ER doctors operate on the front line of the opioid epidemic gripping Erie County and the rest of the country. They deal with people in pain, as well as those addicted to opioids. They see the overdoses and the deaths.
Now, they face an additional challenge.
After Dr. Eugene Gosy’s practice was shut down two weeks ago following his indictment on federal charges of unlawfully distributing narcotics, some of his patients are showing up at area emergency rooms looking for relief from pain, which is his specialty. Gosy & Associates in Amherst was one of the busiest pain-management practices in New York State, treating thousands of patients.
Not long after Gosy’s office closed, emergency departments rolled out new guidelines for prescribing opioids. The hospitals want clear protocols for staff and a united front as Gosy’s patients on narcotic painkillers, needing refills or unsure about the future of their care, seek continued treatment elsewhere.
Patients hoping for the continued treatment of chronic pain or refills of narcotic painkillers probably will be disappointed.
The new guidelines state that a primary care physician outside the emergency department who can follow a patient’s treatment should provide all opioids, such as Oxycontin and hydrocodone, for chronic pain.
The guidelines allow for treating acute pain but state that prescriptions should be for the shortest duration appropriate.
“Everyone expedited this. We needed a health system answer, and we needed it now,” said Dr. Robert F. McCormack, chief of service for emergency medicine at Kaleida Health.
Hospitals report that patients from Gosy’s practice, who were given no advance notice, already have begun to visit emergency departments looking for help.
“Dr. Gosy’s patients are a major concern for us,” McCormack said. “There are a large number of patients who are not able to obtain their medications, and that puts many of them in a precarious position and likely means they’ll seek relief in emergency rooms.”
Opioids have their place, such as for acute pain from severe injuries such as broken bones and bad burns, McCormack said, but doctors must swing the medical pendulum significantly toward the use of non-narcotic alternatives for chronic pain.
“We have all come to realize the significant risk of these drugs. The potential for abuse is high,” he said.
The guidelines
The guidelines codify what emergency room personnel – including doctors, nurse practitioners and physician assistants – generally already do, McCormack said. But he and others see it as an important step in establishing clear, common protocols with limits that can assist the medical providers, inform patients about what to expect and prevent drug-seeking individuals from emergency room shopping.
“This is not a major change, but it sends the message to not have unrealistic expectations,” McCormack said.
UBMD physicians had been working on the guidelines in recent months but accelerated their release in the wake of the federal case against Gosy that alleges he provided opioid painkillers without a proper medical reason. Gosy pleaded not guilty but surrendered his license to prescribe controlled substances.
UBMD is the group that represents University at Buffalo-affiliated doctors at Kaleida Health hospitals, including Buffalo General Medical Center and Millard Fillmore Suburban in Amherst, as well as Erie County Medical Center, the Buffalo VA Medical Center and Roswell Park Cancer Institute.
The guidelines also received the blessing of the Erie County Health Department and Catholic Health hospital system, McCormack said.
Who shut Gosy’s office?
The exact circumstances of why Gosy’s practice closed remain unclear.
Defense attorney Joel L. Daniels said it is unfair for patients to blame his client for the sudden shutdown.
“They’re pointing the finger at the wrong person. Dr. Gosy wanted to keep the office open, but he didn’t have a chance,” he said.
Daniels said the government should have anticipated the potential for a crisis from the closing of the practice.
“They let these people twist in the wind,” Daniels said of federal prosecutors. “The government was well aware he had thousands of patients and that, if his practice had to close, there would be problems around the corner.”
He also said Gosy, who was charged with conspiracy to distribute controlled substances and unlawful distribution of narcotics, eventually will prove that he issued prescriptions for legitimate medical purposes.
Gosy, a neurologist, cared for 8,000 to 10,000 active patients, according Daniels. Many were prescribed narcotic painkillers, but others were being treated for such neurologic conditions as epilepsy.
Agents of the U.S. Drug Enforcement Administration were concerned about what would happen, said John Flickinger, resident agent in charge of the Buffalo DEA office.
“This is something we took into consideration during the course of our investigation. We know that there are probably a lot of patients of his practice who have legitimate needs for pain medication,” Flickinger said. “That is one reason why he is the only person charged in this case. “
Another full-time doctor and eight other people, physician assistants and nurse practitioners, still work at Gosy’s clinic and are available to assist patients and prescribe drugs, he said.
But with the practice shut down, his patients are looking elsewhere for painkillers, and many are showing up in emergency rooms.
“We feel bad,” McCormack of Kaleida said, referring to the predicament Gosy’s patients confront. “But we are dealing with a true epidemic. There is a major effort now to move away from managing pain with narcotics and for leaving the prescribing of opioids to the physicians with the most knowledge of the patient.”
Catholic Health system hospitals – including Mercy, Sisters and Kenmore Mercy – also have noticed an increase in patients coming from Gosy’s practice and will treat them like any other patient while applying protocols, Dr. Brian D’Arcy said.
“People are running out of medication. Many of them have legitimate pain and addiction issues,” said the senior vice president of medical affairs. “It’s a very big problem superimposed on an even larger drug problem.”
Patient advice
The website of Gosy & Associates states that the office will reopen May 16. In the meantime, public health officials have advised patients to seek care from their primary care physicians, a pain-management specialist or one of the area’s federal qualified health centers.
While that is sound advice, many primary care physicians are reluctant to prescribe narcotic painkillers.
Doctors shy away because of the increased government scrutiny. It’s also difficult to distinguish between patients with legitimate pain and those seeking drugs to feed an addiction.
To make matters worse, there is a limited number of pain-management specialists in the area, and many of those practices are full.
“I have a few more days before I run out of pills, and then I’m going to be in an ER in a fetal position from withdrawal symptoms,” said Patrick Mann, a former newspaper pressman who injured his back in 1998 when a forklift struck him.
His situation exemplifies the experiences of others. Over the years, Mann said he tried many non-narcotic medications and procedures to relieve his intense and chronic pain before being prescribed the brand name opioids Opana and Oxycontin in 2013.
“When I’m told off-handedly to just find another doctor, I want to scream. It’s not that easy. And when people suggest that this may be a good time to get off these drugs, it’s so callous. Withdrawal is horrible. You get so sick. It’s literally hell. And the pain that returns is all-consuming,” Mann said.
Mann said he has called seven pain-management physicians in the Buffalo area, and was told they were not taking new patients.
“I tried everything I could before going the opioid route. I take these drugs as prescribed. I play by all the rules about pill counts and urine tests. And now I’m being left to my own devices,” he said.
ER pain management
Management of pain in the emergency department is a challenge, particularly without an objective measure of pain amid a drug crisis revolving around painkillers.
Research shows that opioid prescribing began to decline in emergency rooms after 2010, following a decadelong large increase that didn’t match the growth in visits for painful conditions.
Emergency medicine doctors prescribe a small share of all opioids prescribed in the United States, just 5 percent in 2012, according to a 2015 study in the American Journal of Preventive Medicine.
But ER doctors have been among the high-frequency prescribers of opioids.
Of all the prescriptions they wrote in 2012, nearly 21 percent were for opioids, although most were low pill counts and immediate-release formulations.
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