Punam Patel, DO & Steven Sattler, DO Emergency Medicine Residency Program

1. A Descriptive Study of the Effect of the Medford Pharmacy Shooting on Prescriptions for Opioids Dispensed from a nearby Suburban Academic Emergency Department Punam Patel, DO & Steven Sattler, DO Emergency Medicine Residency Program Good Samaritan Hospital Medical Center West Islip, NY

2. INTRODUCTION On June 20, 2011, a man entered a Long Island pharmacy approximately 20 miles away from our hospital and shot a pharmacist, a clerk and 2 bystanders, while stealing 11,000 tablets of Hydrocodone.1 Pain is the most common reason for seeking care in the emergency department (ED).2 Over the past decade, the Joint Commission has placed increased focus on adequate analgesia through patient satisfaction surveys.3 Despite these implementations, emergency physicians (EPs) continue to be accused of oligoanalgesia.4 In 2012, the National Survey on Drug Use and Health estimated that 23.9 million Americans were current illicit drug users.5 Prescription opioids represent the fastest growing drug abuse problem in the United States. Deaths from prescription opioid analgesics are significantly greater than those from cocaine and heroin combined.6 The growing addiction fuels acts of aggression in order to obtain opioids. Legislation was recently signed to help New York State enforce stricter prescription drug abuse monitoring through the introduction of the Internet System for Tracking Over-Prescribing law (I-STOP).7This was devised to enhance the existing New York State Prescription Monitoring Program (PMP) with goals to provide better patient care and to deter prescription drug trafficking.8 In managing pain complaints, EPs must treat pain while minimizing prescribing habits that enable substance abuse by patients and in turn the general public.9 We compared the frequency of ED prescriptions written for controlled opioid substances in the three months prior to and the three months following the Medford pharmacy shooting. This allowed us to ascertain if EPs took measures to decrease the problem in their community prior to statewide planning and implementation of I-STOP. We hypothesized that in response to the tragedy there would be a decrease in the frequency of opioids prescribed.

3. METHODS This was a retrospective descriptive chart review. The study setting was a suburban academic ED that has annual census of 95,000 visits. All patients 21 years and older between the dates of March 1, 2011 –September 30, 2011 were included in this study. The data extracted included: account number, age, sex, race, and prescriptions. Each opioid prescription was tallied and characterized. The hospital’s institutional review board approved the study protocol.

4. RESULTS Between March 1, 2011 and September 30, 2011, 30,772 patients 21 years of age and older were seenin our ED. During this time period, a total of 16,942 prescriptions were written, of which 6,132 were for opioids (table 1). A mean of 19.7% (SD 0.854) of patients received an opioid prescription before the pharmacy shooting and 19.97% (SD 1.102) after the incident (figure 1). 95% CI = -2.502 to 1.962. The p-value was 0.75, showing there was no statistically significant difference in the frequency of opioid prescribed. Oxycodone was the most frequently prescribed opioid, accounting for 87% of opioid prescriptions (figure 2). Table 1. Demographics of patients receiving opioid prescriptions versus all patients with any prescription over the study period Figure 2. Comparison of type of opioids prescribed Figure 1.Percentage of ED visits discharged with an opioid prescription

5. DISCUSSION & LIMITATIONS At the onset of this study the authors hypothesized that after the Medford shootings, EPs in a near-by ED would write fewer opioid prescriptions than prior to the shootings. However we found there was no significant difference between the prescribing patterns before and after the shooting. Appropriate pain management remains a challenge to EPs. The authors speculate that generally EPs were prescribing based on the American College of Emergency Physicians (ACEP) clinical policy on opioids for acute pain management which recommends prescribing low dose narcotics for less than one week.2 While short-duration prescriptions are less likely to contribute significantly to substance abuse, prescribing any opioid analgesics could potentially exacerbate the epidemic. The implementation of programs such as I-STOP and PMP allows EPs to screen patients’ prescription records for recent narcotic prescription fills. This will make it easier to identify patients at risk for opioid addiction and offer earlier intervention. However, since EPs’ generally prescribe a limited amount of opioid analgesics for acute pain this legislation may not affect their practice. Further studies could help evaluate EPs’ current prescribing practice after the implementation of I-STOP. Several limitations of the study exist. The hospital is twenty miles from where the shooting took place. There are other hospitals in the surrounding area, thus limiting the generalization of our findings. Increasing the length of the study period might have revealed a change in prescribing habits. Lastly, this study does not evaluate the amount of pills per prescription written. This information would allow us to evaluate if (instead of writing fewer prescriptions) EPs decreased the amount of pills they prescribed. Finally, this is a retrospective chart review and inherently has all the associated limitations.

6. REFERENCES 1Stelloh, Tim. “Man Pleads Guilty in 4 Killings at Long Island Pharmacy.” The New York Times 8 Sept. 2011. Web. 30 Mar. 2014.. 2David Baehren MD, Catherine Marco MD, Danna DrozRPh, SameerSinha BS, Megan Callan BA, Peter Akpunonu BS. "A Statewide Prescription Monitoring Program Affects Emergency Department Prescribing Behaviors." Annals of Emergency Medicine (2010): 19-23. 3Stephen V. Cantrill MD, Michael D. Brown MD, Russell J. Carlisle MD, Kathleen A. Delaney MD, Daniel P. Hays PharmD, Lewis S. Nelson MD, Robert E. O'Connor MD, AnnMarie Papa RN, Karl A. Sporer MD, Knox H. Todd MD, Rhonda R. Whitson RHIA. "Clinical Policy: Critical Issues in the Prescribing of Opiods for Adult Patients in the Emergency Department." Annals of Emergency Medicine (2012): 499-525. 4Isabelle Decosterd MD, Olivier Hugli MD, Emmanuel Tamches MD, Catherine Blanc MD, ElyazidMouhsine MD, Jean-Claude Givel MD, Bertrand Yersin MD, Thierry Buclin MD. "Oligoanalgesia in the Emergency Department: Short-Term Beneficial Effects of an Education Program on Acute Pain." Annals of Emergency Medicine (2007): 462-471. 5Substance Abuse and Mental Health Administration. Results From the 2012 National Survey on Drug Use and Health. Rockville, MD: Office of Applied Studies, 2013. 6David Baehren MD, Catherine Marco MD, Danna DrozRPh, SameerSinha BS, Megan Callan BA, Peter Akpunonu BS. "A Statewide Prescription Monitoring Program Affects Emergency Department Prescribing Behaviors." Annals of Emergency Medicine (2010): 19-23. 7Prescription Monitoring Program. Part 80 (10 NYCRR). 2013. https://www.health.ny.gov/regulations/recently_adopted/docs/2013-08-27_prescription_monitoring_program.pdf 8Prescription Monitoring Program (PMP) Registry. https://commerce.health.state.ny.us/public/hcs_login.html 9Todd MD, Knox H. "Pain and Prescription Monitoring Program in the Emergency Department." Annals of Emergency Medicine (2010): 24-26. 10Genevieve McGerald DO, Ron Dvorkin MD, A. Sharma MD, S. Lovell-Rose MD. "A Prescription for Schedule II Opioids and Benzodiazepines increase after the introduction of computer-generated prescriptions." Academy of Emergency Medicine (2009): 508-12.