Narcotic Prescription Abuse

Written by: Everett Castle, MD, FACEP

Over the past 10 years, prescription drug abuse has come to the attention of the media, Congress, DEA, American College of Emergency Physicians (ACEP), Emergency Physicians and Providers of health care in general. The fast growing drug abuse problem in the USA is from prescription narcotics produced from the opium poppy and synthetic compounds with similar affects.  Narcotic prescription drugs include Percocet, Vicodin, Methadone, Opana and Oxycontin.

Overdose on prescription medications have escalated in the past 10 years, and deaths that were once dominated by heroin and cocaine, are now equal heroin and cocaine combined. There are about 35,000 deaths from narcotic prescriptions per year. In the USA someone dies from narcotic overdose every 14 minutes. Deaths from opioids were 4,000 in 1999 and 14,800 in 2008.  Prescription narcotic drug overdose is the second leading cause of death in the USA after motor vehicle crashes.

The combined sales of drugs from 1999 to 2010 have quadrupled (from 180 mg of morphine per person in 1999 to 710 mg of morphine in 2010).  Reported from the Robert Wood Foundation, there were 201.9 million prescriptions dispensed in 2009, which is enough narcotic to supply every adult in USA with 30 day prescription for 5mg Vicodin.

Where do people obtain narcotic prescriptions?
These medications are initially obtained from Emergency Departments, Urgent Care Centers and Provider’s Offices. These prescriptions are dispensed by a variety of practitioners include MDs, DOs, NPs, PAs, and dentists. In the emergency department, 42% of visits are related to painful conditions. Patients obtain prescriptions from these many sources and others from black market drug dealers, relatives, and friends. Many pills are diverted by patients to illegal sources and sold. There is a lucrative market for these medications. Medications can be sold at a high value to pay for living expenses like food, and to pay for alcohol and cigarettes. Seventy percent of people who abuse drugs have obtain these medications from friends and relatives

Who takes these medications?
The demographics have been studied and prescription drug abuse has been found to be most likely in high income people because they have insurance and lower income people who have Medicaid (AHCCCS). Lower income people have worse health problems. Middle class people have more out of pocket expenses and take fewer medications.

The diversion of narcotics medications is most problematic for teens. The main source of drugs is from the medicine cabinets, nightstands, and dressers of parents.  Locally, I have been informed of people selling narcotics openly in theaters. Standing up in seat and announce they have a container of Vicodin for sale. Teens have reported that they can purchase Vicodin easier than obtaining beer.

How do people die from narcotic medications?
Narcotics depress ones respiratory drive. People who ingest, snort, smoke, or inject narcotics in excessive amounts can stop breathing within a few minutes and die if not resuscitated by someone.  Narcan, is a medication can be given which is the antidote for narcotic poisoning or intubate the patient and breath for them. Unfortunately, people combine many different substances while taking these medications. Substance abusers can take more than one substance.  Alcohol when used in excessive amounts can suppress drive to breath. Sedatives which include commonly benzodiazepines (Ativan, Valium , Xanax, and Restoril can also have respiratory depression effects .  Narcotics if taken in combination of any of these other drugs and alcohol the result may be catastrophic. Death may occur rapidly if person is left unattended or takes the combination alone.

Special attention has been given to Oxycontin. In the early days of the epidemic Oxycontin was called Hillbilly Heroin. The illegal use of Oxycontin was wide spread in Appalachia and spread across the South. Recently pharmacies in Florida have been investigated by DEA and fined for dispensing excessive amounts of narcotic medication. Oxycontin was commonly used by crushing tablet dissolving in water and injecting intravenously. Since 2010 with pressure from FDA and DEA, pharmaceutical companies that makes Oxycontin has compounded the Oxycontin pill to be in a special form that is difficult to crush and dissolve in water.  The FDA is moving to have all narcotic tablets made in that form. People who have been using Oxycontin by injection will mostly like switch to heroin. Heroin has become cheaper on the black market and more available. More deaths are likely to occur.

What is being done and needs to be done about this horrendous inappropriate use of prescription drugs?
The DEA has encouraged pharmacies and states to form a patient registry of narcotic prescriptions. If providers suspect abuse, doctor shopping, and diversion we can access a prescription database, which is available in Arizona. All narcotic prescriptions are registered with the date and amount of medication dispensed. It would be beneficial if government insurances, Medicare, and Medicaid (AHCCCS) would police patients for excessive prescriptions for narcotic medications. Third party payers along with government insurances have not been mandated to check on narcotic use.  The FDA in 2007 has approved Risk Evaluation and Mitigation Strategies (REMS) for extended-release and long-acting opioid analgesics. Currently Obtaining REMS information is not mandatory but by 2013 providers my need documentation of classes or self-study to provide these prescriptions. If not, mandatory compliance would be low.

What are some of the DOs and DON’Ts with use of narcotics prescriptions?

• Do keep close tabs on all narcotic prescriptions. Store narcotic medication away from children in safe place and away from children of all ages.
• Do not take too much medication.
• Do take medication as prescribed by provider.
• Do call 911 if family or friends find you unarousable, SOB, or problems breathing.
• Do call 911 if child has taken narcotic medication.
• Do not give medication to others.
• Do not take medications unless prescribed to you.
• Do not stop taking opioid or opioid like medications without talking with your health care provider.
• Do not drink alcohol while taking pain medications.
• Do not take sedatives when taking pain medications.

If you need information about narcotic pain medications, speak with health care provider and/or pharmacist.

Arizona poison control can be contacted for accidental ingestion and information – phone 800-222-1222, 24 hours a day, 7 days a week.

Do not hesitate to call 911 for overdose of narcotic medications  The American College of Emergency Physicians (ACEP) has recently passed guidelines for narcotic prescriptions. The high points of the guidelines are listed below. (Taken from ACEP NEWS August 2012)

  1. Use state prescription monitoring program to help identify non-cancer patients who are at risk for diversion or doctor shopping.
  2. For the patient being discharged from Emergency Department with acute low back pain providers should ascertain whether non-opioid analgesics and non-pharmacologic modalities will be adequate for initial pain management. Opioid medications should be used for more severe pain or if prescribed medications are inadequate. If opioids are prescribed should be for the lowest amount and short duration less than one week. Risk should be evaluated for risk of misuse, abuse and/or diversion.
  3. For the adult patient with new onset musculoskeletal pain short acting opioids such as oxycodone and hydrocodone may be prescribed. Providers should consider risks and benefits to patient. 4. In the Emergency Department an adult patient with non-cancer chronic pain exacerbation providers should avoid routine prescribing. If opioids are prescribed the lowest amount possible should be used and for less than one week duration. Physicians should honor existing physician-patient pain contracts /treatment agreements . Existing state prescription drug monitoring programs should be accessed to evaluate risk of misuse, abuse and diversion. To view ACEPS policy, go to www.acep.org/clinical policies.

The epidemic must be addressed on multiple fronts. All providers of narcotic prescriptions should be aware of problems of misuse, abuse, and diversion. Mental health agencies federal and state agencies should be at the forefront of education in schools and provide information in media about this epidemic of abuse and death from misuse of these medications. Increased penalties for diversion if caught and increase detoxification of known abusers.

Health Tip of Month

If you have TIDE PODS product in house hold and have children /toddlers use extreme caution. The container looks like a candy jar. Store where children do not have access. This product is not in childproof container. The PODS are a multicolored soap product and are attractive have been reported to have been ingested by children. The PODS look like candy. If small child ingests do call 911. This product can cause respiratory arrest in small child.

Written by Everett Castle, MD, FACEP

Everett Castle, MD, FACEP is the current Medical Director and Corporate Manager of High Desert Clinic Urgent and Occupational Care in Sierra Vista, Arizona. Born in Tucson and long-time Arizona resident, Dr. Castle attended the University of Arizona as an undergraduate. He graduated from the University Arizona College of Medicine and completed his postgraduate medical training at Maricopa County Hospital in Phoenix.

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