Drug overdose is the leading cause of accidental death in the U.S.¹, with an all-time record high of 81,000 total drug-related deaths for 2020.² Therefore, it is more important than ever that doctors understand how to incorporate safe prescribing in their practice.

The drug mortality supply chain

The supply chain of drug mortality can be divided into the illicit market and the medical market. The illicit market is dominated now by illicit fentanyl that is coming across our borders. Although there is little the medical community can do to stop this supply, they can be involved with the treatment and prevention of drug addiction.

On the other spectrum, the medical supply chain of medication overdose mortality is in the control of the healthcare community. In 1999, the death rate per 100,000 from unintentional medications that excluded fentanyl was 2.0. It peaked in 2011 at 5.7. Since then it has been slowly decreasing, although the latest studies “suggest an acceleration of overdose deaths during the pandemic.”³

New Dr. Messias‘ Review Notes appear at the end of the story.

In order to decrease the mortality of unintentional medication overdoses, the medical community must focus on safe prescribing, particularly the use of concurrent central nervous system (CNS) depressants, such as opioids, benzodiazepines, sleep aids, and cannabis-related products.

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Because the impacts of these drugs are addictive, we must be involved in coordinating the medications that patients get from other providers. We also must be aware of all of the other places where patients may get these types of neuroactive substances, including over-the-counter access, street purchases, taking other people’s medications, and so forth.

The medical community has stepped up to the plate by following the CDC Guidelines for safe opioid prescribing in chronic pain⁴.  However, some argue that in some places the pendulum has swung too far with excessive denial of opioids.

Innovations in safe prescribing

Innovations in safe prescribing are available to help with the management of both acute and chronic pain using fewer opioids. Multimodal approaches include

• • • psych-behavioral aspects
    • physical modalities
    • procedures
    • alternative medications

-ERAS and ALTO

ERAS, Enhanced Recovery After Surgery⁵, is a growing modality that can decrease reliance on opioids and improve recovery.

ALTO, Alternatives to Opioids, involves the use of regional blocks, trigger point injections, and non-opioid approaches for acute exacerbations of pain.

-Benzodiazepine stewardship

There is a movement towards benzodiazepine stewardship, similar to opioid stewardship. This is because these medications are not first-line therapy for anxiety or insomnia. Some are also risky. Alprazolam (Xanax), for example, is associated with 50% of benzodiazepine deaths. Its time of onset is rapid, but it is also short-acting, making it the most prone to addiction.

Adulteration of street drugs

Adulteration of street drugs with illicit fentanyl is quite common. Drugs involved include heroin, methamphetamine, cocaine, as well as fake pills of oxycodone, hydrocodone, and Xanax. Fentanyl has even been found in vaping products. This means that any drug not obtained from a pharmacy can, often unbeknownst to the user, have fentanyl in it. 

The medical community can proactively respond to this problem in two ways:

1. Prescribe naloxone to people (or their family and/or friends) who may be using illicit drugs

2. Include fentanyl in urine drug screens obtain in a hospital setting.

A positive fentanyl test can alert the patient, doctor, and friends, as well as lead to a prescription of naloxone and disposal of the tainted product. Fentanyl testing should be automatic and universal in a hospital setting. To bring fentanyl testing to your institution, you can access a Fentanyl Tool Kit.⁶ 

The Doctors Company closed claims study

Building a strong doctor-patient rapport can help facilitate tough conversations with patients about opioid or other CNS depressant prescriptions and reduce risks that could lead to malpractice suits.

The Doctors Company reviewed 782 claims that closed between 2015-2019 in which patient harm involved medication factors. In 118 of these claims (15%), the medications were narcotic analgesics. Seventy-four percent of these claims (n=87) were in the outpatient setting, including:

• Physicians’ offices and hospital clinics (90%).
• Emergency room (6%).

The admitting diagnoses for these outpatient narcotic-related claims were pain, including chronic pain not otherwise specified (NOS) (66%), spine-related pain (7%), joint/extremity-related pain (3%), mental health issues (6%), and drug abuse/dependence (3%).

Patient allegations for these claims included improper medication management or treatment (80%), other medication-related issues, such as unknown allergies or adverse reactions (10%), and ordering the wrong dose (4%).

Final diagnoses in these claims included poisoning by methadone, heroin, and opiates/narcotics NOS (53%), drug dependence (20%), and adverse effects of medications (8%).

Communication problems are among the patient-contributing factors that lead to injury, appearing in 48% of claims. Incomplete or unclear communication can compromise patients’ ability to understand the doctor’s instructions and, especially in the case of pain medications, also make them feel as if the doctor doesn’t care about their issues or concerns.

Managing patients who ask for or expect prescriptions

The following tips can help when dealing with prescription requests:

• Don’t jump to conclusions

Don’t make the mistake of jumping to conclusions that the patient is a drug seeker just because the patient is there repeatedly for the same pain complaint. It could instead be an opportunity to catch a missed diagnosis. Treat this patient like any other patient. Take a good history, including a very detailed medication history. Do a thorough physical examination. See if something was missed on previous visits.

• Utilize the prescription drug monitoring program (PDMP)

According to the CDC, “a prescription drug monitoring program⁷(PDMP) “is an electronic database that tracks controlled substance prescriptions in a state. PDMPs can provide health authorities timely information about prescribing and patient behaviors that contribute to the epidemic and facilitate a nimble and targeted response.”

Your state PDMP is a valuable tool. Use it to learn about all your patient’s scheduled prescriptions, not just to check for doctor shopping. Think of this extra step in the same way that you do when you check old records for allergies and prior illnesses.

• ONE doctor – ONE pharmacy

The gold standard is to have ONE doctor and ONE pharmacy for all controlled medication given for three months or more. This is true for dental pain, fractures, fibromyalgia, cancer, anxiety, and ADHD. If you see a patient for the third month of controlled medication, start a medication agreement or consent process if you plan on continuing this therapy.

• Employ shared-decision making

Use shared decision-making when patients are found to be taking drug combinations or dosing that are not recommended. The Veterans Affairs administration has helpful clinical tools⁸ on opioid and benzodiazepine⁹ tapering that is available to any clinician. 

• Ask how medications are being taken

When patients say that their medication is not working, ask the patient, “How are you taking the medication?” You’ll be surprised how many patients take ibuprofen at doses of 400 mg twice a day. This is a low dose that may not be enough to control pain.

Take a detailed medication history and provide patient education about the right dosage, right timing, and side effects to be aware of is essential to medication safety. You may remind the patient that the best approach to chronic pain is a multi-modal approach.

• Signal the seriousness of the drug

When you hand a patient a prescription for a controlled medication, add a few words to let the patient know that these are serious medications: “I will give you a prescription for Norco. Please realize that this is a medication that can be abused. Keep it secure, take it only as prescribed, and do not drive if not fully alert.“

• Be cognizant of health literacy

Be aware of the level of health literacy of the individual patient and adjust your language appropriately. Ask patients to repeat back the information you gave to ensure they properly understand.

• Refer to a specialist when a substance use disorder is uncovered

If patients are found to have an opioid use disorder, benzodiazepine use disorder, or other substance use disorder, connect them to treatment. If you do not have the expertise, refer your patient to an addiction specialist. Alternatively, The National Clinical Consultation Center¹⁰ provides peer consultation in the use of buprenorphine for patients with opioid use disorder.

 How to say “No” nicely

Here are some good answers for specific patient questions and situations, or “How to say No, nicely”.

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References

1. Drug Overdose, Overdose Trends.  Drug Policy Alliance.  httpss://drugpolicy.org/issues/drug-overdose

2. Overdose Deaths Accelerating During COVID-19, CDC Newsroom. Dec 2020 httpss://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html

3. Holly Hedegaard, M.D., Arialdi M. Miniño, M.P.H., and Margaret Warner, Ph.D.

   Drug Overdose Deaths in the United States, 1999–2018,   NCHS Data Brief No. 356, January 2020 CDC httpss://www.cdc.gov/nchs/products/databriefs/db356.htm

4. CDC Guideline for Prescribing Opioids for Chronic Pain — the United States, 2016. Center for Disease Control and Prevention. Recommendations and Reports / March 18, 2016 / 65(1);1–49 
5.  Recovery Program. UNC School of Medicine.Basics of Enhanced Recovery.  httpss://www.med.unc.edu/anesthesiology/enhancedrecovery/overview/components-of-enhanced-recovery/
6. Fentanyl Tool Kit.  San Diego Rx Task Force. httpss://www.sandiegorxabusetaskforce.org/fentanyl-toolkit

7. Prescription Drug Monitoring Programs (PDMPs), Opioid Overdose, Centers for Disease Control and Prevention  httpss://www.cdc.gov/drugoverdose/pdmp/states.html

8. Veteran’s Administration Opioid Taper Decision Tool httpss://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdfVeteran’s Administration Opioid Taper Decision Tool 
9. Re-evaluating the Use of Benzodiazepines: A Focus on High-risk Populations. US Department of Veterans Affairs. httpss://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Benzodiazepine_Provider_AD_Educational_Guide.pdf
10. Substance Use Management, National Clinical Consultation Center. httpss://nccc.ucsf.edu/clinician-consultation/substance-use-management/

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New Dr. Messias‘ Review Notes.
 

The opioid epidemic has taken lives through what some call “deaths of despair” and we physicians played multiple roles in that tragedy. This short overview does an excellent job explaining these roles both in the illicit as well as the medical marketplace fueling drug-associated mortality.

In response to this epidemic, several innovations to foster safer prescribing have been implementing and they are starting to have a positive effect. It is incumbent on us – healthcare providers, in general, and physicians, in particular – to use these measures to honor our duty to “do no harm.”

The list of ways to say “no” nicely is particularly helpful along with some of the tools listed among the references.

Every physician whose practice includes the great power of prescribing
potentially addictive and lethal drugs is wise to remember
Spider-Man’s motto:

“with great powers come great responsibilities.“