PPM Editorial Board Examines Steps to Prevent Accidental Overdoses
Be an Astute Prescriber
Peter Moskovitz, MD
Use opioid pain relievers (OPRs) judiciously and according to established guidelines, but also fairly. Remember Pellegrino’s dictum: It is immoral to withhold opioids because of a fear of addiction or abuse. Balancing efficacy and safety is never easy.
Know yourself: Recognize when you are caring for a patient whose needs are beyond the scope of your practice or your ability to maintain control of the relationship. Abusive behavior feels like an affront to your professionalism and your empathy for the patient’s predicament. Your anger won’t help your patient or give the patient behavioral control.
Understand and recognize depression and suicidality. Assess regularly and refer promptly.
Understand and recognize the difference between dependence, tolerance, and abuse (personal abuse leading to overdose and abuse that takes the form of diversion). (The term “addiction” should probably be abandoned.)
- For dependent patients, a) have one physician write prescriptions and one pharmacy fill them; b) have an OPR storage plan that is secure; c) refill prescriptions monthly or at shorter intervals; and d) have direct contact with the patient at each refill to assess mood, affect, and state of consciousness.
- For tolerant patients who may be at greatest risk for accidental overdose, a) follow step 1; b) switch medications at regular intervals; c) expand multimodal therapy; and d) refer for counseling to maximize behavioral control.
- For abusive patients (those with a history of medication, alcohol, or “recreational” drug abuse, or when reasonable doubt about compliance exists when tolerance emerges), a) follow steps 1 and 2; b) conduct urinalysis; c) consider referral to another pain management practitioner for better behavioral control; and d) maintain regular communication with the pharmacist and check the patient’s “profile” for abuse or diversion.
- For patients who actively abuse OPR prescriptions (beyond the control of steps noted above), a) report abuse to the pharmacist, referring physician, other practitioners, and law enforcement; b) refer for inpatient detoxification and a program to “start over”; and c) consider discharge for noncompliance with urinalysis, which is undesirable no matter how “mad” you are at an abusive patient.
ePrescribing Is Key to Managing Prescriptions And Interactions
This is a very important subject and a major issue that has been exacerbated by the growth of the pain management industry in the United States.
I believe busy pain practitioners need up-to-date information that can help them effectively prescribe for and monitor their patients. That can only happen by getting into electronic prescribing (ePrescribing), which gives doctors a very effective tool to view patient prescriptions and interactions (eg, drug–drug, other possible allergies). It also allows them to view what other doctors have prescribed for their patients. Without having access to the ePrescribing network, it is almost impossible to determine what prescriptions a patient is taking, and doctors have to rely either on what the patient tells them or on outdated prescription information. This also leads to overdoses.
Having access to the ePrescribing network also can help thwart “doctor shopping” by patients who go to different clinics as well as cross state lines to get additional “meds.” Currently, there is no effective way to monitor this across state lines. The ePrescribing network allows physicians to pull in drug formularies and, in a few months, get information on filled and refilled prescriptions back from the pharmacies electronically.
With government intervention for the adoption of electronic health record systems over the past year, ePrescribing has taken on an even more important role. Studies have shown that ePrescribing has already helped in reducing drug fatalities.
As of June 2010, the Drug Enforcement Agency (DEA) has finally allowed ePrescribing of controlled substances, which is a huge step toward better management of the prescribing of controlled substances and monitoring of patients’ dosages and interactions. Surescripts, the main company that connects pharmacies to ePrescribing companies, had to recode its computer software to allow for proper provider authentication and ensure proper chain of command in ePrescribing controlled substances. That work has been finalized and was slowly getting rolled out in the last quarter of 2011 by states. This is crucial to all pain doctors because they do so much of the controlled substance prescribing. (It is important to note that many, if not most, pain doctors are still not ePrescribing!)
Editor’s Note: Mr. Winterkamp is CEO/President of Addison Health Systems, Inc, which markets an electronic medical record system.
Ask Patients to Document And Safeguard Opioids
Gary W. Jay, MD, DAAPM, FAAPM
Raleigh-Durham, North Carolina
No matter how careful a physician may be, there is not much that can be done to help a patient who uses opioids inappropriately. The patient may take his opioid appropriately and doze off. Upon awakening, unsure if he already took his medication, he may take a second dose in order to help himself sleep or perform some activity. The bottom line is that patients are human, and even the best-treated patients (or untreated people) can forget if they’ve taken a pill and take another one in an effort to be compliant, but accidents happen, most frequently—fortunately—not fatal.
On the other hand, when grandma has a bottle of acetaminophen and hydrocodone (Vicodin) in her medicine cabinet or dad has some oxycodone (OxyContin) given to him for a failed back syndrome, there is typically nothing to stop a teenager (or anyone) who wants to “take some” (steal) and use them indiscriminately. These are the individuals who may die of an “accidental overdose”; that is, they didn’t try to kill themselves; they just wanted to get high.
For these reasons, I do two things with my patients to go a step further to prevent opioid drug stealing: I ask them to obtain a small safe—a single gun safe is sufficient (and not too expensive)—and always keep their medications in it. As long as the combination is not common knowledge, that can help.
I also tell my patients to keep a notebook and write down the time they take every pill, and further ask them to consult that notebook before they take every pill so they don’t accidentally take too much medication in a short period of time.
I also suggest putting their medications in an individual travel pill holder with multiple plastic sections that they can use to lay out their pills and mark the sections according to the time the pills are to be taken.