The abuse of prescription drugs, especially opioid painkillers, is a growing public health concern. Our Medical Director, Dr. Tamas Peredy, is also a doctor with the Maine Medical Center Emergency Department. He answered some questions about this issue from an ED doctor’s perspective.
The FDA has called prescription drug abuse an “epidemic.” Do you agree with this based on what you are seeing in the emergency department?
TP: I have heard the terms epidemic and pandemic to describe the rapid rise in prevalence of prescription (primarily opioid) misuse. This problem is blatantly evident in my emergency department practice. I have seen a rapid rise in complications related to chronic opioid therapy including injuries and deaths, pain complaints related to opioid induced hyperalgesia and withdrawing patients with interrupted opioid supplies. The evidence is now clearer than ever that a steady dose of an opioid loses its efficacy after only several weeks while escalating doses to maintain efficacy causes an ever-increasing side effect profile. Also I have seen a general acceptance of sharing of prescriptions due to the high costs. When shared with others for non-medical purposes in particular, the risks are great for addiction, drug-related criminal activity and health endangering risky behaviors.
Do ED doctors get training on how to assess pain? What about training on how to address the risks of abuse?
TP: Emergency doctors provide crucial acute symptom relief in the setting of multiple painful diagnoses. The relief of suffering is a patient’s right and a primary obligate of a physician. They generally understand the pharmacology of pain relief not just with opioids but other adjunctive therapies. Pain however is a subjective negative stimulus that is experienced differently by different individuals. There are no good objective measures and thus physicians have had to rely upon subjective biased views to validate the patient’s pain. Physicians have been taught an overly simplistic single axis yardstick of pain from zero to ten. Now more sophisticated analyses take into consideration functional impairment and the amount of psychological suffering that often accompanies pain.
Physicians are generally better doctors than detectives, regardless of media hyperbole. They neither have the time nor resources to perform exhaustive investigations into patient’s histories to attempt to catch them at misrepresentation. Also, folklore around drug-seeking behavior identification is poorly validated in research literature. Now more tools than ever are available, however, to assist in identifying patients who may exhibit obvious patterns of medication misuse, such as shared electronic medical records, prescription monitoring programs and adulteration-proof prescriptions.
Do EDs have policies related to prescribing pain medication to patients? Do you think professional associations or hospitals should have policies or recommendations on prescribing prescription pain medications?
TP: Most hospitals, emergency departments, professional associations and physician practices have adopted policies to support the limited distribution of opioid therapy. Some policies are geared toward educating patient groups and adjusting expectations. Policies that are robust and flexible can support a balanced approach to pain management while those that are inflexible and extreme do not allow for individual concerns and treatment options.
Do you think prescription monitoring programs are used as much as they should be?
TP: The current prescription monitoring programs are an excellent idea with only mediocre implementation. The concept that a physician prescriber can check a database of past prescriptions for their patient is an obvious safety tool that prevents doctor-shopping or medication duplication. On the other hand, states have turned to low-cost vendors to deliver the needed information technology solutions. Access to the information becomes clunky and difficult. So much information is needed regarding the patient to avoid misidentification that the search becomes cumbersome and time-consuming. Striking a balance between patient privacy, accuracy, security and rapid access has yet to be achieved.
Do you think ED doctors can or should play a role in educating patients and families about medication safety—proper storage and disposal, not sharing, etc.?
TP: ED doctors must play a key role in educating patients regarding the safety of the medication they prescribe. Generally in the past we have limited the scope of the discussion to the safety of the patient taking the medication; however, it is clear that environmental safety issues are of equal concern, for example, if there are small children or teens in the house. Opioids are a target for home burglaries and an important source of unintended exposures. Educating patients about proper product stewardship including medication disposal is very important.
Are there ways ED doctors and poison centers are working together on this issue? Is there more that they can do?
TP: Poison centers have traditionally served as the virtual EDs of the pharmacology information world. They have primarily provided treatment information after the misuse or overdose has occurred. I think that EDs could better reinforce the idea that poison centers exist not just for toddlers who accidentally ingest things in their environment but also for adults who have questions about dosing, drug interactions and side effects. Other resources such as doctors’ offices and retail pharmacies can provide similar information; however, they may involve the inconvenience of waiting on the line or being unavailable after hours. Ideally, in the future health records should be shared among poison centers so that staff can assist patients with the most accurate information.