Risk Reduction: Opioid Overdose

The recent death of Michael Jackson puts pain medications in focus and under the spotlight again. The tabloid’s claims only serve to fuel speculation about something most of the medical profession is already acutely aware of: the over-prescribing of pain medications that allows potentially lethal drugs to be acquired through legitimate channels to end up on the street.

On a busy night, an ER can be slammed non-stop for 8-12 hours. Each ER doctor may be expected to see dozens of patients each of those hours, to attend to everything from minor traumas to the aftermath of a gang war shoot-out. In the midst of it all will be patients complaining of pain — tooth aches, belly aches, back pain, sunburn, sleeplessness… You name it, the addicts and dealers have thought it up. Pressed for time and unwilling to deny drugs that grant relief to a patient who is truly in pain, the physician will order an injectable and write a prescription for a pain medication. If the doctor begins prescribing a non-narcotic, the patient objects that he has already tried that, that an anti-inflammatory doesn’t work… perhaps even threatening the doctor. When that “patient” leaves, he leaves with a week or month’s supply of opioids that will be consumed in a night, perhaps bringing some of those drugs right back into the ER in the form of an overdose. Others may go directly to the morgue. Either way, when access to narcotics is abused, it doesn’t often end well.

At the core of it all are a few factors: Firstly, the doctor doesn’t want to inflict unnecessary misery on the patient who has legitimate pain. This brings us to that opioids don’t affect everyone equally. An amount which provides relief for one patient’s symptoms may barely scratch the surface of another patient’s pain, making it difficult to know how much is Relief, and when that turns to abuse. Finally, there’s a general lack of accountability. High profile cases like Michael Jackson and Heath Ledger’s deaths may fall under a forensic microscope, but in most circumstances, physicians are not called to justify or account for the prescription…or at least they haven’t been so far.

There is talk of establishing a standard and guideline for the prescribing of opioid drugs. If this should occur (and such legislation often follows high-profile cases,) the physician will have to add yet another issue to the list of things that he can be sued over. If a death can be even remotely connected to the prescription of narcotics, it’s a sure bet that the ambulance chasers will be circling overhead.

Today’s Medical Malpractice risk managment decidedly should include documenting the rationale employed for the prescribing of opioids and other narcotic substances. If the patient presents complaining of severe pain and that recommended non-prescription remedies have failed to provide relief, it may be wise to document this complaint and require that the patient sign to certify that they’ve made the complaint, along with the rationale which led to the prescription. Sending the patient home with a small supply or prescription and a referral to a pain managment specialist may be the best thing for the patient, the physician and the abuser who might otherwise have gotten those drugs on the street. “First, do no harm.”

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