LAS VEGAS—Pain medicine providers face the life-and-death issue of balancing the risks for patients of undertreated pain with the specter of patients developing abuse problems that can lead to drug overdose deaths.
Over 100 million Americans suffer from chronic pain and recent studies indicate that prescription drug abuse has resulted in an alarming increase in both injury and death, said Stephen J. Ziegler, PhD, JD, of Indiana University-Purdue University in Fort Wayne, Indiana, and co-presenters Joshua Gunn, PhD, and P. Michael Murphy, DBA. “Rates have risen roughly five-fold since 1990,” noted Dr. Ziegler to attendees at PAINWeek 2014.
There were fewer than 5 unintentional prescription drug overdose deaths per 100,000 patients in 2004, and nearly 10 per 100,000 just three years later, in 2007, when 27,658 people died this way nationwide. There are multiple causes for these overdoses, including patients’ nonadherence with prescription and dosing directions, measurement issues, polypharmacy, and intentional poly-substance abuse.
Diversion of medications for use by people who were not prescribed those drugs, is another source of overdose risk, thanks in part to recreational “pharm parties” at which medications are shared.
Prescription drug abuse and overdose deaths are a “growing epidemic,” regardless of age, race, social class, economic status or geographic location, agreed co-presenter P. Michael Murphy, DBA, of the Clark County Office of the Coroner/Medical Examiner in Las Vegas, Nevada.
More than 40% of these deaths involve opioid analgesics and benzodiazepines, he said. Leading prescription drugs involved in accidental and suicidal overdoses were oxycodone, alprazolam, hydrocodone, morphine and methadone.
Methadone is a leading factor, involved in a third of overdose deaths, Dr. Ziegler added.
Inconsistent methods of determining therapeutic levels – and causes of death – are a problem, he said. Maintaining good documentation is key when a patient’s overdose death is investigated. “The Devil is in the details,” he said. “The government does not expect HCPs to be perfect – only reasonable.”
Medicolegal death investigations are undertaken when deaths are suspicious or sudden and unexplained, associated with criminal activity, or unattended by a physician, Murphy said.
Just how overdose death investigations are undertaken, and by whom, varies from state to state, Murphy noted. In drug overdose deaths, investigations will focus on whether the decedent or another person was the prescribed patient for the drug involved, the type and amount prescribed and on hand at the time of death, and whether the same drug was prescribed by more than one physician. Medical records, physician notes, prescribed/administered drugs, pharmacy dispense logs and toxicology analyses may all be consulted in the course of such investigations.