Dealing Life: How to prescribe opioid painkillers responsibly
Prescribing opioid painkillers responsibly can save the lives of the 44 people a day – or more than 16,000 a year – who die from opioid overdoses. And unless your last name is Kevorkian, that’s why you became a doctor in the first place, isn’t it? And unless you’re a comic book character or a pro wrestler, you don’t want to go down in history as one of a group of people who are remembered by the moniker ‘Dr. Death.’ And yet pain relievers and heroin are the main driver of overdose deaths in the United States. Now, the latter substance is only ‘prescribed’ by guys known who go by such nicknames as Mother Superior – you know, on account of the length of their habit. But some physicians have been overprescribing opioids, especially for chronic, non-cancer pain. By way of example, healthcare providers wrote 259 million prescriptions for opioid pain relievers in 2012 – enough for every American adult to have a bottle of pills.
However, there is not only little evidence that long-term opioid treatment improves chronic pain, function, and quality of life, but long-term use of opioid painkillers for chronic pain can be linked to abuse and overdose, in particular in high doses. So much so that although the amount of pain Americans reported remained essentially the same, the amount of painkillers prescribed and sold in the United States all but quadrupled in the period between 1999 and 2013 – and deaths from prescription painkillers have also quadrupled since 1999. Now I will respectfully ask you a question. You do not accept cheeseburgers – or the other alternative presented in Menace II Society as a form of payment, do you? If the answer is no, and it better be, why sink down to the level of street dealers? And more importantly, how to avoid sinking down to that level?
The first step is to provide patients with safe and effective pain management in order to lower the risk of misuse, abuse, and overdose of prescription opioids.
Safe and effective pain management
Talk to your patients about:
· The risks of taking prescription opioids, such as addiction, overdose and death.
· A variety of pain treatment alternatives that may be appropriate for their condition, for instance over the counter pain relievers, physical therapy and exercise, or electrotherapy.
Follow these practices for prescribing painkillers:
· Prescribe the lowest effective dose and only the quantity needed for the expected duration of pain.
· Plan with your patients on how to stop opioids after their treatment is done.
· Provide patients with information on how to use, store, and dispose of opioids.
· Avoid combinations of prescription opioids and sedatives unless there is a specific medical indication.
If available, use your state’s prescription drug monitoring program (PDMP) to help you identify patients who might be misusing prescription drugs and are at risk of overdose. A PDMP – not to be confused with a certain 50 Cent song – is a state-run electronic database intended for tracking the prescribing and dispensing of controlled prescription drugs to patients. Some characteristics of a PDMP include the following:
· Universal use. PDMPs are only useful if you check one before prescribing. Some states require healthcare providers to check its PDMP before prescribing certain controlled substances in certain circumstances.
· Real-time. Pharmacists can enter prescription data into state PDMPs at varying intervals – for example, monthly or daily. But it is ‘real-time’ input – under 5 minutes – that can provide PDMP users with the most updated information on a patient’s recent prescriptions.
· Active. PDMPs are not passive databases; state health departments can use them to understand the behavior of the epidemic and inform and evaluate interventions, as well as to send ‘proactive’ reports to authorized users to protect patients at the highest risk and identify inappropriate prescribing trends.
· Ease of use and accessibility. Integrating PDMPs into electronic health record (EHR) systems allows physicians to delegate PDMP access to other allied health professionals in their practice and streamline the process for providers to register with the PDMP.
If you suspect that a patient has a substance abuse problem, you can refer him or her to the Substance Abuse and Mental Health Services Administration’s National Helpline at 1-800-662-HELP (4357). And remember these three tidbits:
1. Static prescribing rates equal fewer deaths.
2. More prescription painkillers, same pain.
3. More prescription painkillers equals more deaths.