How Do Emergency Physicians Interpret Prescription Narcotic History When Assessing Patients Presenting to the Emergency Department with Pain?

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1 credits ville for this rticle see pge 80. How Do Emergency Physicins Interpret Prescription Nrcotic History When Assessing Ptients Presenting to the Emergency Deprtment with Pin? y A Grover, MD; Gus M Grmel, MD, FACEP, FAAEM Perm J 2012 Fll;16(4): Astrct Context: Nrcotics re frequently prescried in the Emergency Deprtment (ED) nd re incresingly used. Prescription monitoring progrms ffect prescriing y Emergency Physicins (EPs), yet little is known on how EPs interpret prescription records. Ojective: To ssess how EPs interpret prescription nrcotic history for ptients in the ED with pinful conditions. Design/Min Outcome Mesures: We creted n nonymous survey of EPs consisting of fictitious cses of ptients presenting to the ED with ck pin. For ech cse, we provided prescription history tht vried in the numer of nrcotic prescriptions, prescriing physicins, nd nrcotic potency. Respondents rted how likely they thought ech ptient ws drug seeking, nd how likely they thought tht the prescription history would chnge their prescriing ehvior. We clculted κ vlues to evlute interoserver reliility of physicin ssessment of drug-seeking ehvior. Results: We collected 59 responses (response rte = 70%). Respondents most suspected drug seeking in ptients with greter thn 6 prescriptions per month or greter thn 6 prescriing physicins in 2 months. Mediction potency did not ffect physicin interprettion of drug seeking. Respondents reported tht ccess to prescription history would chnge their prescriing prctice in ll cses. κ vlues for ssessment of drug seeking demonstrted moderte greement. Conclusion: A greter numer of prescriptions nd greter numer of prescriing physicins in the prescription record incresed suspicion for drug seeking. EPs elieved tht ccess to prescription history would chnge their prescriing ehvior, yet interoserver reliility in the ssessment of drug seeking ws moderte. Introduction Pin is common prolem for which ptients seek cre in the Emergency Deprtment (ED), ccounting for up to 42% of ll visits. 1,2 As pin control in the ED is often indequte, incresing emphsis hs een plced on pin relief. 2,3 Nrcotic prescriing hs incresed to the point tht the US, constituting 4.6% of the world popultion, uses 80% of the world s opite supply, including 99% of the world s hydrocodone supply. 4 In ddition, the use of prescription medictions for nonmedicl resons hs incresed. Approximtely 7 million Americns over the ge of 12 yers use prescription medictions for nontherpeutic resons ech yer, with nerly 50 million Americns hving used prescription drugs recretionlly during their lifetime. 4,5 Prescription drug use hs ecome n epidemic in the US, nd not without mjor consequences. Adverse events from the nonmedicl use of prescription mediction ccount for more thn 700,000 ED visits nnully, nd deths due to nrcotic overdose hve tripled since 1996, with nerly 14,000 opite-relted deths in Deths resulting from prescription opite mediction ccount for three-fourths of deths due to ll prescription medictions. 8 Ptients who present to the ED to otin mediction for nontherpeutic resons re common, estimted to e s high s 20% of ll ED ptients. 9 Most of the literture on drug-seeking ptients in the ED consists of necdotl dt or smll studies, giving Emergency Physicins (EPs) little informtion on how to identify these individuls The incresing prevlence of prescription mediction use, prticulrly nrcotic use, mkes it importnt for EPs to e le to identify ptients presenting to the ED seeking mediction for nontherpeutic purposes. Numerous scoring systems hve een developed to identify ptients with nrcotic ddiction, ut they were developed outside the ED nd often involve long, complex surveys tht re too cumersome to use in the ED Prescription monitoring progrms hve emerged s mens of identifying ptients trying to otin mediction for nontherpeutic resons The use of prescription monitoring progrms in the ED hs een shown to ffect prescriing ehvior, 25,27 nd in one study such progrm chnged EP prescriing prctice in more thn 60% of cses. 25 Although most sttes in the US hve prescription monitoring progrms, little is known out how to cliniclly interpret the informtion otined in prescription records in the ED. The gols of this investigtion were to ssess, using survey instrument, how EPs interpret prescription nrcotic history when ssessing ptients presenting to the ED with pin. We imed to understnd how vritions in the numer of nrcotic prescriptions, numer of prescriing physicins, nd potency of the nrcotic in the prescription history ffected how likely EPs perceived ptient s demonstrting drug-seeking ehvior. We lso sought to ssess how useful EPs elieved tht ccess to prescription history ws in ssessing ptients in the ED with pin, nd how well EPs greed on whether ptient ws drug seeking. y A Grover, MD, is Chief Resident in the Stnford/Kiser Emergency Medicine Residency Progrm in CA. E-mil: cgrover@stnford. edu. Gus M Grmel, MD, FACEP, FAAEM, is Senior Emergency Physicin t the Kiser Snt Clr Medicl Center, Co-Progrm Director of the Stnford/Kiser Emergency Medicine Residency Progrm, nd Clinicl Professor (Affilite) of Surgery (Emergency Medicine) t Stnford University. He is lso Senior Editor for The Permnente Journl. E-mil: gus.grmel@kp.org. 32 The Permnente Journl/ Fll 2012/ Volume 16 No. 4

2 Methods Study Design nd Setting This study consisted of n nonymous voluntry online survey t one cdemic medicl center in Cliforni. The ED in this suurn re sees pproximtely 51,000 ptients per yer. Demogrphiclly, 54% of ptients re etween the ges of 18 nd 65 yers, nd 27% of ptients re ge 17 yers or younger; 48% of ptients re white, nd 29% of ptients re Ltino. The survey consisted of 6 fictitious cse vignettes, ech presenting the sme cse of 35-yer-old mn in the ED with chief complint of low ck pin. This ptient reported tht he hd history of slipped disk nd routinely took nrcotic pin mediction ut hd run out of mediction nd could not see his regulr physicin for few dys. For ech of the six cses, prescription history for the prior two months ws provided. Ech prescription history contined the following informtion for ech cse: dte tht ech prescription ws filled, nme of the mediction, dose of the mediction, numer of pills prescried, nd the nme of the prescriing physicin. This is comprle with dt provided y the Cliforni Prescription Drug Monitoring Progrm, except tht the Cliforni progrm lso provides the ptient s dte of irth nd ddress, the nme of the phrmcy t which the ptient filled the prescription, nd the prescriing physicin s license nd Drug Enforcement Administrtion numers. As we elieved tht most of the ssessment of whether ptient exhiits drug-seeking ehvior lies in the numer of prescriptions, the potency of mediction, nd the numer of prescriing physicins, we did not include this dditionl informtion in the dt provided in our survey. Ech cse vried in the numer of prescriptions per month, the numer of prescriing physicins, nd the potency of the nrcotic. A summry of the prescription histories from ech of the 6 cses ppers in Tle 1. The low-potency nrcotic in our survey ws hydrocodone-cetminophen t dose of 5 mg nd 500 mg, respectively, nd the high-potency nrcotic ws oxycodone, 5 mg. The order of the 6 cses ws the sme for ech respondent, nd the survey softwre llowed respondents to review questions in ny order nd to modify previously sumitted nswers efore sumission. To the est of our knowledge, there hs een no erlier study of how the vilility of prescription history ffects ssessment y n EP of whether ptient is exhiiting drug-seeking ehvior. We creted six clinicl vignettes on the sis of wht Tle 1. Prescription histories for ech cse in the survey No. of prescriptions per month No. of prescriing physicins Nrcotic potency Low Low Low Low Low High we considered were likely scenrios tht might e encountered in the ED. We lso tried to vry the numer of prescriing physicins prescriptions nd mediction potency in n ttempt to find threshold t which EP suspicion for drug-seeking ehvior would chnge. These vignettes were not vlidted, lthough they were reviewed extensively nd pilot-tested with our reserch dvisers. Respondents were sked to red ech cse, including the prescription history. After reviewing ech cse, respondents were sked 2 questions: How likely do you think this ptient is drug seeking? nd How much would hving the informtion in the prescription record chnge your prescriing prctice? For ech question for ech cse, respondents were sked to rte their nswers on scle from 1 to 4, with 1 eing very unlikely, 2 eing unlikely, 3 eing likely, nd 4 eing very likely. Although it is controversil nd lcking stndrd definition, we chose to use the term drug seeking ecuse it is used frequently in clinicl prctice nd in the medicl literture. Every physicin hs different understnding of wht constitutes drug-seeking ehvior. Becuse our reserch ojective ws to lern how EPs ssess prescription history in ptients presenting with pinful condition, we elieved tht using this term ccurtely reflects wht occurs in clinicl prctice. Additionlly, our reserch im ws to determine whether EPs consider prescription history useful rther thn to identify how this informtion ffects prescriing prctice. As such, we did not sk our respondents wht mediction they would prescrie in ech cse, or if the prescription history would mke them more or less likely to prescrie opite medictions. We creted the survey using online survey softwre (SurveyMonkey, Plo Alto, CA; 2011). It ws ville for responses for onemonth period. We intended for the survey to tke less thn five minutes, nd respondents were given this informtion. There ws no finncil incentive for prticipting, nd no penlty for not prticipting. We sent out link to the online survey vi recruitment e-mil to ll resident physicins in the Emergency Medicine (EM) residency ffilited with n cdemic West Cost Medicl Center. We sent the sme recruitment e-mil to ll ttending EPs working more thn two shifts per month t this sme Medicl Center. One reminder e-mil with link to the online survey ws sent two weeks fter the initil recruitment e-mil. Dt Collection nd Anlysis We collected dt using SurveyMonkey online survey softwre nd imported the rw dt from the online softwre to computer spredsheet (Excel 2007, Microsoft, Redmond, WA) for review nd nlysis. For dt nlysis, we chose 1 s the index cse, ecuse it represented wht we perceived to e prescription history for ptient receiving regulr cre from primry cre physicin or pin mngement physicin. We then mde individul comprisons etween the physicin responses for ech of the remining cses nd 1, to isolte the effect of chnges in ech of the 3 vriles (numer of prescriptions per month, numer of prescriing physicins in the record, nd strength of the nrcotic). For exmple, 1 nd 2 differ in tht we chose to use the term drug seeking ecuse it is used frequently in clinicl prctice nd in the medicl literture. Every physicin hs different understnding of wht constitutes drug-seeking ehvior. The Permnente Journl/ Fll 2012/ Volume 16 No. 4 33

3 1 involved 3 prescriptions per month, wheres 2 involved only 1.5 prescriptions per month. Compring s 1 nd 2 llowed us to nlyze how chnge in the numer of prescriptions per month ffected physicin ssessment. Ech comprison consisted of compring the verge response vlue for 1 to the verge response vlue for ech of the remining cses. For reference, summry of the prescription history in ech cse is provided in Tle 1. Becuse ctegoricl dt were collected, p vlues for ech comprison were clculted using the Wilcoxon rnk sum test. To ssess the interoserver reliility within our responses, we clculted the Fleiss κ vlues. For ech scenrio, we clculted the κ vlues to ssess the likelihood of drug seeking. Sttisticl nlysis ws performed using Microsoft Excel 2007 nd open-source online sttisticl softwre (Sttcto ). Results We received responses from 30 ttending EPs out of 48 ttending EPs who worked t this Medicl Center, nd from 29 EM residents of 36 EM residents in the progrm, giving us totl response rte of 70%. The response rte for residents ws 81%, nd tht for ttendings ws 63%. Of the resident respondents, 28% were Postgrdute Yer (PGY) 3, 38% were PGY 2, nd 34% were PGY 1. Tle 2. Physicin ssessment of likelihood tht the ptient ws drug seeking Averge response score Percentge of chnge vs index cse p vlue Index cse 3.1 NA NA 2 (1.5 prescriptions per month) < c 3 (6 prescriptions per month) c 4 (3 prescriing physicins) (6 prescriing physicins) < c 6 (high-potency nrcotic) On scle from 1 to 4, with 1 eing very unlikely, 2 eing unlikely, 3 eing likely, nd 4 eing very likely. Index cse hd 3 prescriptions/month, 1 prescriing physicin, nd low-potency nrcotic. c Sttisticlly significnt. NA = not pplicle. Tle 3. Physicin ssessment of likelihood tht ccess to prescription history would chnge prescriing ehvior Averge response score Percentge of chnge vs index cse p vlue Index cse 3.4 NA NA 2 (1.5 prescriptions per month) < c 3 (6 prescriptions per month) (3 prescriing physicins) (6 prescriing physicins) (high-potency nrcotic) On scle from 1 to 4, with 1 eing very unlikely, 2 eing unlikely, 3 eing likely, nd 4 eing very likely. Index cse hd 3 prescriptions/month, 1 prescriing physicin, nd low-potency nrcotic. c Sttisticlly significnt. NA = not pplicle. The first question for ech cse sked, How likely do you think this ptient is drug seeking? The verge response score for the presenttion in the index cse (3 prescriptions per month, 1 prescriing physicin, nd low-potency nrcotic) ws 3.1 of 4. A decrese in the numer of prescriptions per month to 1.5 in 2 decresed the verge response to 2.4 of 4 (p < 0.001), wheres n increse in the numer of prescriptions per month to 6 in 3 incresed the verge response to 3.5 of 4 (p = 0.02). Incresing the numer of prescriing physicins per month to 6 in 5 incresed the verge response to 3.7 of 4 (p < 0.001). A summry of the verge response scores nd p vlues for ll cses is in Tle 2. The second question for ech cse sked, How much would hving the informtion in the prescription record chnge your prescriing prctice? The verge response score for the presenttion in the index cse ws 3.4 of 4. Decresing the numer of prescriptions per month to 1.5 in 2 decresed the verge response to 3.0 of 4 (p < 0.001). A summry of the verge response scores nd p vlues for ll cses is in Tle 3. All κ vlues of the ssessment y our respondents s to whether ptient ws drug seeking were etween 0.40 nd Our respondents demonstrted only fir to moderte greement in their ssessments of these cses. A complete list of the κ vlues for the ssessment of drug seeking for ech cse, s well s reference vlues for the interprettion of κ vlues, 28 re in Tle 4. To ssess if difference existed in the ssessment of drug seeking etween resident nd ttending physicins, we clculted the verge suspicion for drug seeking for ll cses for oth resident nd ttending physicins. For the 6 cses, the verge suspicion for drug seeking y resident physicins ws 3.16 of 4.0, wheres the verge suspicion for drug seeking y ttending physicins ws 3.12 of 4.0 (p = 0.86). Discussion In our nonymous online survey of resident nd ttending EPs t single cdemic Medicl Center, we found tht greter numer of prescriptions per month nd greter numer of prescriing physicins per month incresed physicin suspicion for drug-seeking ehvior. On the sis of the dt in Tle 2, the scenrios in which our respondents most suspected drugseeking ehvior were s 3 (6 prescriptions per month) nd 5 (6 prescriing physicins in 2-month period). In oth cses, our respondents predicted the likelihood of drug seeking greter thn or equl to 3.5 of 4. This finding suggests tht our respondents elieved tht the ptient in these cses ws very likely to e drug seeking. A greter numer of prescriing physicins in the prescription history incresed suspicion for drug-seeking ehvior slightly more thn did greter numer of prescriptions per month. Despite our study s limittions, these dt suggest tht 6 or more prescriptions per month nd 6 or more prescriing physicins on prescription history should rise concern tht ptient presenting to the ED is trying to otin prescription mediction for nontherpeutic resons. We decided priori not to ssess in wht fshion the informtion in prescription history ffects prescriing ehvior. Rther, our survey determined tht EPs elieved tht ccess 34 The Permnente Journl/ Fll 2012/ Volume 16 No. 4

4 to prescription records ws helpful nd would chnge their prescriing prctice when ssessing ptients presenting to the ED with pin in ll of our fictitious cses. Therefore, whether EPs should ccess ptient s prescription history ech time ptient presents to the ED with n cute pinful episode is worth considering. Although it my tke few extr moments on usy shift, routinely ccessing such informtion (if ville) my e powerful tool to screen for ptients with concerning nrcotic use. Pseudoddiction hs een defined s n itrogenic condition resulting from indequte pin mngement, in which ptients exhiit drug-seeking ehviors to otin mediction to relieve their pin. 8 When ptients receive dequte nlgesi, these ehviors typiclly cese. The ehviors exhiited y ptients ttempting to otin prescription mediction who suffer from pseudoddiction re nerly identicl to those suffering from ddiction, mking it extremely difficult to differentite etween the two conditions. These conditions re even more difficult to differentite in the cute cre setting. 9 Our survey did not ttempt to differentite etween ddiction nd pseudoddiction. Insted, we focused our study on drug-seeking ehvior regrdless of the cuse, ecuse we felt tht this more likely reflects wht is encountered in the ED. The ssessment of whether ptient is drug seeking hs een completely sujective efore the development of prescription monitoring progrms. It would seem tht the provision of n ojective prescription history would llow physicins to etter determine whether ptient is drug seeking. However, our survey demonstrted tht our respondents hd only moderte greement in this ssessment. It is uncler exctly why the interoserver reliility of this ssessment ws so poor. Although this my e the result of vrition in how EPs choose to ssess pin in their clinicl prctice or vrile clinicl experience with drug-seeking ptients, it is possile tht some of our respondents did not hve enough experience using prescription history. However, our comprison of the ssessment of drug-seeking ehvior etween ttending nd resident physicins did not show significnt difference. This lck of experience ppered more likely to e relted to overll inexperience with prescription monitoring progrms rther thn inexperience relted to level of trining. Further experience with prescription monitoring progrms nd reserch on drugseeking ehvior my improve EP use nd interprettion of such progrms in the future. Limittions Our study hd severl limittions. First, our survey hd limited numer of respondents nd ws confined to one cdemic Medicl Center, which limits the generlizility of these dt. Our survey consisted of physicins of vrying experience levels. Nerly 50% of our respondents were EM residents, which my limit the ility of our dt to e generlized to the generl EP popultion s well. Another limittion is tht our cses were simulted cses only. Although we found sttisticlly significnt differences in EP concern for drug seeking sed on differences in ptient s prescription history, these differences my not e cliniclly significnt, ecuse seeing ptient in person is Tle 4. Interoserver reliility of physicin ssessment of scenrios Likelihood of drug-seeking ehvior (κ) very different from reding cse presenttion on computer. Additionlly, the use of nonvlidted clinicl vignettes my e source of potentil is. Furthermore, the initil cse presenttion of young mn with chronic ck pin presenting to the ED requesting nrcotic pin mediction my e source of is, s it is y itself concerning for drug-seeking ehvior. We lso looked t physicin suspicion of whether ptient is drug seeking nd whether physicins thought the informtion in the prescription record would e helpful; we did not survey our respondents to see wht they would ctully prescrie to the ptient in ech cse. Furthermore, sking our respondents whether they thought ptient ws drug seeking might hve incresed their suspicion in ll cses for drug-seeking ehvior. Along this sme line, oth uthors hve een involved with reserch on drug-seeking ehvior in the pst, nd perhps knowing tht the reserch study ws eing performed y our reserch group incresed suspicion for drug-seeking ehvior in ll cses. None of our survey cses included ptient who hd zero previous nrcotic prescriptions, which might hve provided dditionl informtion on how prescription histories re interpreted. Finlly, the term drug seeking lcks uniform definition, which might led to inconsistencies relted to physicin s response to n online, nonymous survey. Conclusion In our nonymous survey of 6 fictitious cses of 35-yer-old mn presenting to the ED requesting nrcotics for low ck pin, greter numer of prescriptions per month nd greter numer of prescriing physicins listed on the prescription record incresed EP suspicion for drug-seeking ehvior. In ddition, our survey demonstrted EPs elieved tht ccess to nrcotic prescription history ws likely to chnge their prescriing ehvior. However, there ws only moderte interoserver reliility in the EP ssessment of whether ptients were demonstrting drug-seeking ehvior. v Disclosure Sttement The uthor(s) hve no conflicts of interest to disclose. Interoserver greement Index cse 0.45 Moderte 2 (1.5 prescriptions/month) 0.35 Fir 3 (6 prescriptions/month) 0.45 Moderte 4 (3 prescriing physicins) 0.42 Moderte 5 (6 prescriing physicins) 0.57 Moderte 6 (high-potency nrcotic) 0.40 Fir Interprettion of κ vlues 28 : 0 = poor greement, = slight greement, = fir greement, = moderte greement, = sustntil greement, = lmost perfect greement. Index cse hd 3 prescriptions/month, 1 prescriing physicin, nd low-potency nrcotic. The Permnente Journl/ Fll 2012/ Volume 16 No. 4 35

5 Acknowledgment Kthleen Louden, ELS, of Louden Helth Communictions provided editoril ssistnce. References 1. Pletcher MJ, Kertesz SG, Kohn MA, Gonzles R. Trends in opioid prescriing y rce/ethnicity for ptients seeking cre in US emergency deprtments. JAMA 2008 Jn 2;299(1):70-8. DOI: jm O Connor AB, Zwemer FL, Hys DP, Feng C. Outcomes fter intrvenous opioids in emergency ptients: prospective cohort nlysis. Acd Emerg Med 2009 Jun;16(6): DOI: 3. Rupp T, Delney KA. Indequte nlgesi in emergency medicine. Ann Emerg Med 2004 Apr;43(4): DOI: nnemergmed Mnchiknti L, Singh A. Therpeutic opioids: ten-yer perspective on the complexities nd complictions of the esclting use, use, nd nonmedicl use of opioids. Pin Physicin 2008 Mr;11(2 Suppl):S Results from the 2009 ntionl survey on drug use nd helth: Volume I. Summry of ntionl findings. HHS Puliction No. SMA Findings. Rockville, MD: Sustnce Ause nd Mentl Helth Services Administrtion; 2010 Sep. 6. Drug Ause Wrning Network, 2006: Ntionl estimtes of drug-relted emergency deprtment visits. DHHS Puliction No. SMA Rockville, MD: Sustnce Ause nd Mentl Helth Services Administrtion; 2008 Aug. 7. Wester LR, Cochell S, Dsgupt N, et l. An nlysis of the root cuses for opioid-relted overdose deths in the United Sttes. Pin Med 2011 Jun;12 Suppl 2:S DOI: 8. Centers for Disese Control nd Prevention (CDC). Vitl signs: overdoses of prescription opioid pin relievers United Sttes, MMWR Mor Mortl Wkly Rep 2011 Nov 4;60(43): Hnsen GR. The drug-seeking ptient in the emergency room. Emerg Med Clin North Am 2005 My;23(2): DOI: emc Hwkins SC, Smeeks F, Hmel J. Emergency mngement of chronic pin nd drug-seeking ehvior: n lterntive perspective. J Emerg Med 2008 Fe;34(2): DOI: McN C, Foot C, Ting J, Breeze K, Stickley M. Dignosing drugseeking ehviour in n dult emergency deprtment. Emerg Med Austrls 2006 Apr;18(2): DOI: Zechnich AD, Hedges JR. Community-wide emergency deprtment visits y ptients suspected of drug-seeking ehvior. Acd Emerg Med 1996 Apr;3(4): DOI: t03443.x 13. Crlson MJ, Bker LH. Difficult, dngerous, nd drug seeking: the 3D wy to etter ptient cre. Am J Pulic Helth 1998 Aug; 88(8): McN C, Foot C, Ting J, Breeze K, Stickley M. Profiling ptients suspected of drug seeking in n dult emergency deprtment. Emerg Med Austrls 2006 Apr;18(2): DOI: Chn L, Winegrd B. Attriutes nd ehviors ssocited with opioid seeking in the emergency deprtment. J Opioid Mng 2007 Sep- Oct;3(5): Ginutsos LP, Sfrnek S, Huer T. Clinicl inquiries: is there well-tested tool to detect drug-seeking ehviors in chronic pin ptients? J Fm Prct 2008 Sep;57(9): Chou R, Fnciullo GJ, Fine PG, Miskowski C, Pssik SD, Portenoy RK. Opioids for chronic noncncer pin: prediction nd identifiction of errnt drug-relted ehviors: review of the evidence for n Americn Pin Society nd Americn Acdemy of Pin Medicine clinicl prctice guideline. J Pin 2009 Fe;10(2): DOI: jpin Moore TM, Jones T, Browder JH, Dffron S, Pssik SD. A comprison of common screening methods for predicting errnt drug-relted ehvior mong ptients receiving opioids for chronic pin mngement. Pin Med 2009 Nov;10(8): DOI: Wu SM, Compton P, Bolus R, et l. The ddiction ehviors checklist: vlidtion of new clinicin-sed mesure of inpproprite opioid use in chronic pin. J Pin Symptom Mnge 2006 Oct;32(4): DOI: org/ /j.jpinsymmn Butler SF, Budmn SH, Fernndez KC, et l. Development nd vlidtion of the Current Opioid Misuse Mesure. Pin 2007 Jul;130(1-2): DOI: Butler SF, Fernndez K, Benoit C, Budmn SH, Jmison RN. Vlidtion of the revised Screener nd Opioid Assessment for Ptients with Pin (SOAPP-R). J Pin 2008 Apr;9(4): DOI: jpin Belgrde MJ, Schmer CS, Lindgren BR. The DIRE score: predicting outcomes of opioid prescriing for chronic pin. J Pin 2006 Sep;7(9): DOI: Gilson AM, Kreis PG. The urden of the nonmedicl use of prescription opioid nlgesics. Pin Med 2009 Jul;10 Suppl 2:S DOI: org/ /j x 24. Brrett K, Wtson A. Physicin perspectives on pilot prescription monitoring progrm. J Pin Pllit Cre Phrmcother 2005;19(3):5-13. DOI: dx.doi.org/ /j354v19n03_ Behren DF, Mrco CA, Droz DE, Sinh S, Clln EM, Akpunonu P. A sttewide prescription monitoring progrm ffects emergency deprtment prescriing ehviors. Ann Emerg Med 2010 Jul;56(1):19-23.e1-3. DOI: Yokell MA, Green TC, Rich JD. Prescription drug monitoring progrms. JAMA 2012 Mr 7;307(9):912. DOI: jm Grover CA, Grmel GM. How do emergency physicins interpret prescription nrcotic history when ssessing ptients presenting to the emergency deprtment with pin? [strct]. Ann Emerg Med 2011 Oct;58(4 Suppl):S DOI: Sim J, Wright CC. The kpp sttistic in reliility studies: use, interprettion, nd smple size requirements. Phys Ther 2005 Mr;85(3): Door Opite, n. An unlocked door in the prison of Identity. It leds into the jil yrd. The Devil s Dictionry, Amrose Bierce, , Americn editorilist, journlist, stirist, nd uthor 36 The Permnente Journl/ Fll 2012/ Volume 16 No. 4

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