This week’s New England Journal of Medicine (NEJM) in the histrionically titled article, “A Flood of Opioids, a Rising Tide of Deaths”, very roughly outlines a reported increase in deaths and injuries due to prescription medicines like opiates (Fentanyl, hydrocodone, morphine, Oxycontin, Vicodin, etc.) and benzodiapines (Valium, Klonipine, Ativan, Xanax etc.). The article references a Center for Disease Control (CDC) Morbidity and Mortality Weekly Report (MMWR) that purports to estimate the increase in numbers of deaths and injuries from prescription pain medications. However, there is no evidence of an attempt to ensure that the abused drugs actually came from prescriptions written for the patent. In fact, the highest rates of abuse necessitating Emergency Room visits involved people under 24 years old.
I assume that most people have gone through the hassle of buying pseudoephedrine since the law made us all work harder than drug seekers trying to score narcotics. The law in Texas is stricter than the silly limit placed on the decongestant by federal law. I don’t think patients have to show their driver’s license and have their name checked in a national database in order to buy Fentanyl patches, much less Vicodin or Xanax. (In case you’re wondering, the legal limit without a prescription is lower than the maximum dose.)
The State of Washington is moving that way, according to the NEJM article:
Once a new law goes into effect in mid-2011, opioid prescribers in Washington State will have to enter their patients’ clinical responses to treatment in a statewide database and consult a pain specialist if a patient’s daily dose goes above a specified threshold.
As a Family Physician, I don’t like the imposition of a legal requirement to refer to a specialist – even if I normally would do so. But as a potential patient, I would prefer my prescription medicines were a matter left between me and my personal physician.
It seems that the underlying purpose is more to change the way that doctors practice medicine than to prevent ER visits.
At the time that patients initially present with pain, they will be asked to complete a confidential computerized questionnaire assessing factors such as daily pain level, mood, quality of life, and history of mental illness or substance abuse. At each subsequent visit, they will complete a brief follow-up questionnaire. Health care providers can review each patient’s longitudinal record in making treatment decisions, and studies of de-identified patient data can be used to measure population-wide outcomes and set policy. Cahana hopes that clinical feedback will help shift practitioners away from an “overreliance on pills, devices, and surgical procedures” and toward the use of nondrug treatments, such as graded exercise or behavior-modification programs.
(Should I tell them that their nondrug treatments will cost more than the pills?)