The problem of prescription opiate diversion, misuse and overdose is serious and pervasive, now rivaling car accidents as the major cause of accidental death in the US – over 1,500 every month. Prescription opiates such as Vicodin®, Lortab®, OxyContin® and Methadone require a physician’s or dentist’s prescription to obtain, but they are widely diverted (used by others for non-medical reasons) leading to overdoses and deaths. The severity and breadth of this problem has prompted many state congressional hearings seeking a ban or major restriction on the prescription of these often abused medications. Such legislative actions are well-intentioned and seemingly simple solutions to a deadly problem – but they are actually simplistic; lacking in appreciation of problem complexity and thus too simple to be effective.
Most of the diverted prescription opiates that ultimately cause overdose deaths come from pain management prescriptions. Pain is the most common symptom among patients seeking care from their primary care physicians and most types of pain (e.g. low back pain) are based only on patient self-report and cannot be verified through laboratory testing. Prescription opiates, unlike illegal opiates such as heroin, have a well-established and very effective role in pain management. There are alternatives to opiates like non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, but they are less potent and high doses taken over long periods have been associated with serious liver disease. For these reasons, opiates are the most commonly prescribed class of medications (over 100 million prescriptions per year); over 70 percent are prescribed by primary care physicians (dentists also); and the great majority of patients prescribed these medications take them safely as directed with significant benefit. Thus, it is unrealistic and simplistic to ask physicians to stop prescribing opiates for the great majority of their patients suffering from pain. However, there are some simple ways physicians could modify their prescribing practices allowing the medications to continue to provide relief from significant pain while also reducing the problems of opioid diversion and overdose death.
In this regard, the surgeon, Dr. Atul Gawande’s bestselling book The Checklist Manifesto is quite instructive. In the book, Dr. Gawande and his colleagues reduced physician error rates and attendant complications and deaths from surgical procedures by adopting a simple procedure long used by the airline industry to assure that proper procedures are always followed – a checklist. Dr. Gawande observed that despite (perhaps because of) the extraordinary training, proficiency and experience of surgical teams, there were few standard safeguards in place to assure an operation would always follow agreed upon procedural steps – a protocol. Simply by initiating a pre-surgical checklist comprised of the agreed-upon procedural steps, even very experienced surgical teams showed remarkable reductions in errors, untoward events, complications and deaths.
As has been done in surgery, the procedures for evaluating, prescribing and following a candidate for opioid pain medication has been consolidated into a procedural protocol (a “checklist”) by specialists from the American Pain Management Society. Five common sense procedures are recommended as part of responsible opioid prescribing and patient education:
1. Evaluate the patient for known predictors of opioid abuse and dependence including a history of substance dependence and/or significant psychiatric illness.
2. Obtain written agreement from the patient that s/he will only obtain medications from one physician and will only fill prescriptions at one pharmacy.
3. Consult the state prescription drug monitoring program; and register any newly prescribed patient on that program.
4. Get an oral history of the patient’s recent medication use; then obtain and analyze a urine drug screen – discrepant results should be a cause for cautious prescribing.
5. Instruct the patient and obtain his/her consent to follow safe usage and storage procedures for the prescribed medication.
These basic steps have been endorsed by pain management physicians, are relatively easy to implement and make good common sense, but are rarely performed by prescribing primary care physicians or dentists. Of course performing this checklist will not prevent those who are determined to misrepresent and take advantage of a physician’s efforts to provide compassionate care. But these simple steps will make misrepresentation and diversion more difficult, could improve responsibility and adherence to treatment among the great majority of patients and may save thousands of lives – all with just a simple checklist.
A. Thomas McLellan, PhD
CEO, Treatment Research Institute
The author has no financial relationships with the pharmaceutical industry.