After reading the commentary by Jessica Dare Evans [“Narcotic abuse in the emergency department,” October, p. 138], I feel I need to contact you. I am a PA with more than 20 years’ experience in emergency medicine and am currently involved in the treatment of mostly substance abuse and hepatitis C. I am in complete agreement with Ms. Evans that prescription drug abuse is a monumental problem and will almost certainly get worse before it gets better. I find that she has made some assertions in her column that are not supported by the literature and has made some statements that are not correct regarding the Drug Abuse Warning Network (DAWN).

I agree that emergency providers need to be responsible prescribers and must play a role in containing prescription drug diversion, but data from the CDC show that emergency rooms are actually one of the lesser sources of diverted medications. A large majority of diverted medications are acquired by recurring prescriptions written by a single ongoing prescriber. Most often this is a primary care provider or pain clinic.

DAWN, unfortunately, does not provide a searchable database of patient prescription histories. DAWN is a database maintained by the Substance Abuse and Mental Health Services Administration ( that compiles information on emergency room visits that can be attributed to some form of substance abuse. It is used by public health entities, hospital systems, and law enforcement to track trends and look for increasing or changing abuse patterns. No mechanism exists for looking at individual encounters or prescriptions.

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Currently, there is no national database or network that will perform this function. Forty-nine states, the District of Columbia, and the territory of Guam have prescription drug monitoring programs that allow searches of prescriptons for controlled substances that are either written or filled by providers in those jurisdictions. Only a few states, such as Tennessee, allow searches of more than one state, and many states allow access only to providers licensed in that state. In addition, the requirements and mechanism for reporting to the database varies from state to state, and profiles can sometimes be several weeks out of date or missing data entirely.

I wholeheartedly agree with Ms. Evans’ closing sentence. If we are to proceed successfully, we need to set targets based on accurate, complete information. The CDC (, the National Association of State Controlled Substance Authorities (, and the Prescription Drug Monitoring Program Training and Technical Assistance Program ( all have extensive information on their websites, and I highly recommend that anyone practicing medicine, and particularly anyone who prescribes controlled substances, look at these websites.—WILLIAM KELLEY, PA-C, Cherokee, N.C. (205-1)

These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a clinical pearl, submit it here.