of ability to control our own prescribing habits. American culture expects to be free of any and all pain, so narcotics get prescribed for the slightest perceived injury or ouchy.

We need to start saying no to narcotics prescriptions. Is it really that surprising that government has stepped in?

 

[emd123]

As doctors we've shown an unsurprising lack of ability to control our own prescribing habits. American culture expects to be free of any and all pain, so narcotics get prescribed for the slightest perceived injury or ouchy.

We need to start saying no to narcotics prescriptions. Is it really that surprising that government has stepped in?

No.

 

[glorfindel]

As doctors we've shown an unsurprising lack of ability to control our own prescribing habits.

1) YES, +1. We still Rx abx for sinusitis and uris, we ARE influenced by pharm company marketing campaigns (that's why they spend so much $$ on them), and we probably overprescribe opiates in the ED.

American culture expects to be free of any and all pain, so narcotics get prescribed for the slightest perceived injury or ouchy.

2) YES, +1. Most of us have been persuaded that for every pain, for every unpleasant feeling, there's a pill to make it go away. I personally am sick of this attitude. There's still certain subcultures out there (old vets, etc.), who value stoicism. But there are fewer of these people each year. I'm reminded of the twenty-something, fit guy who came to the ER because he had diarrhea after his run. Diarrhea after his run! And he was mighty pissed off with me when I told him to go home and drink fluids -- "what about my diarrhea?" I don't know, what about your diarrhea? *flat stare*

Grrr. Now I'm all pissed off... I'll get over it.

I'm not so sure about Bloomberg. In general, I like to have as much ammunition as possible when I'm declining patient requests for opiates. The Washington state board of health + hospital association + Wash state chapter of ACEP has helped a lot with this through distribution of a "no narc Rx for chronic stuff" poster for EDs. But I'm gonna prescribe what I think is best for the patient.

 

[Khaos]

I agree with the idea that we use narcotics way too often. I even had to watch one 3 month old for 6 hours after her mother accidentally gave the child to much tylenol 3 that was prescribed for an earache. Really!!! F'in tylenol 3 to a 3 month old for an earache!!!! Talk about going on a rant there.

However, I have a huge problem with this. If you have a problem with a doctor prescribing too many narcotics, go after that doctor. Do not let government step in and make such a general demand. It will slowly but surely make demands on everything. Where will it stop? You can no longer order large french fries because you will get fat, you can no longer buy that tootsie roll because you'll get heart disease, you can no longer do risky sports or activities such as bungee jumping, hang gliding, or riding a motorcycle...

I will stop because I could keep going forever.

 

[GeneralVeers]

We can all rant about over-prescription as much as possible, but in the end we are each to blame as individuals for doing it, as groups for allowing our partners to get away with it, and as a specialty for looking the other way.

About 3/4 of my partners give narcs to every ache and pain. They are generally empathetic people who want to alleviate pain, but they do more harm than good.

I don't prescribe narcs unless it's a new acute issue. For chronic issues I check the database and the ER visit history, and give at most 1 day of pain medication. If you've had a visit for chronic pain in the last 6 months, you are out of luck. No pain meds for you.

 

[KidDr]

I agree with the idea that we use narcotics way too often. I even had to watch one 3 month old for 6 hours after her mother accidentally gave the child to much tylenol 3 that was prescribed for an earache. Really!!! F'in tylenol 3 to a 3 month old for an earache!!!! Talk about going on a rant there.

My hospital (dedicated children's hospital) just took codeine off the formulary completely.

 

[deleted206819]

Do you folks really believe that the rise in opiate usage started in the ED? There was a recent article (medscape, I think) stating that the ED was the least culpable of the specialties in bringing about the rise in over prescription of opiates.

To have this legislated upon the us means that we have given up our knowledge and skill and allowed the government to come in and dictate our practice of medicine. If Bloomberg cared about addiction then why not apply it to the PMR, pain medicine, outpatient IM folks that prescribe > 80% opiates out there? Why target the ED?

If you care about over-prescribing in your group, then bring it up and come to a consensus about a plan forward. If you think as a group we over-prescribe, then let's get AAEM and ACEP involved.

Opiate addiction did not start in the ED and will not be curbed by EPs.

Look at this graph from the FDA with respect to the number of prescription for opiates written by EPs and by other specialties. You can find the entire PDF here.

 

[EctopicFetus]

I thought this is what would be given out at the public hospitals. Doctors can write for what they want but if they want more pills they need to go to a pharmacy and pay for it.

Am i wrong?

 

[glorfindel]

Do you folks really believe that the rise in opiate usage started in the ED? There was a recent article (medscape, I think) stating that the ED was the least culpable of the specialties in bringing about the rise in over prescription of opiates.

Irrelevant; question is whether current ED docs are overprescribing opiates. Good graph though. I'd like to see these numbers in the context of total patient visits or total drug Rx.

To have this legislated upon the us means that we have given up our knowledge and skill and allowed the government to come in and dictate our practice of medicine.

It means nothing of the sort. I hear this bleating about the bad, bad government so often, I personally am tiring of it. This Bloomberg stunt imo is not anything to flip out about. Now, if the bad, bad government announced that they would no longer be issuing licenses to practice medicine or prescribe drugs, well, that'd be something that'd shake our world.

 

[deleted206819]

Per the FDA report, IR opioids totaled 234 million prescriptions and ER opioids total 22.9 million prescriptions. The ED accounted for 10,998,000 IR prescriptions (or 4.7%) in 2009. The total number of prescriptions were 3.8-3.9 billion in 2009 to give you some context.

In 2009, the ED saw 136.1 million visits of which 45.4 million where injury related. If we hypothesis that one visit = one prescription for IR opioids then only 24% of patients received a prescription but then again this is hypothetical.

Source: http://www.cdc.gov/nchs/fastats/ervisits.htm

 

[glorfindel]

Per the FDA report, IR opioids totaled 234 million prescriptions and ER opioids total 22.9 million prescriptions. The ED accounted for 10,998,000 IR prescriptions (or 4.7%) in 2009. The total number of prescriptions were 3.8-3.9 billion in 2009 to give you some context.

In 2009, the ED saw 136.1 million visits of which 45.4 million where injury related. If we hypothesis that one visit = one prescription for IR opioids then only 24% of patients received a prescription but then again this is hypothetical.

Source: http://www.cdc.gov/nchs/fastats/ervisits.htm

Awesome; thanks for those numbers!

 

[RustedFox]

Imagine this: !?!!

Press-Gainey: "Customer satisfaction is paramount ! Give narcs !"

The new-Bloomberg legislation: "Don't Give Narcs ! Its the law !"

alskdjf;lkjdfs *keyboard smash* as;dlfkja;sldfkj

This is reason 3345 why I hate New York.

and yes, I realize, there will probably be eleventeen butt-hurt new-yorkers that post after this and say:

"hurr-dee-durr-dee-durr-NEW-YORK-deee-durr-dee-YANKEES-dee-durr-daaa-BROOKLYN-durrrrrrr"

Whatever.

I was there. I saw it. What a mess. A terrible, terrible mess. Cancerous. Mess.

Want to breathe in New York? That'll cost you .37 cents an hour.

Want to park in New York? That'll cost you 11.68 an hour.

Want to ... whatever.... its not worth it...stay the hell out of New York. Period.

 

[deleted206819]

Imagine this: !?!!

Press-Gainey: "Customer satisfaction is paramount ! Give narcs !"

The new-Bloomberg legislation: "Don't Give Narcs ! Its the law !"

alskdjf;lkjdfs *keyboard smash* as;dlfkja;sldfkj

This is reason 3345 why I hate New York.

and yes, I realize, there will probably be eleventeen butt-hurt new-yorkers that post after this and say:

"hurr-dee-durr-dee-durr-NEW-YORK-deee-durr-dee-YANKEES-dee-durr-daaa-BROOKLYN-durrrrrrr"

Whatever.

I was there. I saw it. What a mess. A terrible, terrible mess. Cancerous. Mess.

Want to breathe in New York? That'll cost you .37 cents an hour.

Want to park in New York? That'll cost you 11.68 an hour.

Want to ... whatever.... its not worth it...stay the hell out of New York. Period.

I'm with you there RustedFox. I'm just counting down the days until graduation. Unfortunately, it's still 1.5 years away.

 

[deleted109597]

Where else can you get Chinese food delivered at 4am?

Oh right. Vegas.

New York is fun to visit. I couldn't stand to live there.

 

[Cerberus]

I honestly don't see why non New Yorkers like to bitch so much about the city. You don't like the city, we get it - don't live here or visit - no one will really give a damn. I wish less people liked the city, maybe I could find an apartment at a reasonable price. I don't bitch about how awful backwards BFE mid-west/southern USA is. I don't come into threads about Texas and do a Yosemite Sam impression and make jokes about consanguineous marriages. I've lived in the South/West/and East and wouldn't live in most other parts of the country despite the increased costs of living here.

 

[OccupyTheED]

Imagine this: !?!!

Press-Gainey: "Customer satisfaction is paramount ! Give narcs !"

The new-Bloomberg legislation: "Don't Give Narcs ! Its the law !"

alskdjf;lkjdfs *keyboard smash* as;dlfkja;sldfkj

This is reason 3345 why I hate New York.

and yes, I realize, there will probably be eleventeen butt-hurt new-yorkers that post after this and say:

"hurr-dee-durr-dee-durr-NEW-YORK-deee-durr-dee-YANKEES-dee-durr-daaa-BROOKLYN-durrrrrrr"

Whatever.

I was there. I saw it. What a mess. A terrible, terrible mess. Cancerous. Mess.

Want to breathe in New York? That'll cost you .37 cents an hour.

Want to park in New York? That'll cost you 11.68 an hour.

Want to ... whatever.... its not worth it...stay the hell out of New York. Period.

Born, raised and currently training in NY. Couldn't agree with you more. Love my residency program but as an attending there is NO WAY I would stay here.

 

[shookwell]

There are guidelines only, not laws, and are not mandatory. Any individual ED doc, even those working for the city in an HHC hospital, is free to prescribe whatever he wants.

Basically, the docs who don't prescribe opioids are going to have more ammo to deny patienst, and the ones who do prescribe opioids will ignore this policy. If I had to guess, this policy will change the prescribing habits of less than 5-10% of HHC ED docs.

It's more of an opportunity for Bloomberg to go on TV and make believe he is doing things that are good for you.

 

[RustedFox]

I honestly don't see why non New Yorkers like to bitch so much about the city. You don't like the city, we get it - don't live here or visit - no one will really give a damn. I wish less people liked the city, maybe I could find an apartment at a reasonable price. I don't bitch about how awful backwards BFE mid-west/southern USA is. I don't come into threads about Texas and do a Yosemite Sam impression and make jokes about consanguineous marriages. I've lived in the South/West/and East and wouldn't live in most other parts of the country despite the increased costs of living here.

Here's why:

Because the most popular pastime for New Yorkers is... talking about New York.

http://www.youtube.com/watch?v=Pj2WKny3eZE

 

[deleted109597]

I honestly don't see why non New Yorkers like to bitch so much about the city. You don't like the city, we get it - don't live here or visit - no one will really give a damn. I wish less people liked the city, maybe I could find an apartment at a reasonable price. I don't bitch about how awful backwards BFE mid-west/southern USA is. I don't come into threads about Texas and do a Yosemite Sam impression and make jokes about consanguineous marriages. I've lived in the South/West/and East and wouldn't live in most other parts of the country despite the increased costs of living here.

And yet you just did. Hmm. At least the reasons we don't like NY are legitimate facts, and not stereotypes that are typical of unlearned people.

 

[GeneralVeers]

And yet you just did. Hmm. At least the reasons we don't like NY are legitimate facts, and not stereotypes that are typical of unlearned people.

I actually like New York. There's tons to do, and even though the people are annoying, they are entertaining.

Unfortunately an ER doctor can't make a decent living there with the high costs, and relatively lower reimbursement.

 

[Cerberus]

And yet you just did. Hmm. At least the reasons we don't like NY are legitimate facts, and not stereotypes that are typical of unlearned people.

I wasn't being serious, I've lived in the South, I know the stereotypes aren't entirely true (nor entirely false). NYC certainly isn't as easy of a place to live/practice as the midwest/south, but it's also not as bad a it's portrayed. If you work at a public hospital, yes you can expect to do a lot of the stuff that should be done by techs/nurses. If you work in a community place, it can be a lot different. The only time i've ever put in a PIV is when multiple nurses have failed. Same with foleys. The reimbursement could certainly be better, but it's not bad either (depending on where you work). Also, I lot of patients here are annoying, but we don't have Press Ganeys to worry about so we don't have to bend backwards to please them.

 

[The White Coat Investor]

I honestly don't see why non New Yorkers like to bitch so much about the city. You don't like the city, we get it - don't live here or visit - no one will really give a damn. I wish less people liked the city, maybe I could find an apartment at a reasonable price. I don't bitch about how awful backwards BFE mid-west/southern USA is. I don't come into threads about Texas and do a Yosemite Sam impression and make jokes about consanguineous marriages. I've lived in the South/West/and East and wouldn't live in most other parts of the country despite the increased costs of living here.

The problem with New Yorkers is that they have no idea that Yosemite is over 1800 miles away from Houston, TX. 🙂

Interesting place to visit, but I'd never live in Manhattan. I'm glad so many folks there feel the same way or all the places I really like in this country would be overrun.

 

[The White Coat Investor]

I actually like New York. There's tons to do, and even though the people are annoying, they are entertaining.

Unfortunately an ER doctor can't make a decent living there with the high costs, and relatively lower reimbursement.

No different than California, really.

 

[GeneralVeers]

No different than California, really.

Exactly. Which is why I live in low-cost, no-tax Nevada!

 

[Apollyon]

People from NY can't wait to get back there.
People not from NY can't wait to leave.

Wonderful place to visit for a little bit, but, if you're not a native, when it's time to go, it is.

There are a few places in the US I really, truly do not dig, and would be happy if I NEVER went there again, but I don't go injecting that into conversation just to let my point be known. As we said in Hawai'i, "If where you come from is so great, go back there! We are not holding you hostage. There are at LEAST 5 planes a day flying back to the mainland!"

 

[GeneralVeers]

States I've lived/worked in:

Indiana - nice state, but rather dull. Wouldn't go back

Nebraska - Too cold in Winter, too hot in Summer, and nothing to do.

California - Too expensive, with insane non-nonsensical rules.

Texas - A little hot, but great people, low-taxes, and good work environment

Nevada - Tough work environment, but good weather (if you don't mind 116 degrees), and low taxes. Also a quick flight to the beach.

 

[glorfindel]

Washington - stunning. A lot of rain in the western 1/3d.

Colorado - sublime. Drier than people think, sooo sunny.

Oregon - sweeet. Can't legally pump your own gas.

Michigan - stupendous. Obsessed with something called Ohio State.

Chicago - solid. It's right next to Illinois.

 

[deleted109597]

Texas - A little hot, but great people, low-taxes, and good work environment

Nevada - Tough work environment, but good weather (if you don't mind 116 degrees), and low taxes. Also a quick flight to the beach.

When I go to Vegas I feel refreshed, since the humidity isn't 100%.
OTOH, I can be at the beach in less than 10 minutes.

 

[FulfilledDeer]

States I've lived/worked in:

Indiana - nice state, but rather dull. Wouldn't go back

Nebraska - Too cold in Winter, too hot in Summer, and nothing to do.

California - Too expensive, with insane non-nonsensical rules.

Texas - A little hot, but great people, low-taxes, and good work environment

Nevada - Tough work environment, but good weather (if you don't mind 116 degrees), and low taxes. Also a quick flight to the beach.

Veers - when you say tough work environment, what aspect(s) are you talking about? I only ask because I've was naming the states I would willingly live in recently, and to my (frank) surprise, Nevada was one of them.