Prescription Opioid Deaths: A Preventable Epidemic

Abstract

British author Roald Dahl's children's classic Charlie and the Great Glass Elevator,1Dahl R Charlie and the Great Glass Elevator. Alfred A Knopf, New York1972Google Scholar published in 1972, contains a prescient tale of the unintended consequences of medicine misuse. In a 134-line rollicking poem, Dahl describes the unfortunate but predictable fate of 7-year-old Goldie Pinklesweet, who gobbled up all of her grandmother's chocolate-covered laxatives when left unattended. Dahl's cautionary tale concludes with advice to refrain from availing oneself of items found on the medicine shelf.While Dahl's account is amusing, the current reality of rampant and often fatal misuse of prescription medication is sobering. The Centers for Disease Control and Prevention has published several reports over the past few years drawing attention to this public health crisis and detailing the scope of the epidemic of prescription opioid deaths—14,800 deaths attributed to opioid pain relievers in 2008.2Centers for Disease Control and Prevention Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008.Morb Mortal Wkly Rep. 2011; 60: 1487-1492PubMed Google Scholar The death rate is increasing alongside the rise in opioid prescribing, and there are now more overdose fatalities from prescription opioids than heroin and cocaine combined. Clinicians in most settings—urgent and primary care clinics, schools, homes—including all who care for adults, families and adolescents need to be aware of the problem of nonmedical use of opioid medication.Detailed accounts of unintentional prescription medication overdoses3Hall AJ Logan JE Toblin RL et al.Patterns of abuse among unintentional pharmaceutical overdose fatalities.JAMA. 2008; 300: 2613-2620Crossref PubMed Scopus (668) Google Scholar and reports of high abuse rates of Vicodin and other opioids by teenagers4Wu L Pilowsky DJ Patkar AA Non-prescribed use of pain relievers among adolescents in the United States.Drug Alcohol Depend. 2008; 94: 1-11Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar are a call to action because these deaths are largely preventable. A stark view of this situation is to consider that every diverted opioid pill represents a failure to prescribe the right amount of pain medication to the right patient or without appropriate counseling regarding the potential risks. Recommendations to prescribers aimed at increasing the safety of chronic opioid therapy5McLellan AT Turner B Prescription opioids, overdose deaths, and physician responsibility.JAMA. 2008; 300: 2672-2673Crossref PubMed Scopus (83) Google Scholar and clinical guidelines6Chou R Fanciullo GF et al.American Pain Society/American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.J Pain. 2009; 10: 113-130Abstract Full Text Full Text PDF PubMed Scopus (1701) Google Scholar can be a resource in deciding whether and how best to treat a given patient with chronic opioids. These recommendations include screening patients carefully to identify those with a history of drug addiction or alcoholism, requiring an opioid agreement, and screening urine samples for the medication prescribed and illicit or nonprescribed drugs. The absence of the prescribed medication in urine is concerning because this suggests either diversion or overuse. Attention should be paid to clues that a patient is misusing medication, by reviewing therapeutic monitoring reports from insurers and accessing state-run prescription monitoring programs when available, which can identify doctor-shopping or early refills.An opioid agreement that details the risks of opioids and the terms under which they might be prescribed can be considered a starting point in educating patients about their responsibilities and medication risks. We must make an effort to ensure our patients understand the danger of combining opioids with alcohol and other drugs or tampering with the extended-release property of certain formulations. They also must know the implications of methadone's variable and long half-life and the maximum safe upper limit of combination opioid-acetaminophen preparations. While it might seem unnecessary to reinforce these seemingly obvious cautions at each visit, clearly the lethality of opioids when taken inappropriately is underappreciated by some patients, as evidenced by their willingness to share medication with others. This is, in part, why caring for chronic pain patients is time-consuming and may seem to involve too much risk with too little reward.Part of the decision process whether to prescribe opioids must include a discussion of patient goals. While patients with chronic, nonmalignant pain may have a desire to be pain free, this is not a realistic goal by virtue of their diagnosis and the limited efficacy of pain medications, regardless of dose. There must be an active partnership between patient and clinician and an understanding that the patient must take steps—not just pills—to manage chronic pain.Patients often present after seeing friends and family members on opioid medication and insist they deserve these, too. Opioid medication for many patients can be considered a nonbeneficial treatment, and there is guidance available regarding how to handle this discussion. Patients are not entitled to any particular therapy, but as Brett and McCullough7Brett AS McCullough LB Addressing requests by patients for nonbeneficial interventions.JAMA. 2012; 307: 149-150Crossref PubMed Scopus (77) Google Scholar argued recently, patients are entitled to our profession integrity, which can mean refusing requests for nonbeneficial treatments based on sound clinical judgment and consideration of potential harms.Besides reinforcing safety measures to minimize opioid theft, misuse, and diversion, other steps that clinicians can take include avoiding prescribing 100 acetaminophen/oxycodone pills when 20 will suffice and offering guidance regarding safe disposal of unused medication, which for opioids generally involves flushing down the toilet.8US Food and Drug Administration How to dispose of unused medicines.www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htmGoogle Scholar The Drug Enforcement Agency has begun to coordinate National Prescription Drug Take Back events semiannually in all 50 states at which unused, unwanted or expired prescription medication can be dropped off at various sites to reduce the risk of medication being taken by those other than whom it was prescribed (www.deadiversion.usdoj.gov/drug_disposal/takeback/index.htlm).When there is evidence of a violation of the opioid contract or lack of functional improvement, we must take the often-unpleasant step of discontinuing prescribing. Reviewing cases with colleagues in a manner similar to a tumor board conference or the professional supervision social workers use may help with the decision-making process and depersonalize the negative interactions with patients who disagree with the decision to discontinue opioids. When deciding whether to prescribe opioids to treat chronic, nonmalignant pain, I find it helpful to remember the educators James Bannon, Jr and Harold Cannon, who wrote, “To be kind is not to be soft or weak, and to be demanding is not to be unfair.”9Banner Jr, JM Cannon HC The Elements of Teaching. Yale University Press, New Haven1997: 109Google Scholar Patients who cannot abide by the terms of an opioid contract are demonstrating they cannot take potentially fatal medication safely.A referral to a pain specialist might yield suggestions for alternative treatments and an opinion as to whether a patient is a suitable candidate for long-term opioid pain medication. Unfortunate or distressing social circumstances or complaints of suffering are not justification for prescribing opioids. Referral to social service agencies or mental health or addiction treatment would be more appropriate.We have an obligation and opportunity to protect the health of individuals and the public through the judicious prescribing of opioid medication. Until the time comes when safer, more effective treatments for chronic pain, depression, and substance abuse are readily available to all patients, continued vigilance for signs of misuse and ongoing guidance regarding appropriate use of opioids are imperative to provide compassionate care without contributing to the public health crisis of unintentional overdose. At best, opioid medication, as one component of a comprehensive treatment strategy, can provide an individual with modest pain relief. Ongoing patient education regarding safe use, storage, and disposal of these medications can save lives as can treatment for depression and addiction. British author Roald Dahl's children's classic Charlie and the Great Glass Elevator,1Dahl R Charlie and the Great Glass Elevator. Alfred A Knopf, New York1972Google Scholar published in 1972, contains a prescient tale of the unintended consequences of medicine misuse. In a 134-line rollicking poem, Dahl describes the unfortunate but predictable fate of 7-year-old Goldie Pinklesweet, who gobbled up all of her grandmother's chocolate-covered laxatives when left unattended. Dahl's cautionary tale concludes with advice to refrain from availing oneself of items found on the medicine shelf. While Dahl's account is amusing, the current reality of rampant and often fatal misuse of prescription medication is sobering. The Centers for Disease Control and Prevention has published several reports over the past few years drawing attention to this public health crisis and detailing the scope of the epidemic of prescription opioid deaths—14,800 deaths attributed to opioid pain relievers in 2008.2Centers for Disease Control and Prevention Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008.Morb Mortal Wkly Rep. 2011; 60: 1487-1492PubMed Google Scholar The death rate is increasing alongside the rise in opioid prescribing, and there are now more overdose fatalities from prescription opioids than heroin and cocaine combined. Clinicians in most settings—urgent and primary care clinics, schools, homes—including all who care for adults, families and adolescents need to be aware of the problem of nonmedical use of opioid medication. Detailed accounts of unintentional prescription medication overdoses3Hall AJ Logan JE Toblin RL et al.Patterns of abuse among unintentional pharmaceutical overdose fatalities.JAMA. 2008; 300: 2613-2620Crossref PubMed Scopus (668) Google Scholar and reports of high abuse rates of Vicodin and other opioids by teenagers4Wu L Pilowsky DJ Patkar AA Non-prescribed use of pain relievers among adolescents in the United States.Drug Alcohol Depend. 2008; 94: 1-11Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar are a call to action because these deaths are largely preventable. A stark view of this situation is to consider that every diverted opioid pill represents a failure to prescribe the right amount of pain medication to the right patient or without appropriate counseling regarding the potential risks. Recommendations to prescribers aimed at increasing the safety of chronic opioid therapy5McLellan AT Turner B Prescription opioids, overdose deaths, and physician responsibility.JAMA. 2008; 300: 2672-2673Crossref PubMed Scopus (83) Google Scholar and clinical guidelines6Chou R Fanciullo GF et al.American Pain Society/American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.J Pain. 2009; 10: 113-130Abstract Full Text Full Text PDF PubMed Scopus (1701) Google Scholar can be a resource in deciding whether and how best to treat a given patient with chronic opioids. These recommendations include screening patients carefully to identify those with a history of drug addiction or alcoholism, requiring an opioid agreement, and screening urine samples for the medication prescribed and illicit or nonprescribed drugs. The absence of the prescribed medication in urine is concerning because this suggests either diversion or overuse. Attention should be paid to clues that a patient is misusing medication, by reviewing therapeutic monitoring reports from insurers and accessing state-run prescription monitoring programs when available, which can identify doctor-shopping or early refills. An opioid agreement that details the risks of opioids and the terms under which they might be prescribed can be considered a starting point in educating patients about their responsibilities and medication risks. We must make an effort to ensure our patients understand the danger of combining opioids with alcohol and other drugs or tampering with the extended-release property of certain formulations. They also must know the implications of methadone's variable and long half-life and the maximum safe upper limit of combination opioid-acetaminophen preparations. While it might seem unnecessary to reinforce these seemingly obvious cautions at each visit, clearly the lethality of opioids when taken inappropriately is underappreciated by some patients, as evidenced by their willingness to share medication with others. This is, in part, why caring for chronic pain patients is time-consuming and may seem to involve too much risk with too little reward. Part of the decision process whether to prescribe opioids must include a discussion of patient goals. While patients with chronic, nonmalignant pain may have a desire to be pain free, this is not a realistic goal by virtue of their diagnosis and the limited efficacy of pain medications, regardless of dose. There must be an active partnership between patient and clinician and an understanding that the patient must take steps—not just pills—to manage chronic pain. Patients often present after seeing friends and family members on opioid medication and insist they deserve these, too. Opioid medication for many patients can be considered a nonbeneficial treatment, and there is guidance available regarding how to handle this discussion. Patients are not entitled to any particular therapy, but as Brett and McCullough7Brett AS McCullough LB Addressing requests by patients for nonbeneficial interventions.JAMA. 2012; 307: 149-150Crossref PubMed Scopus (77) Google Scholar argued recently, patients are entitled to our profession integrity, which can mean refusing requests for nonbeneficial treatments based on sound clinical judgment and consideration of potential harms. Besides reinforcing safety measures to minimize opioid theft, misuse, and diversion, other steps that clinicians can take include avoiding prescribing 100 acetaminophen/oxycodone pills when 20 will suffice and offering guidance regarding safe disposal of unused medication, which for opioids generally involves flushing down the toilet.8US Food and Drug Administration How to dispose of unused medicines.www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htmGoogle Scholar The Drug Enforcement Agency has begun to coordinate National Prescription Drug Take Back events semiannually in all 50 states at which unused, unwanted or expired prescription medication can be dropped off at various sites to reduce the risk of medication being taken by those other than whom it was prescribed (www.deadiversion.usdoj.gov/drug_disposal/takeback/index.htlm). When there is evidence of a violation of the opioid contract or lack of functional improvement, we must take the often-unpleasant step of discontinuing prescribing. Reviewing cases with colleagues in a manner similar to a tumor board conference or the professional supervision social workers use may help with the decision-making process and depersonalize the negative interactions with patients who disagree with the decision to discontinue opioids. When deciding whether to prescribe opioids to treat chronic, nonmalignant pain, I find it helpful to remember the educators James Bannon, Jr and Harold Cannon, who wrote, “To be kind is not to be soft or weak, and to be demanding is not to be unfair.”9Banner Jr, JM Cannon HC The Elements of Teaching. Yale University Press, New Haven1997: 109Google Scholar Patients who cannot abide by the terms of an opioid contract are demonstrating they cannot take potentially fatal medication safely. A referral to a pain specialist might yield suggestions for alternative treatments and an opinion as to whether a patient is a suitable candidate for long-term opioid pain medication. Unfortunate or distressing social circumstances or complaints of suffering are not justification for prescribing opioids. Referral to social service agencies or mental health or addiction treatment would be more appropriate. We have an obligation and opportunity to protect the health of individuals and the public through the judicious prescribing of opioid medication. Until the time comes when safer, more effective treatments for chronic pain, depression, and substance abuse are readily available to all patients, continued vigilance for signs of misuse and ongoing guidance regarding appropriate use of opioids are imperative to provide compassionate care without contributing to the public health crisis of unintentional overdose. At best, opioid medication, as one component of a comprehensive treatment strategy, can provide an individual with modest pain relief. Ongoing patient education regarding safe use, storage, and disposal of these medications can save lives as can treatment for depression and addiction.